Columbia  ?imbet£(itp 
intljcCitpofietetogork 

College  of  Pfjpgicianfl!  ant  g)ttrgeonBi 


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laltet  p.  f  amejS 


A  TEEATISE 


PRINCIPLES  AND  PRACTICE 
OF  MEDICINE. 


BY 

ARTHUR  R.  EDWARDS,  A.M.,  M.D., 

PEOFESSOR    OF    THE    PRINCIPLES    AND    PRACTICE    OF    MEDICINE    AND    OF     CLINICAL    MEDICINE    IN    THE 

NORTHWESTERN    UNIVERSITY    MEDICAL    SCHOOL,    CHICAGO;       ATTENDING 

PHYSICIAN    TO    MERCY,    WESLEY    HOSPITALS,    ETC. 


ILLUSTRATED  WITH  101    ENGRAVINGS  AND  19   PLATES. 


LEA  BROTHERS  &  CO., 
PHILADELPHIA  AND  NEW  YORK, 

1907. 


Entered  according  to  Act  of  Congress,  in  the  year  1907,  by 

LEA  BROTHERS  &  CO., 

In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE. 


So  wide  is  the  range  of  Modern  Practice  that  an  author  who  would 
cover  it  in  a  single  volume,  and  a  reader  who  would  grasp  it  intelli- 
gently, must  approach  their  respective  tasks  with  the  aid  of  thorough 
system.  In  the  following  pages  an  effort  has  been  made  to  deal  with 
the  subject  in  this  manner,  from  its  main  divisions,  which  follow  the 
most  rational  classification,  down  to  the  subordinate  paragraphs. 
Careful  use  has  been  made  of  types  of  various  prominence  to  facilitate 
the  finding  of  a  topic  and  the  appreciation  of  its  importance.  With  the 
vast  mass  of  material,  an  attempt  has  been  made  so  to  arrange  the 
facts  that  the  reader  may  grasp  the  process  of  reasoning. 

Passing  from  these  mechanical  details  to  the  characteristics  which 
the  author  has  endeavored  to  impress  upon  the  book,  it  may  be  noted 
that,  as  far  as  possible,  the  causative  pathology  has  been  blended  with 
the  consecutive  clinical  features  of  disease,  that  reasons  have  been 
given  for  facts,  that  exceptions  have  been  subordinated  to  what  is 
usually  found  at  the  bedside,  and  that  the  allurements  of  typical  clinical 
pictures  and  dogmatic  generalizations  have  been  avoided  because  they 
hold  neither  in  practice  nor  at  the  postmortem  table. 

The  author  also  conceives  that  a  book  on  Practice  should  be  well- 
directed,  which  implies  that  it  should  deal  adequately  with  scientific 
theories  and  principles,  but  that  it  should  recognize  that  the  final  object 
of  its  existence  is  the  a'pplication  of  knowledge  to  the  cure  or  alleviation 
of  disease.  Accordingly,  an  unusual  amount  of  space  has  been  devoted 
to  treatment,  to  the  detailed  consideration  of  drugs  and  to  numerous 
formulae  and  prescriptions  ready  for  the  student  to  use  or  improve 
upon.  The  physiological  action  of  drugs  has  been  dwelt  upon  care- 
fully because,  in  the  writer's  experience,  the  symptoms  of  disease  are 
often  confounded  with  those  of  the  remedies  exhibited  for  its  cure. 

The  reader  will  also  find  a  large  number  of  tables  giving  the  differ- 
ential diagnosis  of  diseases  likely  to  be  confused,  or  in  many  instances, 
of  entire  subjects,  such  as  those  of  the  liver  and  kidney,  the  chief  erup- 
tive diseases  and  those  of  the  typhoid  group.  They  are  practical 
though  necessarily  schematic.  Nowadays  the  border-lines  of  surgery 
and  medicine  overlap,  and  the  practitioner,  internist  and  surgeon  must 


vi  PREFACE 

be  familiar  with  the  province  of  each  other.     For  this  reason,  as  far  as 

the  scope  of  the  treatise  admits,  surgical  indications  and  results  are 

introduced. 

The  writer  wishes  to  acknowledge  the  extremely  careful  attention 

bestowed  by  the  Publishers  upon   every  literary  and  typographical 

detail,  and  the  assistance  of  Dr.  F.  G.  Dyas  and  Dr.  Mihon  Mandel 

in  the  proof  reading. 

A.  R.  E. 

Chicago,   1907. 


CONTENTS. 


Page. 


Section  I.  Specific  Infections  17 


Section  II.         Diseases  of  the  Circulation 377 


Section  III.       Diseases  of  the  Respiratory  Tract 


485 


Section  IV.        Diseases  of  the  Digestive  Tract 573 


Section  V.  Diseases  of  the  Kidney 


767 


Section  VI.        Diseases  of  the  Blood 


,831 


Section  VII.       Diseases  of  the  Ductless  Glands 877 


Section  VIII.     Constitutional  Diseases 


.903 


Section  IX.        Diseases  of  the  Nervous  System 


.941 


Section  X.  Intoxications.    Sunstroke 1241 


Section  XI.        Diseases  Due  to  Animal  Parasites 1257 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonprinciOOedwa 


SECTION  I. 


THE  SPECIFIC  INFECTIONS 


TYPHOID  FEVER. 

The  name  {Typhos,  Stupor)  refers  to  the  clouded  mentahty,  and 
dates  from  Hippocrates.  The  disease  was  first  recognized  by  Louis  of 
Paris  (1829),  and  was  first  described  as  a  separate  disease  by  Gerhart 
and  Pennock  (1837). 

Definition. — Typhoid  fever  is   a  general  infection,  characterized — 

1.  Etiologically  by  the  Bacillus  typhosus. 

2.  Anatomically  by  hyperplasia  and  ulceration  of  the  lymphatic 
structures  of  the  intestine,  hyperplasia  of  the  spleen  and  mesenteric 
glands,  and  by  parenchymatous  change  in  other  organs. 

3.  Clinically  by  a  characteristic  fever,  roseolous  eruption,  enlarge- 
ment of  the  spleen,  slow  pulse,  a  peculiar  serum  reaction,  typhoid 
bacilli  in  the  blood,  and  often  by  intestinal  symptoms. 

Etiology. — ^The  typhoid  bacillus  was  first  seen  by  Eberth  and  Koch 
(1880),  and  first  cultivated  by  Gaffky  (1884). 

1.  Characters. — It  has  short,  thick,  rounded  ends,  is  three  times  as 
long  as  wide,  in  length  is  one-third  the  diameter  of  a  red  blood-cor- 
puscle, and  its  numbers  are  usually,  but  not  always,  proportionate  to 
the  degree  of  infection.  It  is  polymorphous,  sometimes  thread-like, 
varies  in  different  media,  contains  no  spores  (though  it  is  maintained 
that  a  spore  is  found  at  one  pole),  is  flagellated,  and  actively  motile. 
It  grows  best  at  body  heat,  and  is  a  facultative  anaerobe  growing  on 
various  solid  and  fluid  media,  especially  on  agar,  gelatin,  and,  char- 
acteristically, on  the  potato.  It  does  not  produce  acid,  ferment  lactose, 
produce  indol,  or  coagulate  milk.  It  stains  with  aniline  dyes,  but  not 
by  Gram's  method;    is  not  inoculable,  but  produces  the  typhotoxin. 

2  17 


18  THE  SPECIFIC  INFECTIONS 

Until  recently,  animal  inoculations  have  been  negative.  It  is  said 
that  typical  lesions  have  been  produced  in  the  chimpanzee, 

2.  Location. — It  is  found  in  the  ulcers,  in  the  lymphatics  of  the  mesen- 
tery, in  the  spleen,  in  the  intestines  at  autopsy  (chiefly  in  the  upper 
small  intestine),  in  the  fseces,  in  the  blood,  in  the  internal  viscera,  in 
the  urine,  in  the  roseolse,  less  frequently  in  the  lungs,  muscles,  uterus, 
oesophagus  and  tongue,  and  in  various  secondary  foci,  as  in  pleurisy, 
pneumonia  (sputum),  endocarditis,  meningitis,  parotitis,  osteomyelitis, 
and  abscesses.  According  to  Lynch,  it  has  also  been  isolated  sixteen 
times  from  the  blood  of  the  foetus  in  maternal  typhoid  infections.  In 
curious  cases  typhoid  bacilli  may  occur  in  the  stools  of  individuals,  par- 
ticularly children,  not  suffering  from  typhoid  fever. 

3.  Tenacity. — Its  tenacity  of  life  is  great,  the  germ  persisting  for  years 
in  bone  lesions  and  enduring  from  three  weeks  to  three  months  after 
death.  It  lives  below  zero,  from  two  to  twenty-two  weeks.  It  resists 
drying,  except  in  thin  layers,  for  months,  and  lives  some  time  in  water, 
seldom  longer  than  three  weeks,  although  its  multiplication  is  pre- 
vented by  saprophytes.  It  is  killed  in  a  few  hours  by  direct  sunlight. 
The  germ  may  live  for  months  in  ice,  sour  milk,  faeces,  or  in  the  up- 
per, but  not  in  the  deeper,  layers  of  the  soil.  It  may  live  a  year  in  soiled 
clothes,  which  explains  contagion  in  washerwomen  and  nurses. 

4.  Entrance. — It  resists  gastric  juice  fairly  well,  yet  its  chief  and 
probably  sole  atrium  is  the  digestive  tract,  the  infection  being  carried 
in  water  (its  main  medium),  milk,  butter,  ice,  vegetables,  or  oysters. 
As  shown  in  the  Spanish-American  and  Boer  wars,  dried  faeces  con- 
taining the  bacilli  may  be  carried  by  flies  and  sand.  Alice  Hamilton 
found  the  bacilli  in  flies  in  the  Hull  House  region  of  Chicago.  Cock- 
roaches and  other  insects  may  also  convey  infection. 

5.  Exit. — The  germ  leaves  the  body  chiefly  in  the  faeces  and  urine, 
which  are  dangerous  even  far  into  convalescence,  and  which  are  the 
chief  means  of  dissemination,  the  disease  being  less  often  conveyed 
directly  from  one  individual  to  another,  although  direct  infection  occurs 
in  hospitals  and  camps.  Lenz  found  that  certain  persons  after  a 
typhoid  attack  become  "chronic  carriers  of  typhoid  bacilli,"  the  bacilli 
remaining  in  their  dejecta  for  one  or  even  fifteen  years. 

From  a  practical  standpoint,  the  direct  etiological  diagnosis  is  of 
somewhat  limited  value,  since  (a)  differentiation  from  the  colon  bacillus 
requires  an  expert  bacteriologist;  (6)  the  bacillus  does  not  appear 
early  nor  invariably  in  the  stools,  where  the  diagnosis  is  difficult;  and 
(c)  since  direct  splenic  puncture  for  diagnosis  alone  is  no  more  justifi- 
able than  in  malaria.  The  bacillus  itself  is  found  in  the  blood  early 
in  the  first  week.  In  the  second  week  the  serum  usually  gives  the 
distinctive  Widal  reaction. 

Predisposing  Etiology. — 1.  Reduced  pyhsiological  resistance,  as 
from  overwork  or  mental  depression,  is  a  frequent  predisposing  cause; 
yet  typhoid  very  often  occurs  in  the  robust.  It  is  claimed  that  the 
weak  or  emaciated  are  immune,— e.  g.,  those  with  syphilis,  tubercu- 
losis, cancer,  endocarditis,  antvmia,  or  convalescents  from  other  dis- 


TYPHOID  FEVER  19 

eases.  Some  immunity  is  claimed  in  pregnancy,  lactation,  and  the 
puerperium.  Alimentary  affections,  according  to  Bouchard,  such  as 
decreased  hydrochloric  acid  formation,  or  dilated  stomach,  favor 
infection.  Most  cases  occur  in  time  of  war,  or  among  the  poorer 
classes,  or  among  recent  residents  in  typhoid  localities. 

2.  Season. — For  reasons  not  known  most  cases  develop  in  the  late 
summer  and  fall  ("autumnal  fever"). 

3.  Age. — ^The  years  from  fifteen  to  twenty-five  include  most  cases 
(56  per  cent.),  yet  foetal  cases  are  recorded,  and  a  few  cases  occur  in  the 
first  year  of  life.  Their  number  increases  from  the  first  to  the  fifth 
year.  Between  the  fifth  and  fifteenth  years  as  many  are  affected  as 
after  thirty-five.    The  disease  is  relatively  rare  after  fifty. 

4.  Geographical  Distribution. — Typhoid  is  endemic  rather  than 
epidemic.  Although  it  is  the  most  common  continued  fever  in  tem- 
perate climates,  it  is  a  world-wide  disease  and  sustains  a  most  intimate 
relation  to  the  water  supply,  the  disposal  of  sewage,  the  density  of 
population,  and  personal  hygiene. 

Immunity. — Congenital  immunity  is  not  proved.  Immunity  has  no 
relation  to  the  severity  of  the  disease,  though  it  is  usually  conferred 
after  one  attack,  but  is  not  life-long  nor  as  frequent  as  in  the  case  of 
scarlatina.  In  the  Hamburg  epidemic  (1887),  2x1)  per  cent,  of  the 
cases  were  second  attacks;  and  in  Eichhorst's  series  there  were  over 
4  per  cent,  of  second  attacks.  These  second  attacks  equal  or  even 
exceed  the  original  in  severity. 

Sjnnptoms. — The  general  clinical  picture  offers  more  variability 
than  that  of  any  other  infection.  Typhoid  is  not  an  intestinal  disease, 
but  a  general  infection.     Its  forms  are: 

1.  The  typical  enteric,  frequently  with  diarrhoea,  tympany,  hemor- 
rhage, and  perforation. 

2.  The  septicsemic,  without  any,  or  with  very  slight,  anatomical 
intestinal  lesions,  though  responding  to  the  Widal  test  and  accom- 
panied by  bacillaemia. 

3.  Other  localizations  than  enteric;  e.g.,  in  the  lung,  larynx,  bone, 
etc. 

4.  Mixed  infections — malaria,  streptococcus,  colon  bacillus,  etc. 

5.  Paratyphoid,  with  close  clinical  resemblance  to  typhoid  but  with 
organisms  differing  culturally  and  in  their  agglutinating  reactions. 
(See  Diagnosis). 

The  incubation  lasts  one  to  two  weeks,  with  symptoms  more  vague 
than  in  other  acute  infections, — e.  g.,  depression,  pains  in  the  head, 
back,  or  limbs,  dulness  of  hearing,  disturbed  sleep,  or  perhaps  chilli- 
ness, night-sweats,  anorexia,  epigastric  oppression,  constipation,  or 
even  diarrhoea.  The  incubation  lasted  only  three  days  in  a  girl  who 
took  a  pure  typhoid  culture  with  suicidal  intent. 

The  first  week  corresponds  anatomically  to  the  intestinal  catarrh 
and  the  beginning  of  medullary  infiltration  of  Peyer's  plaques.  The 
disease  dates  from  the  fever,  which  each  evening  is  from  1°  to  lh° 
higher  than  on  the  previous  day,  until  a  temperature  of  103°  to  104°  is 


20  THE  SPECIFIC  INFECTIONS 

reached.  The  pulse  is  full,  dicrotic,  and  rapid,  but  not  high  in  propor- 
tion to  the  fever.  The  tongue  is  coated  white.  Thirst,  dry  cough, 
enlarged  spleen,  eruption  of  rose  spots,  and  typhoid  bacilli  in  the 
blood,  are  found.  The  abdomen  shows  slight  distention  and  ten- 
derness over  the  ileocfecal  region  or  epigastrium.  Delirium  is  infre- 
quent, and  headache,  constipation,  dulness  and  apathy  are  usually 
present. 

The  second  week  corresponds  to  the  end  of  medullary  infiltration 
and  the  beginning  of  eschar-formation.  The  fever  is  higher  and  usually 
continuous.  The  morning  remission  is  less.  The  pulse  is  full,  faster, 
and  less  dicrotic.  The  blood  responds  to  the  Widal  test.  The  tongue 
is  dry  and  glazed,  as  are  also  the  lips,  pharynx,  and  mouth,  to  which 
the  mucus  adheres.  The  voice  is  weak.  The  bronchitis  increases, 
and  the  urine  is  febrile.  Abdominal  symptoms  are  often  aggravated. 
Meteorism  appears.  Yellow  pea-soup  dejecta,  which  are  involuntary 
in  severe  cases,  occur.  The  face  is  apathetic,  its  lines  obliterated,  the 
mouth  half  open,  and  the  upper  lip  retracted,  showing  sordes. 
Roseolse  usually  develop  during  this  week.  Nervous  symptoms  in- 
crease with  higher  fever;  delirium  follows;  the  patient  becomes 
less  querulous;  and  euphoria  from  narcosis  by  the  toxins  is  the  rule, 
while  pain  suggests  complications.  The  patient  may  begin  to  recover, 
or  may  die  at  this  stage  from  hemorrhage  or  nervous  toxaemia. 

The  third  week  is  the  stage  of  ulceration.  The  fever  gradually  de- 
clines with  marked  morning  remissions  and  unaccountable  variations. 
The  pulse  is  smaller,  and  faster  (100  to  120),  and  loses  its  dicrotism;  it 
is  sometimes  slower.  The  tongue  clears  and  the  roseolse  disappear, 
being  replaced  by  miliaria  from  sweating.  In  exceptional  cases  diar- 
rhoea may  be  seen  for  the  first  time  in  this  week.  Emaciation  is  marked. 
When  the  fever  falls,  the  patient  complains  of  hunger,  weakness,  and 
pain.  Death  may  occur  in  the  typhoid  state  from  heart  weakness, 
pulmonary  inflammation,  paralysis  of  the  nerve-centres,  hemorrhage, 
or  perforation. 

The  fourth  week  (cicatrization)  usually  marks  convalescence,  as  the 
average  duration  of  typhoid  is  from  three  to  six  weeks;  though  in 
severe  cases  the  symptoms  assigned  to  the  third  week  may  continue. 
Convalescence  may  be  uneventful,  or  marred  by  slight  temperature, 
rapid  pulse,  palpitation,  nausea,  vomiting,  muscular  weakness,  exag- 
gerated reflexes,  etc. 

Symptoms  in  Detail. — To  avoid  repetition,  and  to  explain  anatomi- 
cally the  clinical  signs  and  symptoms,  the  typhoid  pathology  will  be 
incorporated  under  the  appropriate  organs,  and  complications  and 
sequels  will  be  classified  with  the  more  common  typhoid  manifesta- 
tions. 

1.  Fever. ^ — Fever  is  an  expression  of  toxfemia,  and  is  a  cardinal 
symptom  of  typhoid.  It  is  subacute.  It  lasts  more  than  fourteen 
days  (averaging  three  to  four  weeks),  usually  comes  on  without  chill, 
and  resolves  by  lysis.  It  is  the  best  studied  chapter  in  the  disease 
since  the  time  of  Wunderlich,  who  in  dubious  cases  diagnosticated 


TYPHOID  FEVER 


21 


Ivphoid  from  the  fever  chart  alone.  In  its  incipiency  there  is  usually  a 
gradual  rise  for  three  to  five  days.  Wunderlich  placed  great  stress 
upon  this,  though  the  rise  is  sometimes  sudden  or  accompanied  by  a 
chill.  Chomel  (1834)  described  cases  with  sudden  onset  and  De 
Mussy  (1884)  spoke  of  an  explosive  onset;  a  sudden  onset  is  observed 
in  10  per  cent,  of  typhoid  cases.  The  writer  saw,  with  Dr.  Korssell,  a 
child  whose  temperature  rose  suddenly  to  106°  on  the  second  day. 

In  the  first  week,  corresponding  to  the  catarrh  and  medullary  infiltra- 
tion, the  evening  temperature  is  to°  to  1°  more  than  in  the  morning, 
and  the  ascension  is  ladder-like.  When  there  is  an  initial  chill,  every 
other  possible  disease  should  first  be  excluded,  yet  Osier  observed 
chills  in  24  per  cent,  of  his  cases.  Chills  occur:  (a)  at  the  onset,  espe- 
cially in  children,  and  in  light  forms;  (6)  throughout  the  course,  and 
accompanied  by  sweats,  the  sudoral  type  of  the  French;  (c)  in  compli- 
cations— pneumonia,  pleurisy,  otitis  media;  {d)  after  antipyretics, 
tubbing,  or  (e)  in  defervescence,  sometimes  from  secondary  sepsis. 


Fig. 

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CONTINUOUS 


Typical  typhoid-fever  curve. — The  heavy  line  marks  the  temperature  curve,  and  the  broken  line 

the  pulse  curve. 

In  the  second  week,  corresponding  to  the  end  of  infiltration  and  to 
the  formation  of  the  slough,  the  fever  is  continuous  from  one-half  to 
three  weeks,  Curschmann  distinguishing  two  types:  (i)  one  and  one- 
half  weeks  fastigium,  and  (ii)  three  weeks  fastigium.  Especially  high 
temperature  suggests  complications;  if  the  fever  becomes  very  high, 
the  course  is  apt  to  be  severe.  Sometimes  a  pseudo-collapse  may  occtir, 
particularly  in  subjects  between  twenty-five  and  thirty  years  of  age. 

In  the  third  week  (ulceration),  the  fever  is  remittent,  the  amphibolic 
stage  of  Wunderlich,  and  the  stadium  hecticum  of  Traube.  The  cause 
of  fever  variations  is  not  known. 

The  fourth  week  (cicatrization)  is  the  stage  of  "steep  curves,"  lasting 
from  three  to  eight  days.     When  a  sudden  drop  occurs,  recurrences 


22 


THE  SPECIFIC  INFECTIONS 


and  relapses  are  not  infrequent.  A  critical  fall  of  the  temperature 
sometimes  follows.  Jaccoud  observed  a  brusque  defervescence  in  29 
per  cent,  of  his  cases.  The  fever  may  be  intermittent  or  remittent 
throughout  the  disease^  especially  in  children,  the  aged,  and  in  severe 
cases.  Irregularity  and  variations,  especially  when  protracted,  cause 
difficulty  in  diagnosis,  suggesting,  perhaps,  miliary  tuberculosis  or 
sepsis. 

Fig.  2. 


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Typhoid  fever;  irregular  fever  curve  throughout  the  course.' 


r  Convalescence. — In  its  first  week  the  fever-curve  is  usually  sub- 
normal; when  not  so,  some  irregularity  must  be  looked  for.  Later 
there  is  a  gradual  rise  to  normal. 

In  the  typiis  inversus,  seen  chiefly  in  children  and  the  aged,  the 
morning  temperature  is  higher  than  the  evening  record.  Afebrile 
typhoid  is  exceptional.  Modification  of  temperature  may  be  caused 
by  visits  from  friends,  excitement,  entrance  to  the  hospital,  diet,  hem- 
orrhage, abortion,  peritonitis,  and  other  complications. 

2.  The  Splenic  Tumor. — The  splenic  tumor  is  a  cardinal  symptom 
occuring  early  and  frequently,  persisting  in  exacerbations  and  relapses. 
In  importance  and  size,  it  ranks  second  to  the  splenic  enlargement  of 
malaria  and  sepsis.  The  cause  of  this  tumor  is  the  bacillus  or  its 
toxins  (not  the  fever)  which  produce  splenic  hyperemia  and  hyper- 
plasia— changes  closely  analogous  to  those  in  the  intestinal  lymph- 
structures.  Massive  endothelial  proliferation  is  said  by  Mallory  to 
occur  in  the  splenic,  lymphatic,  and  medullary  vessels.  In  the  first 
week  the  spleen  is  hypersemic  and  swollen  to  two  or  even  three  times 
its  normal  size.  Its  markings  are  indistinct.  In  the  second  week 
it  is  more  pulpy  and  darker.  By  the  fourth  week  it  has  usually  dis- 
appeared, but  as  long  as  we  find  the  splenic  tumor,  the  disease  has 
not  ended. 


TYPHOID  FEVER  23 

Frequency. — (a)  Anatomically  the  splenic  tumor  is  present  in  98.4 
per  cent,  of  the  cases.  Its  rare  absence  is  explained  by  thickening  of 
the  capsule,  old  induration  or  infarction  of  the  organ,  or  extreme 
emaciatioti.  (6)  Clinically,  it  is  present  in  75  to  80  per  cent.  (Cursch- 
mann)  or  90  per  cent.  (Leube).  The  percentage  varies  with  the  skill  of 
the  observer,  the  method  of  examination,  the  epidemic,  and  age  of 
the  subject  (the  sign  being  often  absent  in  children,  in  adults  older 
than  forty-five  years,  or  after  hemorrhage).  It  should  be  palpated 
with  the  patient  in  the  right  diagonal  position.  This  is  difficult  in 
pain,  tympany,  and  in  an  anomalous  position  of  the  colon.  The  author 
has  twice  seen  the  spleen  ruptured  by  deep  or  rough  palpation.  Per- 
cussion of  the  spleen  is  worthless.  It  should  be  remembered  that  the 
spleen  may  be  ectopic.  The  examiner  should  stand  or  sit  on  the  right 
side  of  the  patient,  palpating  with  the  right  hand  pressing  evenly  on  the 
abdomen,  and  the  left  hand  hooked  beneath  and  lifting  up  the  lower 
left  ribs.  Relatively  rare  splenic  complications  are  abscess,  infarcts 
and  rupture. 

3.  Dermal  Symptoms. — (a)  Rose  Spots  (roseola  typhosa,  tdclie 
rosee  lenticulaire  of  Louis)  constitute  the  third  cardinal  symptom. 
They  are  round  spots,  varying  from  the  size  of  a  pin-head  to  that  of  a 
lentil  (lenticular),  circumscribed,  rose-colored,  slightly  elevated  to  the 
touch,  purely  hypersemic,  and  therefore  disappearing  on  pressure  and 
reappearing  on  its  release,  not  often  fusing,  and  later  becoming  darker, 
but  leaving  no  mark,  with  sometimes  a  vesicle  at  their  apex,  and  rarely 
desquamating,  except  in  a  few  infantile  or  juvenile  cases.  They  are 
rarely  hemorrhagic,  and  therefore  the  commonly  used  term,  petechia, 
is  inappropriate.  Being  purely  hypersemic,  they  are  not  found  at 
autopsy.  They  scarcely  ever  pustulate.  They  may  be  seen  as  early  as 
the  fourth  day,  especially  in  women  and  children,  but  usually  appear 
from  the  seventh  to  the  tenth  day.  They  occur  in  crops,  during  two 
weeks,  each  crop  lasting  from  three  to  five  days.  Occasionally,  they 
outlive  the  fever.  Their  location  is  on  the  lower  breast  and  abdomen, 
though  they  sometimes  appear  twenty-four  hours  earlier  on  the  back, 
because  of  its  warmth.  They  rarely  occur  on  the  neck  or  face,  and 
generally  are  more  frequent  on  the  proximal  than  on  the  distal  parts 
of  the  extremities.  If  there  are  many  on  the  lower  parts  of  the  limbs, 
they  are  probably  not  roseolfe.  They  number  five  to  ten,  or  even  thirty. 
They  are  more  abundant  in  women,  less  so  in  children  and  the  aged, 
and  seldom  so  abundant  as  to  resemble  measles  closely.  Their  fre- 
quency varies  somewhat  with  the  epidemic.  Eichhorst  found  them 
in  more  than  1,200  cases,  Leube  in  80  per  cent.,  Osier  in  93  percent., 
and  Murchison  in  33  per  cent. 

Typhoid  bacilli  have  been  found  in  the  roseolse  in  50  to  80  per  cent. 
of  the  cases  and  may  establish  a  doubtful  diagnosis,  but,  of  course, 
rarely  an  early  one;  Polacco  found  the  bacilli  in  100  per  cent,  and 
Krause  in  94  per  cent,  of  their  cases.  In  other  diseases,  as  miliary 
tuberculosis,  meningitis,  tuberculosis,  and  pneumonia,  they  are  very 
rarely  encountered. 


24  THE  SPECIFIC  INFECTIONS 

(6)  Other  Cutaneous  Manifestations. — Other  cutaneous  mani- 
festations are:  urticaria;  erythema,  even  of  the  nodose  or  exudative 
forms;  pelioma  typhosum,  or  the  tdche  hleudtre — pale  blue  spots  meas- 
uring 4  to  10  millimeters,  due  to  pediculosis,  and  therefore  seen  in  parts 
nearest  the  pubic  or  axillary  hair,  etc. ;  erysipelas,  phlegmon  and  fu- 
runcles (increased  by  hydrotherapy) ;  alopecia  after  the  typhoid  attack, 
rarely  followed  by  permanent  baldness.  The  typhoid  odor  is  musty 
or  semi-cadaveric.  Miliaria  are  frequent,  though  less  than  in  sepsis 
and  more  common  than  in  measles  or  scarlatina.  They  usually  appear 
late  in  the  third  or  fourth  week.  Herpes  is  rare,  occurring  in  less  than 
1  per  cent,  of  the  cases.  The  author  has  observed  it  only  ten  times  in 
upwards  of  1,800  cases.  It  is  far  less  frequent  than  in  pneumonia, 
malaria,  typhus,  meningitis,  and  influenza.  Decubitus  occurs  in  1  per 
cent.,  mostly  in  severe  and  hospital  cases.  Noma  is  a  rare  complica- 
tion. In  204  cases  of  gangrene  collected  by  Keen,  50  per  cent,  occurred 
in  the  leg,  25  per  cent,  in  the  face,  neck,  and  trunk,  and  the  balance 
in  other  locations.  McFarland  and  Hare  have  reported  a  number  of 
cases  in  Philadelphia.  Sweats  and  chills  occur  in  the  "  typhus  sudor- 
alis,"  especially  in  the  latter  half  of  the  fever  course,  described  in 
Naples  by  Borelli  and  in  Paris  by  Jaccoud,  ffidema  is  due  most 
frequently  to  phlebitis,  sometimes  to  anaemia,  and  rarely  to  nephritis. 
The  skin  sometimes  shows  atrophic  strise  like  those  of  pregnancy. 
Desquamation  may  occur,  particularly,  in  children. 

4.  Circulation. — (a)  The  Slow  Pulse. — The  slow  pulse  is  the  fourth 
cardinal  symptom.  In  uncomplicated  cases  it  follows  the  temperature 
in  the  early  stages,  but  is  lower  than  the  fever  would  justify,  especially 
in  men  under  forty  years ;  e.  g.,  pulse  90  with  the  fever  103°.  It  is  rather 
faster  in  women,  in  children,  and  in  the  nervous.  Its  slowness  is  due 
to  an  inhibitory  action  of  the  toxins  on  the  medulla  or  the  heart,  a  fact 
not  recognized  either  by  the  older  or  by  some  of  the  modern  writers. 
The  author  has  seen  four  typhoid  cases  in  which  the  pulse  ranged  from 
fifty-six  to  sixty-four,  with  the  fever  above  103°  and  the  respirations 
above  forty.  Slowness  is  of  good  import.  A  fast  pulse  early  in  the 
typhoid  course  is  a  poor  prognostic,  especially  in  men.  Irregularity 
or  crossing  of  the  pulse  and  temperature-curves,  is  also  ominous. 
The  pulse  may  become  faster  from  heart  or  lung  inflammation,  perfora- 
tive peritonitis,  hemorrhage,  and  severe  intoxication.  It  may  also 
run  up  on  visiting  days,  in  women,  children,  emaciated  and  nervous 
individuals,  or  in  the  stage  of  great  temperature  variations.  At  first  a 
little  tense  in  volume,  it  soon  becomes  dicrotic,  which,  with  slowness, 
suggests  typhoid.  Dicrotism,  evidenced  by  a  double  shock,  occurs  in 
80  per  cent,  of  cases,  but  is  not  prognostic.  It  is  usual  in  adults,  is 
absent  in  children  and  often  in  adults  at  the  fastigium  in  very  severe 
cases.  Since  it  indicates  lack  of  arterial  tone,  it  is  also  absent  in  arterio- 
sclerosis. In  Osier's  Clinic,  the  blood-pressure  was  found  to  be  115  to 
125  millimeters  of  mercury  in  the  systole,  and  85  to  100  millimeters  in 
diastole.  In  the  first  stage  of  convalescence,  when  there  is  subnormal 
temperature,  the  pulse  is  usually  normal  in  rate,  or  slow,  which  is  ex- 


TYPHOID  FEVER  25 

plained  by  disturbed  conductivity  in  the  heart  muscle.  Myocarditis 
is  possibly  the  cause  in  some  cases.  In  the  second  stage  it  is  usually 
higher  than  normal,  especially  after  the  patient  gets  out  of  bed,  after 
eating,  or  a  movement  of  the  bowels.  On  the  whole,  bradycardia  in 
convalescence  is  more  common  than  tachycardia. 

Fig.  3. 


Pulse  tracing  in  typhoid,  showing  dicrotism. 

(6)  Heart  Muscle. — In  the  heart  muscle  early  changes  are  rare. 
Parenchymatous  degeneration,  evidenced  by  albuminous  granules, 
nuclear  swelling,  and  pigmentation,  are  found  later,  the  heart  as  a 
whole  being  flabby,  soft,  pale,  and  even  waxy.  Fatty  and  hyaline 
degeneration,  vacuole  formation,  segmentary  myocarditis,  and  a  ten- 
dency toward  muscle  regeneration,  are  the  usual  findings  in  fatal 
cases.  Interstitial  myocarditis,  like  that  of  diphtheria  or  scarlatina, 
occurs  in  over  50  per  cent,  of  typhoid  cases  (Rhomberg).  It  usually 
regresses  without  functional  or  organic  disturbance,  and  chronic  myo- 
carditis rarely  develops.  Its  clinical  signs  may  appear  at  the  end  of  the 
second  week,  and  last  into  the  fourth  week,  or  it  may  develop  first  in 
convalescence.  The  symptoms  are  gradual  dilatation,  weak  tones 
(especially  the  first  tone  at  the  apex),  accentuation  of  the  second  pulmonic, 
a  systolic  bruit,  and  a  fast,  irregular  pulse  with  lessened  tension  but  with- 
out dicrotism.  Tachycardia,  without  myocarditis,  may  result  from  the 
toxins  acting  on  the  medulla  oblongata.  Recovery  is  usual,  even  if  the 
myocarditis  lasts  two  or  three  months. 

Dilatation  of  the  right  heart  may  be  observed  in  severe  cases.  Less 
frequent  are  the  following  complications:  Cardiac  thrombosis  and 
embolism;  pericarditis  ([one  in  1,000  autopsies],  mostly  fibrinous,  and 
mostly  in  complicating  sepsis);  endocarditis  ([one  in  1,000],  mostly 
mural  over  myocarditic  patches),  sometimes  due  to  Eberth's  bacillus; 
collapse,  with  its  usual  signs,  which  may  cause  death  from  heart  de- 
generation, or  from  toxic  vasomotor  paralysis  (as  in  diphtheria,  pneu- 
monia, or  pyocyaneus  infections).  Myocarditis  is  the  most  common 
cause  of  collapse,  while  pulmonary  embolism,  uraemia,  cerebral  hemor- 
rhage, etc.,  are  far  less  common.  Sometimes  no  clear  cause  is  discovered 
at  autopsy.  Collapse  develops  mostly  in  strong  men  (80  per  cent,  of 
Dewevre's  140  cases)  and  most  often  during  convalescence.  (See  Prog- 
nosis.) 

(c)  Vessels. — In  the  vessels,  arteritis  typhosa,  most  often  found  in 
the  femoral  artery,  is  rare,  W.  W.  Keen  collecting  only  forty-four 
cases.     It  is  a  specific  inflammation  caused  by  the  typhoid  bacillus. 


26  THE  SPECIFIC  INFECTIONS 

Spontaneous  gangrene  may  result.  Arterial  embolism  from  marantic 
thrombi  is  rare.  Phlebitis  typhosa  occurs  in  1  per  cent,  (to  2.6  per  cent., 
Thayer)  of  the  cases,  being  considered  marantic  or  infective  (Eberth's 
bacillus  or  pus  cocci),  when  pain  and  fever  are  present;  it  occurs 
chiefly  in  males,  is  unilateral  and  is  usually  left-sided,  since  the  left 
vein  has  a  slower  current,  being  crossed  by  the  right  iliac  artery 
(Liebermeister).  The  symptoms  are  pain,  coldness,  oedema,  and  some- 
times a  tender,  palpable  cord,  which  should  be  manipulated  most 
carefully,  if  at  all,  lest  embolism  be  caused.  Thrombosis  usually  occurs 
in  the  saphenous  vein  where  it  empties  into  the  femoral,  sometimes 
in  the  popliteal  vein,  and  rarely  in  the  arms.  It  may  extend  from  the 
leg  to  the  cava,  when  the  other  leg  may  be  involved.  There  is  some 
danger  of  detachment,  pulmonary  embolism,  and  sudden  death;  but 
relative  recovery  is  usual  after  two  or  three  months. 

(d)  The  Blood.— The  red  blood-cells  average  4,000,000.  Their 
reduction  is  always  slow,  and  anaemia  is  especially  frequent  dur- 
ing the  third  week  or  in  relapses.  An  apparent  increase  of  the  red 
disks,  analogous  to  that  observed  in  cholera,  may  result  from  loss  of 
fluids,  as  from  diarrhoea  (Hayem).  The  hsemoglobin  decreases  pro- 
portionately to  the  red  cells,  or  slightly  in  excess  of  the  oligocytheemia, 
especially  in  convalescence.  Marked  post-febrile  ansemia  is  not  com- 
mon. The  leukocytes  decrease  from  8,000  to  3,000,  or  even  less,  but 
average  5,000  per  cubic  millimeter.  Occasionally,  large  cells  containing 
numbers  of  red  corpuscles  are  seen.  Leukopenia  is  more  common  in 
typhoid  than  in  any  other  febrile  condition  and  helps  to  differentiate 
it  from  pneumonia,  sepsis,  meningitis,  etc.  It  is  possibly  due  to  destruc- 
tion of  the  lymphatic  elements  by  the  endothelial  phagocytes.  In- 
crease of  the  white  cells  occurs  only  in  complicating  inflammations  or 
in  convalescence.  The  polymorphonuclear  neutrophiles  are  absolutely 
and  relatively  decreased  to  below  50  or  60  per  cent.,  while  they  are 
increased  in  other  infections.  The  large  mononuclear  and  transitional 
forms  are  relatively  increased.  The  eosinophiles  are  greatly  decreased; 
their  return  is  a  good  prognostic  (Tiirck). 

The  Gruher-Widal  serum  test  is  based  on  Pfeiffer's  experiments  on 
immunity  in  cholera  (1884).  Pfeiffer  and  Kolle  not  only  produced 
immunity,  but  found  that  bacteriological  inoculations  in  animals  be- 
came granular  and  gradually  dissolved.  Metschnikoff  and  Bordet 
found  the  same  reaction  in  the  test-tube  with  the  blood-serum  of  ani- 
mals. The  "agglutination"  and  "immobilization"  of  typhoid  bacilli 
brought  in  contact  with  a  typhoid  serum,  was  found  by  Durham  and 
Gruber,  and  also  independently  by  Pfeiffer  and  Kolle.  Gruber  pointed 
out  the  value  of  the  test  in  proving  the  existence  of  a  previous  typhoid, 
while  Widal  applied  the  laboratory  facts  at  the  bedside,  and  found  the 
reaction  during  the  disease.  The  agglutinating  substances  may  pass 
from  the  maternal  blood  to  that  of  the  foetus,  or  from  the  mother's  milk 
to  the  infant's  blood ;  they  may  be  obtained  from  the  serum  of  a  blister 
and  sometimes  from  the  urine,  saliva,  semen,  tears,  or  cerebrospinal  fluid. 
Technique. — A  bouillon  culture,  not  more  than  twelve  to  eighteen 


TYPHOID  FEVER  27 

hours  old,  is  used,  taking  forty  parts  of  the  bouillon  and  one  of  the 
blood  (dilution  of  1  to  40).  The  test  may  be  made  macroscopically 
in  the  test-tube,  or  on  the  microscope  slide,  where  immobilization, 
clumping, "agglutination,  and  final  solution  of  the  bacilli,  may  be 
observed,  sometimes  in  a  very  short  time — an  hour  is  the  usual  time- 
limit  for  the  test.  Ficker  and  Ruediger  have  recently  employed  dead 
cultures  with  equally  accurate  results,  and  this  method  is  certainly 
more  convenient,  safe,  and  capable  of  wider  use  than  the  use  of  living 
bacilli,  especially  in  country  practice.     (Plate  I.) 

Significance. — The  Gruber-Widal  reaction  may  be  found  thirty 
years  after  a  typhoid  attack.  Occasionally  it  is  found  in  rheumatism, 
sepsis,  miliary  tuberculosis,  meningitis,  pneumonia,  influenza,  endo- 
carditis, or  icterus,  and  it  is  sometimes  absent  in  typhoid.  While  pres- 
ent in  95  to  97  per  cent,  of  typhoid  cases,  it  often  develops  late;  e.  g., 
on  the  seventeenth  or  the  fortieth  day.  Cabot  found  the  reaction  in 
97  per  cent,  of  5,978  collected  typhoid  cases.  In  Osier's  series  it  ap- 
peared in  93  per  cent,  before  the  eighth  day.  When  it  appears  in  the 
first  week,  it  is  due  to  a  "silently  developing"  infection  (Widal);  i.  e., 
the  typhoid  is  more  advanced  than  we  appreciate.  Leube  considers 
the  test  significant  only  when  it  is  absent  in  the  early  stages  and  develops 
later,  care  being  necessary  in  all  other  cases  whether  the  reaction 
be  positive  or  negative.  The  author  has  long  since  ceased  to  exclude 
typhoid  absolutely  when  no  reaction  is  obtained,  and  he  maintains  the 
importance  of  the  classic  symptom-complex  even  without  the  serum 
reaction.  Undue  importance  is  sometimes  attached  to  this  as  well  as  to 
many  other  laboratory  tests,  invaluable  though  they  may  be  in  connec- 
tion with  the  physical  findings.  In  severe  typhoid  the  test  may  be 
absent,  when  early  cultures  (in  85  to  94  per  cent,  of  the  cases)  may 
reveal  typhoid  bacilli  in  the  blood.  Kasel  and  Mann  believe  the  re- 
action is  not  one  of  infection,  but  one  of  immunity,  agglutination 
becoming  most  marked  toward  the  end  of  the  disease. 

Typhoid  bacilli  have  been  cultivated  from  the  blood  in  a  large  per- 
centage of  cases  (even  88  and  94  per  cent.),  and  undoubtedly  are  present 
in  the  blood  of  every  case.  In  an  analysis  of  535  cases,  Rosenberger 
found  bacilli  reported  in  80  per  cent. 

5.  Nervous  Symptoms. — Typhoid  was  once  called  "nervous  fever" 
(febris  nervosa,  nervenfieber).  The  nervous  system  may  be  conspicu- 
ously involved  even  in  the  incubation  stage. 

(a)  Headache. — Headache  is  almost  invariable,  being  most  often 
frontal  or  occipital,  constricting,  throbbing,  or  a  pressure  sensation. 
It  usually  disappears  in  the  second  week,  and,  if  it  lasts  or  develops 
late,  it  may  indicate  meningitis.  Insomnia  may  be  both  early  and 
lasting.  Stupor  and  sleep  must  be  distinguished  from  one  another, 
since   a  patient   may   be   stuporous   yet   sleepless. 

(6)  The  Typhoid  State. — The  typhoid  state  begins  in  the  second 
week  (v.s.)  with  apathy  and  delirium,  which  is  usually  mild.  The 
patient  may  attempt  to  get  out  of  bed,  and,  in  alcoholics,  delirium  tre- 
mens may  be  simulated  or  actually  develop.     In  mild  cases  delirium 


28  THE  SPECIFIC  INFECTIONS 

lasts  into  the  third  week.  In  very  irritable  subjects,  as  in  women  and 
children,  or  in 'overwhelming  intoxication,  we  may  have  photophobia, 
stupor,  coma,  loud  breathing  with  an  open  mouth,  absence  of  the 
pharyngeal  reflex,  involuntaries,  waving  of  the  hands  (floctitation), 
leaping  of  the  tendons  (suhsultus  tendinum),  picking  of  the  bedclothes 
(carphologia),  trismus,  contractures,  grinding  of  the  teeth,  rigid  neck, 
and  convulsions  (in  children  especially),  which  symptoms  are  not  due 
to  the  fever,  since  they  all  may  occur  with  low  temperature,  but  to 
toxaemia.  In  cbma-vigil  the  patient  is  semi-comatose  subjectively,  but 
the  open,  unseeing  eyes  give  a  "watchful"  appearance  objectively. 
Anatomically  a  "wet-brain"  is  found.  Murchison  observed  convul- 
sions but  six  times  in  2,960  cases.  They  may  develop  in  children,  in 
severe  intoxication,  or  from  such  cerebral  complications  as  meningitis, 
encephalitis,  thrombosis,  or  embolism. 

(c)  Nervous  Complications. — Typhoid  may  begin  as  mania. 
The  author  has  seen  five  typhoid  patients  taken  to  the  detention  hos- 
pital in  the  third  week,  or  even  in  convalescence,  under  a  mistaken 
diagnosis.     It  may  be  a  later  though  generally  a  rare  symptom. 

Psychoses  are  generally  post-febrile,  are  of  the  depressive  variety 
such  as  melancholia,  and  usually  give  a  favorable  prognosis^  though 
alienists  assert  that  one-third  to  one-fifth  do  not  recover.  Edsall 
(1905)  found  that  two-thirds  of  juvenile  cases  recover.  Their  cause 
is  the  exhausting  inanition  of  protracted  toxaemia,  or  sometimes  a 
hereditary  predisposition.     Typhoid  may  cure  a  previous  insanity. 

Meningitis  is  usually  cerebrospinal  and  occurs  in  0.5  per  cent,  of  the 
cases,  mostly  in  women  and  children,  generally  as  a  complication  and 
late  in  the  typhoid  course  during  the  period  of  "steep  curves."  Men- 
ingitis may  be  due  to  the  pneumococcus,  the  pyogenic  cocci,  or  to 
Eberth's  bacilli,  which  have  been  found  on  lumbar  puncture  in  over 
twenty-six  cases  (Cole),  of  which  half  were  serous  and  half  suppura- 
tive. Mastoiditis  as  well  as  tuberculosis  may  cause  the  meningitis, 
there  being  four  recorded  cases  of  the  tuberculous  variety.  Actual 
meningitis  must  not  be  confounded  with  pseudomeningitis  or  "menin- 
gismus,"  in  which  toxaemia  produces  irritative  meningeal  symptoms, 
as  above  enumerated. 

In  the  brain,  oedema,  degenerated  and  pigmented  ganglionic  cells, 
and  nuclear  multiplication,  are  the  most  common  findings  at  the 
autopsy.  Hemorrhage,  embolism,  arterial  and  sinus  thrombosis, 
and  abscess  (sepsis),  are  rare  pathological  complications.  Aphasia, 
monoplegia,  hemiplegia,  and  paralysis  of  the  cerebral  nerves,  are  rare 
clinical  complications.  The  author  has  twice  noted  hemiplegia  devel- 
oping suddenly  in  convalescence,  probably  embolic  from  detached  heart- 
clots.  In  both  cases  the  patients  were  allowed  to  leave  the  bed  too 
soon.     Hawkins  has  noted  seventeen  cases  of  hemiplegia  in  typhoid. 

In  the  spine,  myelitis,  multiple  sclerosis,  infantile  paralysis,  and 
Landry's  paralysis  (Eberth's  bacillus),  are  the  most  common  complica- 
tions or  sequels.  The  knee-jerks  are  sometimes  increased,  especially 
in  emaciated  subjects. 


TYPHOID  FEVER  29 

Neuroses  may  complicate  convalescence,  such  as  chorea,  hysteria, 
neurasthenia,  catalepsy,  Basedow's  disease,  tetany,  paralysis  agitans, 
diabetes  insipidus. 

In  the  nerves,  neuritis  in  the  single  or  multiple  form  {q.v.)  with 
anaesthesia,  paralysis,  and  atrophy,  may  follow  typhoid  as  it  does  other 
infections.  Neuralgia  occurs  late.  In  the  feet  it  constitutes  the  "ten- 
der toes"  of  Hanford,  and  is  seemingly  increased  by  bath  treatment. 
It  always  results  in  recovery. 

6.  Special  Senses.— The  eye  is  rarely  involved.  Muscle  paralysis 
(neuritis)  and  various  inflammations — such  as  simple  or  phlyctenular 
conjunctivitis,  iritis,  panophthalmitis,  uveitis,  and  cataract — are  very 
uncommon.  In  convalescence,  mydriasis  and  paralysis  of  accommo- 
dation often  result  from  exhaustion.  Amaurosis,  either  functional  or 
lasting,  from  disk-disease,  has  been  observed,  as  well  as  retinal  hemor- 
rhages, optic  neuritis,  choked  disk,  optic  atrophy,  orbital  hemorrhage, 
and  venous  thrombosis.  Uhtoft,  in  253  cases  of  optic  neuritis,  found 
17  cases  following  typhoid. 

Involvement  of  the  ear  includes  functional  toxaemic  disturbance  of 
hearing,  abscess,  and  otitis  media  (2  to  14  per  cent.).  Otitis  is  less 
frequent  than  in  scarlatina  or  measles.  Mastoid  disease  and  menin- 
gitis are  very  exceptional. 

7.  Muscles,  Thyroid  Gland,  and  Bones. — The  muscles  anatomically 
are  dry,  of  a  smoked-meat  appearance,  and  may  be  the  seat  of  hemor- 
rhages, rupturCj  granulo-fatty  and  waxy  degenerations,  and  abscess, 
due  to  Eberth's  bacilli  and  pus  cocci.  Myositis  may  explain  some 
cases  of  muscular  tenderness  with  cramps. 

In  the  thyroid  gland,  a  strumitis  typhosa,  with  suppuration  or  re- 
gression, has  been  observed.  It  is  due  to  the  typhoid  bacillus.  Re- 
covery is  the  rule. 

Though  hone  disease  was  observed  in  237  cases  by  Keen,  it  is  much 
more  frequent  than  the  figures  indicate.  Periostitis  is  more  common 
than  bone  disease  proper.  These  complications  are  post-typhoid  and 
are  due  to  the  typhoid  bacillus  (75  per  cent.),  or  pus  cocci  (25  per  cent.). 
They  attack  the  tibia  (38  per  cent.),  the  ribs  (13  per  cent.),  femur, 
ulna,  temporal  bones,  etc.,  and  occur  chiefly  in  young  individuals. 
"Their  most  striking  features  are  chronicity,  indolence,  and  a  re- 
markable tendency  to  recurrence"  (Osier).  Osteomyelitis  may  re- 
semble syphilitic  or  tuberculous  osteopathies.  Typhoid  bacilli  have 
been  found  seven  and  ten  years  after  typhoid  in  osteomyelitic  fistulse. 
Longcope  has  found  marrow  changes  which  resemble  lymphoid  hyper- 
plasia, and  Fraenkel  isolated  typhoid  bacilli  in  the  vertebral  marrow 
in  ordinary  cases  of  typhoid. 

Arthritis  may  be  typhoid  or  gonorrhoeal,  rheumatic,  septic,  etc. 
Keen  has  noted  eighty-four  cases.  It  may  be  poly-  or  mono-articular, 
serous  or  purulent.  The  hip  is  most  frequently  affected.  The  "ty- 
phoid spine,"  of  Gibney,  is  characterized  by  pain,  tenderness,  and 
stiffness  in  the  back.  Local  trouble,  such  as  spondylitis  (six  recorded 
cases),  or  perispondylitis,  is  sometimes  found,  but  the  so-called  typhoid 


30  THE  SPECIFIC  INFECTIONS 

spine  is  often  caused  by  hysteria,  which  is  known  to  follow  various 
acute  infections.    The  prognosis  is  good. 

8.  Digestive  Tract. — The  upper  lip  is  retracted  and  bleeds  easily. 
Sordes  of  dried  saliva,  food,  and  epithelium,  are  observed  on  the  teeth 
and  gums.  Though  the  tongue  shows  nothing  absolutely  character- 
istic, Leube  and  others  attach  special  importance  to  its  appearance. 
At  first  it  is  white  on  the  dorsum,  moist,  flabby,  and  therefore  indented 
by  the  teeth,  and  its  edges  are  red.  It  may  be  moist  throughout  the 
disease.  In  the  second  week  it  becomes  dry  (from  the  fever,  lack  of 
saliva,  and  mouth-breathing),  small  and  fissured;  it  bleeds,  and  a 
brown  or  even  black  coating  replaces  the  white.  In  the  third  week 
or  later,  a  triangular  patch  clears  at  the  tip  of  the  tongue.  Typhoid 
bacilli  are  not  uncommon  on  the  tongue.  Acute  glossitis  is  a  severe 
complication.  Aphthae  are  rare,  but  may  occur  throughout  the  diges- 
tive tract. 

Angina  may  usher  in  the  disease,  or,  occurring  in  the  first  week, 
lead  to  a  wrong  diagnosis.  The  throat  is  swollen,  granular,  and  eroded. 
The  angina  is  usually  of  the  ordinary  type,  but  may  be  specific  (Wagner 
and  French),  due  to  the  typhoid  bacillus.  The  phlegmonous  type 
is  very  dangerous.  An  angina  cachectica  of  white  plaques  or  epithe- 
lium and  bacteria  is  occasionally  observed. 

Parotitis,  occurring  in  |  to  1  per  cent,  of  the  cases,  has  become  less 
frequent  since  special  care  of  the  mouth  has  lessened  infection  ascend- 
ing Steno's  duct.  It  is  usually  one-sided,  is  due  to  the  typhoid  bacillus, 
or  pyogenic  cocci,  and  is  usually  seen  on  the  fifteenth  day.  It  indicates 
a  poor  prognosis,  especially  when  due  to  metastasis,  and  may  reach 
the  skull,  meninges,  or  brain.  Two  personal  cases,  caused  by  the 
typhoid  bacillus,  recovered. 

Sfecifc  typhoid  lesions  are  rarely  observed  in  the  stomach,  although 
Leube  records  an  instance  with  hsematemesis.  Early  and  severe  epi- 
gastric pain  rather  contraindicates  typhoid.  Incipient  nausea  and 
vomiting  are  unusual,  occurring  mostly  in  women  or  children.  If 
observed  at  the  height  of  the  disease  these  symptoms  suggest  menin- 
gitis, overfeeding,  or  perforation,  and  (in  convalescence)  dietary  errors. 

Anorexia  is  observed  at  the  onset  and  during  the  fastigium,  though 
great  hunger  develops  in  convalescence. 

Ulceration  of  the  oesophagus  is  very  rare;  the  cicatrized  ulcer  may 
produce  later  stenosis  (twelve  cases  were  collected  by  J.  E.  Thomp- 
son, 1904). 

The  liver  in  the  early  stages  is  anatomically  hyperremic,  large  and 
firm;  later  its  lobular  markings  become  indistinct  from  cloudy  swell- 
ing and  fatty  change.  The  organ  is  softer,  and  Wagner's  lympho- 
mata  (and  some  focal  necrosis)  occur.  Clinically,  some  tenderness  is 
not  unusual  and  at  times  may  lead  to  an  incorrect  diagnosis  of  liver 
abscess  or  cholecystitis. 

Icterus  is  very  rare  (0.5  per  cent.),  and  its  absence  is  of  diagnostic 
value,  as  the  duodenal  catarrh  common  in  other  infections  is  usually 
absent.    Icterus  may  occur  from  gall-stones,  cholecystitis,  abscess,  and 


TYPtiOID  FEVER  31 

acute  yellow  atrophy.  The  author  has  but  once  seen  icterus  in  typhoid 
fever.  Single  liver  abscess  is  rare,  as  are  suppurative  pylephlebitis  and 
suppurative  cholangitis.  Sheldon  (1903)  noted  twelve  cases  of  multiple 
liver  abscess. 

Bernheim  maintains  that  typhoid  favors  the  formation  of  gall-stones. 
They  may  develop  months,  years,  or  decades  later. 

Cholecystitis  has  been  reported  by  Chiari  and  others;  thirty  cases 
with  perforation  are  on  record.  Tenderness,  pain,  muscular  rigidity, 
and  enlarged  gall-bladder,  are  found  in  most  cases.  Typhoid  bacilli 
are  found  in  the  gall-bladder  in  nearly  all  autopsies,  although  seldom 
having  produced  symptoms,  and  are  held  to  be  the  main  cause  of  re- 
infections. They  may  also  invade  the  bile  tracts  without  producing 
or  following  typhoid.  The  bacilli  in  the  biliary  tract  more  probably 
occur  from  hsematogenous  than  ascending  infection. 

Bretonneau  first  noted  specific  changes  in  the  intestines:  (a)  Hyper- 
cemia,  catarrh,  and  beginning  medullary  infiltration  in  the  lymphoid 
structures  during  the  first  week,  most  changes  being  observed  in  the 
lower  ileum,  whence  the  name  ileo-typhoid.  (b)  Medullary  infiltra- 
tion or  hyperplasia,  during  the  second  week,  occurring  first  in  Peyer's 
patches,  and  then  in  the  follicles.  The  patches  are  oval  and  parallel 
with  the  long  axis  of  the  gut;  they  lie  opposite  to  the  mesenteric 
attachment,  are  3  to  5  (8)  millimeters  high,  and  are  at  first  red,  then 
paler  from  compression  of  the  blood-vessels.  The  infiltration  is  hard 
or  soft.  It  may  be  uneven  and  reach  beyond  the  plaque.  The  soli- 
tary follicles,  even  to  the  sigmoid  flexure  (colotyphoid),  may  be  prin- 
cipally enlarged.  These  changes  are  not  absolutely  distinctive  of 
typhoid,  but  are  more  significant  in  adults  than  in  children,  in  whom 
they  are  frequent  in  digestive  diseases,  the  exanthemata,  and  diph- 
theria. Mallory  believes  that  the  lymphoid  swelling  is*  wholly  ex- 
plained by  the  proliferation  of  the  endothelial  cells  of  the  vessels  to 
act  as  phagocytes;  when  they  degenerate,  fibrinous  thrombi  develop. 
Medullary  infiltration  need  not  advance  to  ulceration.  Regression 
may  occur  and  the  lymph-cells  degenerate  and  disappear.  The  lym- 
phatic structures  may  then  assume  a  reticulated,  or  "shaven  beard," 
appearance,  (c)  Ulceration  occurs  in  the  third  week,  from  anaemic 
necrosis,  slough  formation,  and  exfoliation  of  small  particles.  The 
ulcers  thus  formed  by  the  typhoid  bacilli  are  usually  easily  seen  with- 
out opening  the  gut.  They  have  an  irregular,  oval  outline,  sharp, 
steep,  often  undermined  edges,  with  a  red  floor  generally  composed 
of  the  muscular  coat  and  often  extending  deeper  than  the  eschar. 
The  lower  ileum  is  most  affected  and  may  present  almost  no  normal 
surface  in  extreme  cases.  The  solitary  follicles,  both  in  the  large  and 
small  gut,  ulcerate  at  their  apices.  Baer  has  studied  the  localization 
of  the  typhoid  ulcer  and  states  that  it  may  occur  in  any  part  of  the 
digestive  tract  except  the  mouth.  The  pharynx  is  affected  in  2  per 
cent,  of  the  cases,  the  oesophagus  in  4  per  cent.,  the  stomach  in  2  per 
cent.;  97  per  cent,  of  the  ulcers  develop  in  the  small  intestine,  89  per 
cent,  in  the  ileum,  and  2  per  cent,  in  the  appendix;  33  percent,  in  the 


32  THE  SPECIFIC  INFECTIONS 

large  intestine, — and  there  only,  in  6  per  cent,  {d)  Cicatrization  occurs 
by  formation  of  granulation  tissue  and  growth  inward  of  the  epithe- 
lium. The  patch  is  depressed  and  slightly  pigmented.  The  typhoid 
cicatrix  does  not  narrow  the  intestinal  lumen. 

There  may  be  few  or  no  anatomical  changes  in  the  intestine.  This 
is^  analogous  to  diphtheria  without  membrane,  and  the  exanthemata 
without  eruption.  Slight  bowel  lesions  are  usually  present  in  most 
of  the  cases  reported  "without  intestinal  lesions." 

The  mesenteric  glands  are  swollen,  contain  typhoid  bacilli,  are  al- 
tered like  the  intestinal  lymphatics,  and  may  be  palpable.  The  swell- 
ing occurs  mostly  in  the  second  week.  The  swollen  glands  may 
regress,  soften,  become  tuberculous,  or  suppurate,  sometimes  causing 
peritonitis,  or  simulating  perforation,  as  in  a  case  of  the  author's. 
Only  six  cases  are  recorded  of  suppuration  in  the  mesenteric  glands; 
Le  Conte  reports  a  recovery  after  operation.  Other  lymph-glands 
may  be  similarly  involved. 

No  parallelism  exists  between  the  frequency,  constancy,  or  severity, 
of  the  clinical  symptoms,  and  the  degree  of  anatomical  involvement; 
e.  g.,  in  ambulant  cases  there  may  be  perforation  or  hemorrhage,  or 
typical  lethal  cases  may  occur  without  intestinal  change. 

Meteorism  is  rather  less  common  than  usually  described.  It  occurs 
mostly  in  the  duodenum  or  jejunum  above  the  ulceration,  or  some- 
times involves  the  colon.  It  is  less  frequent  and  less  intense  with 
early  treatment  and  careful  dieting.  If  much  tympany  develops  under 
these  circumstances,  the  prognosis  is  poor,  since  meteorism  is  due  to 
toxsemic  paresis  of  the  intestinal  musculature  rather  than  to  local 
ulceration,  catarrh,  or  serous  infiltration.  The  heart  and  lungs  may 
be  crowded  upward  and  dyspnoea  result.  It  may  occur  with  hemor- 
rhage or  perforation. 

A  thickened  ileum  may  be  palpated.  Abdominal  tenderness  and 
pain  occurred  in  60  per  cent,  of  Osier's  series,  where  particular  atten- 
tion was  paid  to  these  points.  They  are  due  to :  (a)  local  bowel  con- 
ditions, as  gas,  constipation,  inflammation  in  the  ileocecal  region,  or 
perforative  and  peritonitic  complications;  (b)  to  splenic  or  hepatic 
tumefactions;  (c)  pleurisy,  distended  bladder,  phlebitis,  etc.;  (d) 
muscle  changes  or  cutaneous  hyperaesthesia,  so  frequently  observed 
in  fever  of  any  variety. 

Typhoid  appendicitis  may  simulate  ordinary  appendicitis,  which  is 
differentiated  only  by  the  blood -count,  sero-reaction,  or,  most  surely, 
by  the  clinical  evolution;  e.  g.,  the  fever  spots,  etc.,  when  due  to 
typhoid,  precede  local  pain  and  tenderness.  Gurgling  has  no  diag- 
nostic value  whatever  in  typhoid,  although  it  occurs  in  most  cases. 

The  stools  present  no  pathognomonic  chemical  nor  physical  char- 
acteristics other  than  the  bacillus  typhosus,  which  is  often  absent 
during  the  first  week,  and  also  in  the  later  course.  The  dejecta  are 
thin,  offensive,  pea-soup-like,  alkaline,  and  resemble  the  contents  of 
the  small  intestine  (Addison).  Because  the  f feces  are  poor  in  mucus, 
two  layers  form  on  standing,  an  upper  cloudy,  and  a  lower,  yellow- 


TYPHOID  FEVER 


33 


gray,  granular  and  flocciilent  layer.  The  solids  are  4  per  cent.  The 
stools  contain  red  corpuscles  and  triple  phosphates,  the  latter  more 
abundantly  than  in  any  other  disease.  Shreds  or  sloughs  may  also 
be  found. 

Diarrhoea  in  the  febrile  stage  occurs  in  25  to  33  per  cent,  of  the 
cases,  although  some  state  that  it  is  observed  in  most  patients.  Three 
to  six  stools  are  the  average.  If  this  is  exceeded,  the  type  of  the 
disease  is  severe;  prodromal  diarrhoea  rarely  occurs.  Diarrhoea  is  a 
measure  of  the  degree  of  toxaemia  or  of  colonic  involvement,  and  is 
not  a  result  of  ulceration  of  the  small  intestine. 

Hemorrhage  is  seen  in  4  to  6  per  cent,  of  the  cases.  In  point  of 
time  it  is  usually  late,  though  some  assert  that  in  30  per  cent,  it  occurs 
in  the  first  two  weeks.  It  is  less  frequent  in  relapses  and  in  children 
(1  per  cent.).  Ulceration  into  the  muscularis  is  its  chief  cause.  Ooz- 
ing, from  simple  hypersemia,  bleeding  in  the  hemorrhagic  forms  (blood 
dissolution),  and  in  patients  inheriting  the  bleeding  tendency,  are 
exceptional.  Bleeding  is  more  common  in  ambulatory,  delirious,  and 
carelessly  fed  patients.  There  may  be  no  symptoms  if  the  hemorrhage 
is  small  (occult  hemorrhage);  but  if  it  be  large,  acute  anaemia  sud- 
denly develops,  with  collapse,  which  is  evidenced  by  a  fast  pulse, 
lowered  temperature,  and  pallid  skin.    The  intellect  often  clears,  the 

Fig.  4. 


?U  .£E 

TEMP. 

104 

A 

A 

1S« 

103 

aAI 

'vV\/\ 

\ 

/\ 

110 

102 

/v 

\ 

• 

\ 

\ 

'-        -> 

(^^ 

100 

101 

x-'N 

V- 

A// 

^    --.--' 

90 

100 

'^^-''      N 

^. 

A    A 

A 

80 

99 

vv 

\n 

/ 

TO 

\ 

y 

2ND  WEEK 

FOL 

R  COPIOUS 
HAEMORRHAGE 

STC 
S                        TR 

lOLS  WITHOUT 
CES  OF  BLOOD 

Typhoid-fever  curve,  with  fall  of  temperature  (solid  line)  after  hemorrhage  and  rise  of  pulse 
(broken  line).     Note  crossing  of  curves  at  A. 

spleen  becomes  smaller,  and  fresh  blood,  or,  later,  black,  tar-like  move- 
ments, are  voided  (manifest  hemorrhage).  The  abdomen  is  often 
distended.  There  may  be  dulness  on  percussion  from  blood  retained 
in  the  bowel,  if  the  peristalsis  is  weak  and  the  hemorrhage  is  very 
profuse.  In  two  rapidly  fatal  cases  the  entire  abdomen  became  flat 
and  one  and  two  pints  of  blood  were  vomited.  Confusion  with  bleed- 
ing piles  and  bismuth  stools  is  possible.  The  average  number  of 
hemorrhages  is  four. 

Some  patients  improve  at  once  after  hemorrhage,  as  was  remarked 


34  THE  SPECIFIC  IXFECTIOXS 

at  an  early  date  by  Graves  and  Trousseau;  yet  20  to  50  percent,  die. 
Laro'e  blood-clots  are  ominous,  indicatino^  erosion  of  a  larcre  arterv. 
Hemorrhage  may  cause  death  within  an  hour  (Trousseau,  Leymarie). 
Perforation  occurs  mostly  at  the  time  of  eschar-formation,  at  the 
end  of  the  second,  or  in  the  third  week;  but  it  may  also  occur  later, — 
in  the  third  to  fourth  week  (50  per  cent.,  Fitz);  or  from  the  third  to 
the  fifth  week  (Leube).  Scott  found  that  92  per  cent,  occurred  be- 
tween the  second  and  fifth  weeks.  It  develops  in  9  to  12  per  cent,  of 
fatal  cases  and  in  3  per  cent,  of  all  cases,  but  it  very  rarely  occurs  in 
children.  Scott's  figures,  including  9,713  English  and  American  cases, 
show  perforation  in  one-third  of  all  fatal  cases.  Perforation  is  usually 
low  in  the  ileum  (81  per  cent.) ;  or  in  the  colon  or  sigmoid  (12  per  cent.) ; 
in  the  appendix  (3  per  cent.);  in  Meckel's  diverticulum  (2.4  per  cent.); 
or  in  the  jejunum  (1.2  per  cent.).  The  percentages  are  from  Fitz's 
figures.  In  S3  per  cent,  of  the  cases  but  one  perforation  is  found, 
though  several  may  occur,  twenty-five  being  once  observed  in  one 
patient.  It  is  promoted  primarily  by  deep  ulceration,  and  secondarily 
by  severe  infections,  movement,  strains,  coughing,  constipation,  gas, 
or  solid  diet,  which  increases  peristalsis.  It  is  claimed  that  75  per 
cent,  of  the  cases  of  perforation  occur  in  severe  infections.  Three  ' 
types  are  encountered:  (1)  Least  frequently,  undiscovered  latent  per- 
foration; the  typhoid  state  masks  the  perforation,  which  affords  an 
unpleasant  postmortem  surprise.  (2)  More  frequently,  cases  with 
gradual  onset,  and  therefore  ambiguous  symptoms.  (3)  Most  fre- 
quently, cases  with  sudden  symptoms  and  more  or  less  clear  diag- 
nosis. The  symptoms  of  perforation  are:  (a)  Pain  (in  75  per  cent, 
of  the  cases)  due  to  the  perforation  itself,  usually  localized  in  the 
hvpogastrium  or  right  lower  quadrant  of  the  abdomen  and  followed 
later  by  the  pains  of  peritonitis.  In  70  per  cent.,  the  pain  was  sudden 
and  severe;  in  20  per  cent.,  gradual  in  onset. ;  and  in  10  per  cent,  it  was 
absent,  (b)  Tenderness  on  palpation  (75  per  cent.),  evidenced  by 
the  board-like  rigidity  of  the  abdominal  muscles,  (c)  Limitation  of 
the  respiratory  movements  of  the  abdomen,  due  to  pain  and  tender- 
ness, id]  A'omiting  of  gastric  contents  or  fa?cal  matter,  (e)  Intestinal 
obstruction.  (/)  Abdominal  distention,  appearing  possibly  for  the 
first  time — in  which  event  its  .significance  is  enhanced — or  increasing, 
if  already  present.  There  are  cases  in  which  the  abdomen  is  flat  or 
even  retracted;  in  one  typhoid  patient,  seen  first  in  a  dying  condition, 
the  scaphoid  abdomen  contained  three  pints  of  pus.  Abdominal  dis- 
tention crowds  upward  the  diaphragm,  heart,  and  lungs,  and  causes 
hurried  breathing,  (cf)  Disappearance  of  the  flatness  of  the  liver  by 
reason  of  free  gas  in  the  peritoneum.  This  is  most  significant  if  the 
abdomen  was  not  previously  distended.  Perihepatic  adliesions  natur- 
ally prevent  obliteration  of  the  liver  dulness,  and  it  must  always  be 
remembered  that  a  gas-distended  colon  may  overlie  the  liver;  and 
that  in  some  cases  the  colon  normally  overlaps  the  liver,  (h)  Other 
occasional  abdominal  findings  are  flatness  in  the  flanks,  caused  by 
fluid;    the  Beattv-Bright  friction-rub;    absence  of  paristalsis;    rectal 


TYPHOID  FEVER  35 

or  vesical  pain  or  tenderness,  {i)  Marked  leukocytosis  is  not  always 
found,  and  special  emphasis  on  its  absence  is  most  misleading,  as 
the  leukocytes  are  occasionally  decreased,  {j)  Sudden  fall  of  tempera- 
ture, rapid  rise  in  pulse-rate,  and  other  signs  of  shock,  may  occur  at  the 
time  of  perforation,  though  less  frequently  than  the  usual  descrip- 
tions indicate.  The  writer  has  seen  cases  in  which  the  pulse-rate  did 
not  increase.  Dieulafoy  mentions  a  case,  successfully  operated  for 
perforation,  in  which  two  later  perforations  resulted  fatally.  The 
sudden  clearing  of  the  patient's  intellect  may  deceive  the  inexperienced 
physician.  In  the  advancing  generalized  peritonitis,  the  fever,  if  it 
has  fallen,  rises;  the  pulse  becomes  rapid,  small,  and  thready;  the 
skin  clammy  and  dusky,  and  the  features  pinched  (facies  Hippocra- 
tica).  Hiccough  is  common.  The  peritonitis  rarely  remains  local.  In 
six  of  the  author's  cases,  the  local  abscess  was  ruptured  later.  Ninety- 
eight  per  cent,  of  the  unoperated  cases  die. 

Peritonitis  occurs  frequently  in  ambulatory  cases,  from  rupture  of 
the  bowel,  gall-bladder,  spleen,  lymph-glands;  occasionally  from  post- 
typhoid appendicitis  or  without  rupture  of  any  organ  or  tissue.  It 
is  found  in  2  per  cent,  of  fatal  cases. 

9.  The  Respiratory  Tract. — This  is  the  seat  of  frequent  and  mani- 
fold symptoms  and  complications. 

(a)  The  Nose. —  The  nose  is  dry.  Epistaxis  occurs  in  7  to  20  per  cent, 
of  the  cases,  usually  early,  and  in  young  subjects;  it  is  often  profuse, 
sometimes  dangerous,  but  rarely  lethal.  Croup  and  diphtheria  are 
rare;  coryza  is  very  rare.  The  author  has  seen  two  cases  begin  with 
profuse  coryza. 

(b)  Larynx. — Catarrh  is  common.  Decubitus,  with  erosions  of  the 
swollen  hyperplastic  lymph-follicles  (like  the  intestinal  changes),  occur 
in  the  posterior  wall,  followed  often  by  oedema  glottitis.  These  bed- 
sores are  seen  at  the  height  of  the  fever;  occur  rarely  in  children;  and 
are  found  in  5  to  20  per  cent,  of  the  lethal  cases.  Perichondritis  and 
necrosis  are  attended  by  pain,  aphonia,  stenosis,  mediastinitis,  cervical 
cellulitis,  and  diffuse  emphysema.  Tracheotomy  may  be  indicated. 
The  author  has  seen  but  three  cases  of  perichondritis.  Dupuy  (1903) 
collected  255  cases  of  perichondritis  and  submucous  laryngitis,  and 
believes  they  explain  3  to  10  per  cent,  of  typhoid  fatalities.  Without 
operation,  the  mortality  is  98  per  cent.  I^aryngeal  neuritis,  with  cord 
paralysis,  follows  typhoid  in  25  per  cent,  of  the  cases. 

(c)  Air  Tubes. — A  dry  catarrh  of  the  trachea  and  bronchi  is  al- 
most invariable,  while  w/cera^io^i  (in  one-third  of  1  per  cent.)  or  fibrinous 
inflammation  is  rare.  Rales,  retrosternal  dryness,  rawness,  and  pain, 
are  present  in  the  bronchitis  of  typhoid.  At  autopsy  the  bronchial 
glands  are  often  swollen,  and  Eberth's  bacillus  is  sometimes  found. 
Bronchiolitis  is  regular  and  specific.  It  is  found  everywhere  in  the 
lungs,  but  especially  in  the  lower  lobes,  and  (rarely)  wholly  above  and 
in  front.  Coughing  is  not  invariable  but  its  presence  in  early  typhoid 
is  of  value  in  differentiation  from  simple  intestinal  catarrh.  The  out- 
look is  less  favorable  when  severe  and  early  coughing  occurs,  j 


36  THE  SPECIFIC  INFECTIONS 

(d)  Lungs. — Hypostasis,  from  a  dorsal  decubitus  and  weak  heart, 
is  often  relieved  by  change  of  posture.  It  is  very  common,  and  occurs 
in  the  first  half  of  the  disease,  or  at  its  height,  mostly  in  weak  adults 
and  in  cases  of  severe  infection.  Lesser  degrees  of  hypostasis  may  be 
overlooked.  The  percussion-note  is  tympanitic  or  dull.  The  fremitus 
is  increased,  if  the  patient  can  talk,  or  decreased  from  stagnation  of 
secretions.  The  breathing,  and  especially  the  expiration,  is  distant 
(or  sometimes  bronchial).  Rales,  moist,  crepitant,  and  subcrepitant, 
are  heard. 

Lobar  pneumonia  may,  in  rare  instances,  dominate  the  early  clinical 
picture  (pneumo-typhoid)  and  may  be  of  two  types.  The  first  type, 
(a),  is  due  to  Eberth's  bacillus.  The  course  is  that  of  an  initial  pneu- 
monia, which  does  not  end  t}^ically,  but  shows  later  a  typhoid  tem- 
perature, rose  spots,  Widal  reaction,  etc.  These  cases  are  naturally 
confusing,  especially  in  their  incipiency,  and  the  typhoid  is  more  apt 
to  be  overlooked  than  in  the  next  type,  (6)  in  which  the  pneumonia, 
usually  seen  at  the  height  (third  week)  of  the  disease,  is  a  true  com- 
plication, due  to  the  pneumococcus,  though  sometimes  due  to  the 
colon  bacillus  and  streptococcus,  especially  in  sepsis.  The  pneumonic 
symptoms  are  variable,  atypical  (as  in  most  secondary  pneumonias), 
often  without  chill,  mth  a  slower  course,  and  often  with  lysis,  or,  less 
often,  with  such  complications  as  abscess  or  gangrene.  More  than  one- 
half  of  these  cases  die.  Lobular  pneumonia,  from  inhalation,  pus- 
cocci,  and  Eberth's  bacillus,  is  a  true  complication.  Abscess  follows 
pneumonia  or  sepsis;  it  occurs  in  0.7  per  cent,  of  the  fatal  cases. 
Infarct  occurs  in  6  per  cent,  of  typhoid  fatalities.  Marantic  thrombi 
from  the  leg  may  reach  the  lungs  by  way  of  the  right  heart.  This  is 
indicated  by  haemoptysis,  chill,  temperature,  pain,  etc.  Gangrene  (1  to 
2  per  cent,  of  typhoid  autopsies)  occurs  more  often  than  abscess,  is 
seen  late  in  the  disease,  and  is  usually  metapneumonic,  but  may  be 
caused  by  perichondritis  or  aspiration  of  food. 

(e)  Pleura. — Serofibrinous  pleurisy  is  usually  rare  unless  the  lungs 
are  diseased.  Sears  observed  18  cases  in  1,065  typhoid  patients,  and 
Leube  has  seen  several  with  pleural  friction.  Postmortem  statistics 
show  it  in  6  to  8  per  cent.  It  is  most  common  as  empyema  in  conval- 
escence, and  is  due  oftenest  to  Eberth's  bacillus.  In  1903,  fifty-five  cases 
of  pleurisy  were  collected  in  which  the  typhoid  bacillus  was  found. 
Pneumothorax  and  hcemoptysis  are  very  uncommon. 

(/)  Tuberculosis. — Old  latent  tuberculosis  may  be  aroused,  usually 
late  in  the  disease.  It  is  associated  sometimes  vnth.  pneumococcus 
infection.  Other  forms,  such  as  acute  caseous  piieumonia,  subacute 
tuberculous  peribronchitis  with  a  few  bacilli,  fever,  emphysema  and 
aggravation  of  the  bronchial  symptoms,  and  occasionally  miliary  tuber- 
culosis, may  occur. 

10.  Genito-Urinary  Tract. — The  following  conditions  may  be  found : 
(a)  The  urine  is  febrile;  as  water  is  retained  in  fever,  the  urine 
becomes  decreased,  acid,  concentrated,  with  a  specific  gravity  of  1,030 
or  more.     Uric  acid,  urea,  and  toxins,  are  increased ;  the  chlorides,  de- 


TYPHOID  FEVER  37 

creased.  Typhoid  bacilli  are  present  in  25  to  50  per  cent,  of  the  cases, 
or  even  80  per  cent.,  according  to  other  statistics.  The  bacilli  may  give 
the  urine  a  glistening  appearance.  Bacilli  may  persist  from  four 
months  to  several  years  after  recovery.  In  convalescence,  the  urine 
is  increased,  is  neutral  in  reaction,  and  has  a  lower  specific  gravity. 
Sometimes  polyuria  may  occur  during  the  fever.  (6)  Serum  albumin, 
globulin,  and  rarely  peptones,  are  found  in  febrile  albuminuria.  Serum 
albumin  is  found,  in  quantities  varying  from  traces  to  considerable 
amounts,  in  15  to  20  per  cent. of  the  cases;  cylindruria  is  approximately 
half  as  frequent.  The  prognosis  is  three  times  as  unfavorable  when 
albumin  is  found.  It  appears  from  the  seventh  to  the  tenth  day,  is 
frequent  in  the  third  week,  and  its  average  duration  is  twelve  days. 
It  corresponds  anatomically  to  parenchymatous  and  fatty  degenera- 
tion of  the  kidneys,  (c)  Nephritis  in  typhoid  is  of  the  acute  par- 
enchymatous type,  with  the  interstitium  of  the  organ  but  little  involved. 
It  is  often  hemorrhagic,  and  occurs  usually  in  the  first  three  weeks 
but  occasionally  in  convalescence.  It  is  found  in  1  per  cent,  of  the 
cases,  mostly  in  men,  rarely  in  children.  Nephritis  makes  the  prog- 
nosis less  favorable,  as  it  indicates  a  more  severe  infection,  from 
which  50  per  cent,  of  the  cases  die.  Uraemia  and  suppression  of  urine 
are  rare.  If  not  fatal,  nephritis  usually  clears  up  entirely  and  rarely 
remains  in  chronic  form.  Early  and  marked  renal  symptoms  con- 
stitute the  nephrotyphoid  of  French  writers.  Sepsis  may  produce 
septic  nephritis  and  abscesses.  Miliary  typhoid  abscesses  in  the  kid- 
ney may  keep  up  the  bacilluria.  Lymph-nodes  are  found  in  some 
cases,  as  in  the  liver  (Wagner),  (d)  The  urine  of  typhoid  exhibits 
the  diazo  reaction  of  Ehrlich  (1882).  Two  standard  solutions  are 
kept  in  separate  bottles:  No.  1 — a  5-per-cent.  solution  of  hydro- 
chloric acid  saturated  with  sulphanilic  acid,  which  should  be  fresh; 
No.  2 — ^one-half-of-1-per-cent.  solution  of  sodium  nitrite.  To  make  the 
test,  forty  parts  of  No.  1  and  one  part  of  No.  2  are  mixed,  producing 
diazo-benzine-sulphonic  acid.  Equal  parts  of  this  mixed  solution  and 
urine  are  thoroughly  shaken;  one  part  of  ammonium  hydrate  is  then 
allowed  to  flow  carefully  down  the  side  of  the  tube  to  stand  above  the 
urine  mixture.  At  the  junction  of  the  two  fluids,  a  dark  garnet  or 
cherry-red  ring  will  form  in  typhoid  urine,  and  in  normal  urine  only 
a  brown  ring.  The  pink  color  of  positive  tests  is  also  imparted  to 
the  foam  on  shaking,  or  in  marked  dilutions  gives  a  rose-red  hue. 
Osier  found  it  in  69  per  cent.  The  author  has  found  it  in  98  per  cent, 
of  his  cases.  It  occurs  in  the  early  stages  of  the  disease,  also  at  the 
acme  and  during  relapses.  It  is  a  valuable  sign,  though  of  secondary 
rank.  Since  it  is  found  in  numerous  other  acute  and  chronic  condi- 
tions, it  has  no  differential  or  pathognomonic  value.  Its  absence,  to- 
gether with  the  absence  of  other  findings,  contraindicates  a  florid 
typhoid,  (e)  Cystitis  and  pyelitis  occur  during  the  disease  or  in 
convalescence,  and  are  due  chiefly  to  pus  organisms,  or  typhoid  or 
colon  bacilli.  Simple  retention  of  urine  is  not  uncommon.  Uro- 
bilinuria  (Tissier)  and  indicanuria  occur,  but  neither  is  proportion- 


38  THE  SPECIFIC  INFECTIONS 

ate  to  the  seventy  of  the  disease.  Hoemoglohinuria  is  quite  rare,  (/) 
The  genitalia  are  more  often  impHcated  in  women  than  in  men.  Men- 
struation is  disturbed.  It  often  appears  early  in  the  onset  of  typhoid, 
and  is  suppressed  in  60  per  cent,  of  the  cases.  In  some  instances 
haematocele  or  hsematometra  may  develop.  Endometritis,  either  croup- 
ous or  diphtheritic,  vaginal  erosions,  ulcers,  inflammation,  or  gangrene 
and  mastitis,  are  rare  complications.  Pregnancy  is  of  grave  import, 
the  outlook  being  worse  in  its  later  stages  than  in  the  earlier  (e.  g., 
eight  to  ten  weeks).  It  is  most  dangerous  at  the  acme  of  the  fever, 
abortion  and  premature  delivery  being  very  frequent  (65  per  cent, 
of  the  cases).  The  maternal  mortality  is  increased  at  least  twofold. 
Blumer  and  Dobbin  have  reported  puerperal  infection  from  the  typhoid 
bacillus.  Orchitis  usually  develops  late,  or  in  convalescence.  It  occurs 
with  chills  and  fever.  The  patient  almost  always  recovers  in  ten  to 
fourteen  days,  although  suppuration  and  atrophy  have  occurred — • 
fifty-three  cases  were  collated  by  Kinnicutt.  It  is  frequently  associated 
with  urethritis.  Emissions  are  common  in  convalescence. 

Anomalous  Courses. — According  to  Curschmann,  the  following 
anomalous  courses  are  distinguished: 

1.  Malignant. — The  malignant,  hyperpyretic  or  foudroyant  form  is 
rare.  It  is  severe  even  in  the  earliest  stages.  The  temperature  rises 
rapidly  and  there  may  be  hyperpyrexia.  The  pulse  is  soft,  weak,  and 
rapid.  The  status  typhosus  is  profound.  Meteorism,  diarrhoea,  and  al- 
buminuria, are  present,  and  death  from  deep  intoxication  usually  occurs. 

2.  The  Slow  Severe  Form.^ — The  sloiu  severe  form  lasts  from  four 
weeks  to  four  months.  The  fever  is  often  remittent  wdth  frequent 
exacerbations.  Defervescence  may  occur  or  death  intervene,  mar- 
asmus alone  being  found  at  autopsy.  The  severe  types  of  typhoid 
have  grown  rarer,  even  during  the  last  decade. 

3.  Typhus  Abortivus. —  Typhus  levissimus,  typhulus,  typhoidette  of 
Brouardel,  exhibits  a  short  and  mild  course,  temperature  with  a 
short  initial  stage,  or  often  a  crisis,  lasting  six  to  twenty  days.  Bron- 
chitis is  frequent,  the  spleen  enlargement  is  constant,  and  meteorism, 
diarrhoea,  roseolse,  hemorrhage,  or  perforation,  are  rare.  Relapses  are, 
however,  more  frequent. 

4.  Typhus  ambulatorius  (of  the  German,  or  latent  typhoid  of  French 
writers — walking  typhoid),  occurs  in  adults,  especially  in  men,  who 
often  endure  it  by  the  help  of  alcohol.  Some  malaise  may  exist.  There 
are  two  types:  (a)  the  lighter  and  atypical,  and  (b)  the  usual  course, 
very  often  ending  in  hemorrhage,  perforation,  etc.  The  temperature  is 
often  not  marked,  but  is  usually  less  at  night  than  during  the  diurnal 
activity.  The  pulse  is  faster  because  of  exertion.  The  spleen  is  often 
enlarged,  and  the  roseolte  are  frequent. 

5.  Typhus  afebrilis  (Liebermeister  and  Gerhardt)  is  most  often  met 
with  in  family  practice.  It  may  assume  the  ambulatory  form;  and 
is  diagnosticated  by  exclusion  and  by  the  pulse,  spleen,  roseolfe,  diazo 
reaction,  Widal  test,  etc.  Atypical  cases  have  apparently  increased 
ir  recent  years. 


TYPHOID  FEVER  39 

6.  The  hemorrhagic  form  is  characterized  by  nasal,  subcutaneous, 
and  particularly  intestinal  hemorrhage,  constituting  the  blood  dissolu- 
tion of  the  older  writers.  It  occurs  especially  in  children  and  alco- 
holics, and  constitutes  less  than  one-tenth  of  1  per  cent,  of  typhoid 
cases.  The  prognosis  is  usually  but  not  invariably  bad.  The  four 
cases  which  the  author  has  seen  occurred  in  1900,  in  St.  Luke's  Hos- 
pital, where  a  severe  house-epidemic  prevailed. 

7.  Visceral  Forms. — The  so-called  visceral  forms  should  seldom  cause 
confusion,  if  watched  with  care.  They  include  the  gastric  or  bilious 
types,  nervous  fever,  meningo-typhoid,  cerebro-typhoid  (mania,  psy- 
choses), laryngo-  or  tonsillo-typhoid,  nephro-typhoid,  pneumo-typhoid 
with  pneumococcus  mixed  infection  or  Eberth's  bacillus,  (Lepine, 
Chantemesse,  Widal,)  which  is  pneumo-typhoid  in  the  narrowest 
sense. 

8.  In  children  but  few  cases  occur  in  hospitals.  The  temperature 
course  is  shorter  and  milder  than  in  adults.  The  younger  the  patient, 
the  less  is  the  degree  of  fever.  It  may  begin  with  a  chill.  It  is  often 
remittent,  the  "infantile  remittent  fever"  of  Abercrombie  being  really 
typhoid.  Epistaxis  is  less  common.  The  pulse  in  children  is  faster, 
and  more  often  irregular,  than  in  adults;  though  after  the  twelfth  (fifth, 
Filatow)  year,  it  is  equally  slow.  A  weak  and  irregular  pulse  is  very 
rare,  and  a  fast,  irregular  pulse  generally  indicates  meningitis.  Opin- 
ions differ  as  to  the  frequency  of  roseolse;  they  vary  with  the  epidemic, 
but  it  is  probable  that  they  occur  as  often  in  children  as  in  adults.  They 
may  be  fewer  and  may  appear  later,  but  in  some  cases  are  abundant 
and  confluent  (in  children  between  the  fifth  and  tenth  year).  Bed- 
sores are  very  rare,  but  noma  is  more  frequent  than  in  adults.  The 
nervous  system  is  generally  less  frequently  involved  in  children,  though 
if  the  infection  is  severe,  convulsions,  irregular  pupils,  rigidity  of  the 
neck,headache,etc.,  may  occur.  (See Typhoid  State.)  Neuralgias  and 
psychoses  are  rare.  The  frequency  of  aphasia  has  not  yet  been  ex- 
plained. Bronchitis  occurs  as  often  as  in  adults,  but  atelectasis, 
hypostasis,  and  lobular  pneumonia  are  more  frequent.  Children  exhibit 
less  meteorism  and  hemorrhage  (1  percent.),  and  much  less  frequent 
perforation.  There  are  fewer  anatomical  changes.  Splenic  enlarge- 
ment is  less  frequently  palpable  (in  50  percent.),  and  occurs  somewhat 
later.  Initial  vomiting,  pain,  and  perhaps  diarrhoea,  are  more  frequent. 
Alljuminuria  and  nephritis  are  relatively  rare.  GriflBth  and  Ostheimer 
have  assembled  394  cases  in  children,  of  which  325  are  beyond  doubt. 
Of  these,  139  occurred  under  one  year,  187  in  the  second,  and  G8 
between  two  and  two  and  one-half  years.  The  mortality  under  one 
year  {v.  i.)  was  73  per  cent.,  and  of  the  entire  group,  50  per  cent.  Ty- 
phoid is  rare  in  the  first  two  years  of  life.  It  is  sometimes  overlooked, 
being  very  atypical.  The  course  is  short.  Bronchitis,  splenic  tumor, 
and  roseolffi,  are  infrequent.  If  the  disease  is  severe,  a  very  high  tem- 
perature, meningeal  symptoms,  and  initial  vomiting  occur,  and  also 
50  per  cent,  mortality  caused  by  toxtemia,  pneumonia,  perforation,  or 
ulceration  of  the  larynx. 


40 


THE  SPECIFIC  INFECTIONS 


9.  In  the  aged  typhoid  is  infrequent,  especially  after  the  fortieth 
year.  In  such  cases  the  fever  is  lower,  atypical,  and  often  absent. 
The  pulse  is  faster,  irregular,  and  without  dicrotism.  There  is  greater 
lung  congestion  owing  to  weakness  of  the  right  heart,  and  lung  com- 
plications are  more  frequent.  The  nervous  symptoms  are  dominant, 
often  occurring  with  great  depression.  Roseolse  are  fewer  and  bed- 
sores are  more  frequent.  The  spleen  is  much  less  often  enlarged 
because  of  old  infarcts,  induration,  and  a  thicker  capsule.  Tympany 
and  hemorrhage  occur  more  often.  Convalescence  is  naturally  slower. 
In  1903,  the  author  had  under  his  care,  in  Wesley  Hospital,  a  woman, 
aged  fifty-seven,  and  her  mother,  aged  seventy-two,  both  with  typhoid, 
ending  in  recovery. 

Relapses  and  Exacerbations. — Relapses  and  exacerbations  differ 
in  degree  only.  Their  explanation  is  still  obscure,  reinfection  from  the 
gall-bladder,  spleen,  glands,  and  the  bones,  having  been  advanced  as 
causes.  In  the  complete  relapse  the  temperature  falls  to  normal,  or 
nearly  to  normal,  for  five  days  on  the  average,  and  then  fever  and  other 
signs  of  typhoid  reappear.  It  occurs  in  6  to  12  per  cent,  of  the  cases, 
and  vary  with  the  epidemic,  sometimes  occurring  in  as  many  as  35 
per  cent.  Relapses  are  more  common  in  young  (in  one-sixth  of 
Henoch's  cases)  than  in  old  subjects.  They  are  more  likely  to  occur 
(a)  in  light  or  moderately  severe  cases  (75  percent.)  than  in  severe  ones 
(25  percent.);  (6)  when  the  splenic  tumor  does  not  disappear  (Ger- 
hardt;  (here  the  question  may,  of  course,  arise  whether  or  not  the 
spleen  was  enlarged  from  some  previous  disease,  such  as  malaria;)  (c) 
when  the  temperature  in  convalescence  does  not  become  subnormal 
(Curschmann);  or  {d)  when  the  pulse  is  variable  and  rapid  while  the 
patient  is  quiet  (Curschmann). 

Pig.  5. 


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Showing  remission,  exacerbation,  lysis,  and  relapse. 


After  an  average  defervescence  of  five  days,  the  fever  runs  the  same 
course  as  in  the  first  attack,  though  it  is  shorter  by  ten  days  (INIurchi- 
son).  The  pulse:  is  faster  (110  to  130  in  women,  children,  and  weak 
men),  labile,  and  less  dicrotic.  There  are  less  roseolse  (absent  in  27 
per  cent.),    nervous    symptoms,    respiratory    symptoms,    hemorrhage 


PLATE  I. 


Bouillon  Culture  of  Typhoid  Bacilli  before  the  Addition  of  Diluted 
Typhoid  Serum.     ><  SOO.     (  After  Cabot.)     Serum  diagnosis. 


FIG.    2. 


The  Same,  Five  Minutes  after  the  Addition  of  Typhoid  Serum  (dilution 
1  to  lO),  showmg  Typical  Clump  Reaction.     X  400.     (Cabot. ) 


TYPHOID  FEVER  41 

(4  per  cent.),  and  perforation  (0.7  per  cent.),  whence,  as  a  rule,  the 
prognosis  is  relatively  good.  The  duration  of  the  relapse  is  six  to  fifteen 
(even  twenty-one  days),  and  there  are  seldom  more  than  two,^ — three  or 
four  being  very  rare.  The  author  has  seen  five  relapses,  covering,  with 
the  original  attack,  as  many  months.  It  is  said  that  they  may  be  afeb- 
rile, with  a  return  of  the  roseolse,  spleen,  etc.  Relapses  should  not  be 
confused  with  Biermer's  "after  fever,"  due  to  inanition  or  possible 
sepsis.  Recrudescences  are  renewals  of  the  fever  after  it  has  lessened, 
but  not  entirely  subsided.  In  50  per  cent,  of  the  cases  recrudescence 
is  followed  by  more  severe  symptoms. 

Convalescence.^ — Convalescence  requires  fourteen  to  twenty-one 
days,  but  its  duration  is  variable,  and  it  is  not  certainly  established  till 
subnormal  temperature,  at  least  in  moderate  or  severe  infections,  is 
observed.  The  pulse  tends  to  run  high  on  exertion  or  excitement. 
Ansemia,  emaciation,  oedema,  phlebitis,  gall-stones  (formed  by  Eberth's 
bacillus),  tuberculosis,  neurasthenia,  psychoses,  bone,  muscle,  and 
other  complications,  may  occur.  If  the  appetite  is  poor  in  convales- 
cence, complications  are  to  be  expected. 

Diagnosis. — General  Rules. — 1.  The  bacteriological  diagnosis  is  not 
usually  practicable,  for  the  colon  bacillus  confuses  the  inexperienced 
physician  in  the  examination  of  the  urine  and  faeces.  Splenic  puncture 
is  never  indicated,  though  positive  in  95  per  cent,  of  cases  tested.  The 
bacilli  may  be  found  in  the  blood  in  nearly  all  cases,  and  practically 
always  in  the  roseolse. 

2.  Observe  long  and  carefully.  Say  that  "a  diagnosis  is  impossible 
in  the  first  few  days." 

3.  No  single  sign  is  absolutely  diagnostic,  except  bacilli  in  the  blood, 
etc.,  and  the  characteristic  Widal  reaction. 

4.  Diagnosticate  (a)  from  positive  findings,  and  (6)  by  careful 
exclusion. 

5.  The  "typhoid  state"  only  indicates  some  toxaemia,  not  necessarily 
typhoid. 

6.  In  doubtful  cases  remember  the  great  statistical  frequency  of 
typhoid. 

7.  Remember  its  manifold  forms;  e.  g.,  pneumo-typhoid,  etc. 

8.  Be  on  the  safe  side  in  light,  ambulatory,  or  abortive. cases  as  to  the 
diagnosis  and  the  still  more  important  matter  of  treatment. 

The  Cardinal  Signs. — These  are:  (a)  The  Widal  test;  {h)  bacilli  in 
the  blood,  in  the  urine,  in  the  roseolae,  etc.;  (c)  the  roseolse;  {d)  the 
slow  pulse;    (e)  the  fever-curve;  and  (/)  the  splenic  tumor. 

(a)  The  sero-test,  successful  in  95  to  97  per  cent,  of  cases,  is  important. 
As  stated  above,  its  absence  does  not  exclude  typhoid. 

(6)  The  bacilli  in  the  blood  are  found  in  practically  all  cases. 

(c)  The  eruption  has  a  diagnostic  value  in  its  location,  occurrence 
in  crops,  time  of  appearance,  and  short  duration. 

{d)  The  slow  pulse,  and  to  a  much  less  extent  its  dicrotism,  are 
suggestive.  It  is  rarely  to  be  confused  with  the  slow  pulse  of  tubercu- 
lous meninffitis. 


42  THE  SPECIFIC  IX EEC  no. \S 

(e)  The  fever-curve  shovrs  a  gradual,  step-like  onset,  continuous 
fastigium,  steep  curves  in  the  breaking  stage,  and  subnormal  register 
in  established  convalescence. 

(f)  "While  the  splenic  tumor  occurs  in  many  other  infections,  it  is 
per  se  suggestive  after  the  first  week. 

Secondary  Signs. — These  are,  in  order  of  importance,  the  typhoid 
tongue,  the  stools,  bronchitis  (especially  after  the  first  week),  the 
typhoid  state,  leukopenia,  intestinal  symptoms  and  complications,  and 
the  diazo  reaction. 

Symptoms  contraindicating  typhoid  are,  according  to  Leube,  coryza, 
early  vomiting  and  sweating,  herpes,  endocarditis,  retraction  of 
the  abdomen,  persistent  constipation,  and  constant  failure  of  the 
diazo  test.  To  these  may  be  added  leukocytosis  (unless  some  complica- 
tion has  occurred),  icterus,  and  rigors.  All  of  the  above-mentioned 
symptoms  may,  exceptionally,  complicate  t^'phoid. 

Differential  Diagnosis. — Differentiation  from  acute  miliary  tubercu- 
losis may  be  most  difficult.  In  both  diseases  protracted  fever,  splenic 
tumor,  brain  symptoms,  bronchitis  and  bronchopneumonia,  rapid 
pulse,  etc.,  inay  be  observed,  and  miliary  tuberculosis  may  develop  from 
t\'phoid  (Birsch-Hirschfeld,  and  in  two  personal  observations).  Ty- 
phoid may  be  complicated  with  septiceemia,  very  rarely  with  malaria 
in  this  climate,  or  with  meningitis.  The  table  on  pages  44  and  45 
illustrates  the  differential  diagnosis  of  the  diseases  most  likely  to  be 
confused  "^'ith  t^'phoid. 

Exanthematous  typhus  iq.  v.)  and  recurrent  fever  (q.  v.)  are  easily 
distinguished.  The  exanthematous  diseases,  such  as  scarlatina  and 
measles,  are  rarely  confused,  except,  perhaps,  in  the  initial  stage.  A 
most  extensive  eruption  of  roseolas  resembling  measles  is  easily  dis- 
tinguished by  the  course,  temperature  curve,  and  catarrhal  symptoms. 

Fibrinous  jyneiimonia  rarely  resembles  typhoid,  or  still  more  rarely 
occurs  with  typhoid  in  its  earliest  stages.  Though  typhoid  may  begin 
with  severe  bronchitis  or  pneumonic  symptoms,  doubt  usually  exists  only 
during  the  first  few  days.  The  pneumonic  t}^e  of  tj'^hoid,  caused  by 
the  localization  of  the  typhoid  bacilli  in  the  lungs,  is  most  uncommon. 
The  intestinal  symptoms  and  cardinal  findings  of  typhoid  usually 
appear  after  a  few  days  or  one  week,  and  all  doubt  is  then  dispelled. 
Pneumonia  may  undoubtedly  occur  without  local  findings,  and  yet  the 
diagnosis  of  central  pneumonia  should  rarely  be  made,  as  it  is  usually 
incorrect.  Sudden  onset  with  chill,  pain  in  the  side,  sudden  rise  of 
pulse  and  temperature,  rapid  respiration,  bloody,  viscid  sputum, 
herpes,  icterus,  marked  leukocytosis,  and  usually  signs  of  local 
infiltration  or  a  tympanitic  note  over  one  lobe  and  a  few  crepi- 
tant rales,  followed  later  by  some  typical  pneumonic  infiltration  as 
the  disease  advances  from  within  toward  the  periphery  of  the  lung, 
establish  the  diagnosis  of  pneumonia,  usually  on  the  second  or  third 
day. 

Intestinal  anthrax  is  also  accompanied  by  fever,  splenic  tumor,  and 
nervous  symptoms.     Hemorrhagic  vesicles  in  the  mouth,  vomiting. 


TYPHOID  FEVER  43 

colic,  hemorrhage  from  the  intestines  and  kidney,  cyanosis  and  dyspnoea, 
are  suggestive,  and  the  detection  of  the  anthrax  bacillus  in  the  blood, 
urine,  stools,  or  sputum,  and  the  results  of  inoculation,  establish  the 
diagnosis. 

Febrile  gastritis  may  simulate  typhoid,  but  the  fever  is  usually  low  or 
irregular,  and  is  more  often  absent  than  present.  Marked  early  gastric 
symptoms  are  not  common  in  typhoid.  Febrile  enteritis  is  usually 
characterized  by  much  mucus  in  the  stools.  Though  typhoid  may 
occur  with  an  old  enterocolitis,  the  layers  of  the  typhoid  stool  result 
from  the  lack  of  mucus.  Splenic  tumor  has  been  observed  occasionally 
in  enteritis,  but  it  is  most  uncommon.  The  fever  in  enteritis  is  lower 
or  more  irregular,  than  in  typhoid;  and  the  bronchitis,  the  slow  pulse, 
and  the  other  cardinal  signs  of  typhoid,  are  absent.  Cases  of  typhoid 
developing  suddenly  may  be,  at  first,  confused  with  grippe,  diphtheria, 
or  other  diseases.  Febrile  syphilis  should  seldom  cause  diagnostic 
trouble. 

Paratyphoid  (paracolon  infection)  is  due  to  a  bacillus  differing  from 
the  bacillus  of  typhoid  and  of  dysentery,  and  from  the  Bacillus  coli, 
and  resembling  the  Bacillus  enteritis,  Bacillus  psittacosis,  etc.,  yet 
different  from  all  of  these.  Two  types  of  organisms  are  recognized — 
one  producing  a  permanent  and  the  other  a  transient  reaction  in  milk. 
Infection  may  occur  from  milk,  water,  and  tainted  meat.  The  bacilli 
are  found  in  the  stools,  blood,  roseolse,  and  urine,  and  agglutinate  in 
higher  dilutions  (1  to  1,000  or  2,000)  than  the  typhoid  bacilli.  The  first 
cases  were  reported  by  Schottmueller,  in  1900.  In  paratyphoid  the 
temperature  is  more  irregular  than  in  typhoid,  shows  greater  remissions, 
and  may  end  with  a  crisis.  The  pulse  is  slow  and  dicrotic. 
Roseolse  are  often  present  (80  per  cent,  of  the  cases),  the  spleen  is 
usually  enlarged,  and  no  leukocytosis  is  observed.  Prodromal  catarrhs, 
diarrhoea,  cervical  adenitis,  oedema  of  the  lids,  vomiting,  epigastric 
pain,  herpes,  myositis,  arthritis,  pleurisy,  endocarditis,  and  meningitis, 
are  more  common  than  in  typhoid.  The  diazo  test  gives  the  character- 
istic reaction  in  30  to  60  per  cent,  of  the  cases.  The  clinical  course 
covers  two  weeks  (twelve  to  eighty-four  days).  Relapses  are  common. 
The  infection  is  usually  mild,  sometimes  severe,  and  rarely  fatal  (3.6  per 
cent.).  Ulceration  of  the  intestinal  lymph-structures  is  absent  in  the 
fatal  cases,  though  other  necroses  occur,  thus  explaining  the  occasional 
hemorrhage  (5  per  cent.).  Pneumonia  and  perforation  are  unknown. 
The  disease  is  comparatively  rare.  The  blood  does  not  respond  to  the 
Widal  test  nor  are  typhoid-bacilli  found,  but  otherwise  it  is  indis- 
tinguishable from  typhoid.  Grunberg  and  Roily  hold  that  the  Widal 
reaction  is  less  a  specific  than  a  group  reaction,  as  they  found  agglutina- 
tion in  the  paratyphoid  group  by  typhoid  serum.  This  does  not  imply, 
however,  that  failure  to  respond  to  the  Widal  test  excludes  typhoid 
(Johnstone).     A  mixed  infection  with  typhoid  may  occur. 

The  paracolon  organism  (recognized  by  Widal,  in  1897)  presents  a 
serum  reaction  peculiar  to  itself  when  brought  in  contact  with  the 
blood  of  a  patient  suft'ering  from  the  disease. 


44 


THE  SPECIFIC  INFECTIONS 


Pathoqnomonic  Signs 


Typhoid. 


Pulse  and 

ClHCULATION 


Fever 


Typhoid  bacilli  Relatively  slow  di-  Typical  rise,  acme, 
in  the  blood,  croticpulse  early  in  d  eferve  see  no  e  , 
spleen(by  the  disease,  espec- and  subnormal  in 
puncture),  lially  in  men,  and  convalecence. 
urine,   roseolEe,  in   not   too   severe  Remissions  and  in- 


Splenic 
Enlarge- 
ment 


Blood 


or  stools. 
Widal  test. 


infections.  E  n  d  o- termissions  follow- 
carditis  and  peri-  ing  continuous  f  e- 
carditis  very  rare,  ver  speak  for  ty- 
phoid. Responds 
to  hydrotherapy  as 
a  rule.  Sometimes 
chills  at  onset  or  in 
course. 


Very  fre-i Bacilli  in  blood, 
q  u  e  n  t;  early;  Widal  test 
larger  than  later.  No  leuko- 
in  miliary, cytosis  unless  com- 
t  u  b  e  r  c  u-  plications,  but  leu- 
losis;ap-kopenia.  Poly- 
pears  i  nrnorphonuclears 
first  week,   decreased.    Late 


Miliary   Tubercle  bacilli 
TuBERCU-  in  the  blood  or 

LOSIS. 


fre- 


Sometimes  tubercle 


Rapid,  120  or  more  No  cycle;  irregular  Less 

high  even  during  or  remittent.  Sel- q  u  e  n  t,  bacilli  in  blood.  No 
splenic  pulp  ;!remissions;  slowed  dom  long  contin- s  m  a  1  1  e  r  Widal.  Leukocyto- 
tubercles  in  the  in  tuberculous  men- ued.  and  if  so,  long- and  usually  sis  not  often,  but 
choroid.  lingitis   and   in   the  er  than  in  typhoid,  a  p  p  e  a  r  s  more    than   in    ty- 

a  g  e  d.     DicrotismE  xac  erb  a  t  ions  later.  iphoid. 

uncommon.  Some-  with  renewed  dis-j 
times  pericardial  semination  of  tu-i 
rub.  !bercle  bacilli.] 

i  Brain  involvement: 
may  lower  fever  or 
make  it  variable,  as 
inversed  type. 


Malaria. 


Plasmodium  in 
the  blood  (or 
splenic  pulp). 


Pulse  moderate  inilntermittent,  be-  Much  en-! Plasmodium,  mel- 
rate;  sometimes  ginning  very  often  1  a  r  g  e  d;  anaemia,  no  leuko- 
dicrotic;  very  rare- with  chills,  type  more  than  cytosis  save  in  per- 
ly  endocarditis.  varies  (quotidian,  in  typhoid;  nicious  forms, 
tertian,  etc.);  of- and  p e r- Great  and  early 
ten  rises  high  atsists  f  r  e- anaemia.  No  Widal. 
once;  if  continuous  quently  as 
(subcontinudus)  at  ague-cake, 
least  made  irregu- 
lar by  quinine  or 
usually  wholly 
abolished  (for  a 
time  at  least). 


Sepsis     (in-  Cultivation    of  Usually  fast  and  ir- 

cluding  En-  pyogenic  organ- regular;     cardiac 

DOCAHDiTis).  isms,    pneumo-jl  ocalizati  ons 

coccus,    from     jvery     frequent     in 

the     blood     oris ep sis,    puerperal 


various  foci. 


especially,  and  in 
endocarditis  (a  car- 
diac form  of  sepsis) . 
Cardiac  enlarge- 
ment, thrill,  bruit, 
accentuated  p  u  1  - 
monic  tone,  etc. 


Chills,  sweats, 
steep  elevations, 
and  sudden  depres- 
sions almost  al- 
ways at  some  time, 
and  usually  repeat- 
ed with  each  dis- 
charge into  the 
blood  of  infective 
material. 


Especia  1 1  y  Various  organisms 
enlarged'  Marked  pol  jTnor- 
from  sepsis  phonuclear  leuko- 
and  i  n-:cyotsis  very  fre- 
farcts.  Also  qaent;     sometimes 


often    the 

lymph- 

nodes. 


absent  in  endocar- 
ditis.    No  Widal. 


Meningitis.  Lumbar  punc- 
ture (a)  menin- 
gococci, tuber- 
cle baciUi,  py- 
ogenic organ- 
isms, etc.;  ib) 
increased,  tur- 
bid fluid,  etc. 


Rate    differs    with 
type;  variable. 


Differs  with  vari- 
ety, but  seldom  as 
high  as  typhoid;  no 
cycle. 


Rare. 


Leukocytosis  in  ep- 
idemic   and    puru- 
lent types;  rarer  in 
tuberculous.      No 
Widal. 


TYPHOID  FEVER 


45 


Skin 


Lungs 


Nervous  System 


Sputum,  Urine 


Alimentary 
Tract 


Roseolae,  typical  in' Breathing  somewhat  Early  headache,  re-  Typhoid  bacilli  in 
location,  crops,  ap- increased   from   tox- {placed  later  by  de-j urine.  Diazotestin 
pearance,   contain-  semia   (cerebral  lirium.  ty  p  h  o  i  djnearly  all  cases, 
ing  typhoid  bacilli,  breathing)    hyposta-j state,  actual  men- 
Sweating  and  mill-  sis,  or  other  compli-iingitis    very    rare; 
aria  less  often  and  cations.      Rales    be-  intoxication      may 
later.    Icterus  rare   low    and    b  e  h  i  n  d.l  closely    simulate 
Herpes  rare.  Tympanitic      n  o  t  e! meningitis.       Very 

never  heard  in  mili- rarely  disk  changes, 

ary  tuberculosis. 


Mouse-like  breath, 
semi-characteristic 
tongue,  ochre-yel-  / 
low  stools,  ty m- 
pany,  diarrhoea, 
bowel  hemorrhage, 
perforation,  bacilli 
in  stools.  Retracted 
abdomen  or  early 
vomiting  rare. 


Roseolse  absent; 
extremely  rare, 
and  not  then  in 
crops.  Drenching 
sweats  common. 
Herpes  more  than 
in  typhoid.  Skin 
anaemic  and  very 
often  cyanotic. 


Breathing    increased  Meningitis  tubercu- 
even  40  to  60;  cyano-jlosa  very  frequent; 
sis      and      dyspnoea | optic  neuritis;  cho- 
without  a  dequate'roidal   tubercles, 
physjcal    findings. 
Fine    and    localized 
rales  heard  above  and 
in  front.  Tympanitic 
percussion  note  from 
lung  relaxation.   Ev- 
idences of  pleural  ad- 
hesions,    apical 
changes,  fresh   pleu- 
ral rub. 


Tubercle  bacilli 
sometimes  found  in 
sputum,  urine  and 
faeces,  but  are  indi- 
cative of  old  tuber- 
culous lesions,  not 
of  miliary  tubercu- 
losis. Diazo  test 
frequent. 


Diarrhoea  not  com- 
mon, but  may  rare- 
ly occur,  as  indeed 
may  hemorrhages; 
both  may  q  o  m  e 
from  tuberculous 
ulceration  of 
bowels. 


In  severe,  eyes  sub-  If  lung  congestion  Headache  at  9nset 
icteric  or  marked-  (severe  forms) ,  it  is  is  rare;  later  is  of- 
ly  icteric.    Herpes | variable,     recurrent,  ten     pulsating 


very  f  req  uent 
and  urticaria  the 
next  most  frequent 
exanthem. 


shifts   from   lobe    to 
lobe 


neuralgic.  Delir- 
ium from  begin- 
ning in  aestivo- 
autumnal  forms  is 
frequent.  Restless- 
ness, anxiousness. 
In  pernicious  forms 
may  have  convul- 
sions, coma,  etc. 


Haemoglobinuria  in 
pernicious  malaria. 
Diazo  test  fairly 
frequent,  though 
much  less  than  in 
typhoid. 


Nauseating  breath. 
Sometimes  abdo- 
minal pain  even  in 
mild  types;  may 
rarely  have  diar- 
rhoea, even  hemor- 
rhage in  alimentary 
pernicious  types. 
Liver  congestion 
frequent,  also 
icterus. 


Frequent  sweating, 
miliaria.  Septic 
(polymorphous) 
rashes  Subicterus, 
frequently  p  u  r- 
puric  skin  erup- 
tions, herpes  not 
uncommon. 


Bronchitis  frequent. 
Pulmonary  infarcts 
and  pleurisy. 


Dependent  on  Acute  embolic 
cause.  Septic  men-  nephritis,  Pepton- 
ingitis  (with  arth- 
ritis, pleurisy,  etc.) 
cerebral  embolism; 
retinal  hemor- 
rhages or  embol- 
ism. 


Septic  diarrhoea. 


Herpes  in  epidemic 
cerebrospinal  form. 
Tache  c^r^brale. 


Variable    breathing 
Blot's  breathing. 


Early  triad,  head- 
ache, retracted 
neck  and  hyper- 
£esthe«ia.  Head- 
ache violent 
throughout  the  dis- 
ease, convulsions, 
paralysis,  Kernig's 
sign,  etc.  Optic 
neuritis  retinal 
hemorrhage,  tu- 
bercles in  choroid. 


Early  cerebral 
vomiting.     Re- 
tracted  scaphoid 
abdomen. 


46  THE  SPECIFIC  INFECTIONS 

Trichinosis  is  differentiated  from  typhoid  by  the  history,  by  muscu- 
lar pain  and  oedema  in  the  striped  muscles,  by  trichinae  in  the  stools 
and  muscles,  and  by  eosinophilia.  In  typhoid  these  symptoms  are 
absent,  while  the  cardinal  findings,  such  as  the  Widal  reaction,  rose 
spots,  and  enlargement  of  spleen,  are  present.  Two  or  three  cases  of 
double  infections  have  been  reported  (McCrae). 

Prognosis  of  Typhoid  Fever. — The  death-rate  was  formerly  20 
per  cent.,  based  on  50,000  cases  collected  by  Jaccoud.  At  present  it  is 
lower  (5  to  12  per  cent.)  because  of:  (a)  more  accurate  diagnosis, 
thus  including  lighter  cases  in  our  figures;  (6)  the  virulence  of  typhoid 
becoming  less;  (c)  better  hygiene;  and  {d)  better  treatment,  the 
Brand  method,  etc. 

The  'prognostic  factors  are: 

1.  Age:  The  least  mortality  is  between  the  second  and  the  tenth 
years;   the  highest  after  the  twenty-fifth. 

2.  Constitution:  Meagre  and  muscular  patients  are  more  likely  to 
recover  than  the  plethoric,  adipose,  or  robust. 

3.  Sex  is  immaterial,  aside  from  pregnancy. 

4.  Acute  diseases  modify  the  prognosis.  These  are  scarlatina, 
measles,  variola,  diphtheria  (rare),  malaria,  erysipelas  (from  0.7  to  2 
per  cent.),  varicella,  etc. 

5.  Chronic  diseases,  such  as  gout,  diabetes  (low  temperature,  the 
sugar  often  disappearing),  cardiac,  pulmonary,  and  renal  disease; 
alcoholism  (34  per  cent,  mortality  from  weak  heart  or  hemorrhagic 
diathesis) ;  convulsive  affections,  such  as  epilepsy  or  chorea,  may  cease. 

The  prognosis  is  better  in  relapses  than  in  the  original  case. 
Recrudescences  are  dangerous.  In  war  times,  the  prognosis  is  usually 
less  favorable;  the  Spanish- American  war  was  an  exception,  the 
death-rate  being  but  7  per  cent.,  while  in  the  Boer  war  the  mortality 
was  21  per  cent. 

Death  usually  occurs  between  the  eighteenth  and  twenty-eighth 
days,  and  is  caused  by — 

1.  Toxcemia,  the  most  frequent  cause  of  death  (30  to  50  percent.), 
including:  (a)  hyperpyrexia;  (b)  hemorrhagic  types;  (c)  heart  weak- 
ness, vasomotor  paralysis;  and  (d)  brain  paralysis. 

2.  Local  typhoid  lesions,  as  meteorism,  diarrhoea,  peritonitis  (in  16 
per  cent,  of  fatal  cases),  or  hemorrhage  (in  20  per  cent.). 

3.  Complications,  as  lung  inflammations  (in  10  per  cent,  to  15  per 
cent.),  nephritis  (4.5  percent.).  Septicaemia  (secondary  streptococcus 
invasion)  has  been  little  studied  except  by  French  writers  ("forme 
septicemique  generalisee"),  the  symptoms  of  which  are  high  fever,  with 
chills  and  sweats,  abscesses,  enlarged  glands  and  spleen.  Pyaemia  may 
result  from  acute  osteomyelitis,  suppurative  parotitis,  adenitis,  phle- 
bitis, or  splenic  infarction. 

4.  Collapse.  Sudden  death  has  been  discussed  under  changes  in 
the  heart  muscle.  Dieulafoy  estimates  that  sudden  death  occurs  in  2 
per  cent,  of  typhoid  cases.  The  pulse  is  always  more  important  than 
the  fever,  and  early  rapidity  is  unfavorable. 


TYPHOID  FEVER  47 

5.  We  have  already  considered  the  ominous  significance  of  pseudo- 
collapse,  the  typhoid  state,  early  delirium,  diarrhoea,  and  meteorism; 
of  the  various  severe  complications,  such  as  noma,  gangrene,  laryngeal 
perichondritis^,  and  pneumonia;  and  of  the  more  severe  types,  such  as 
the  hyperpyretic  and  hemorrhagic;  and  of  the  ambulatory  varieties. 
Typhoid  beginning  suddenly  entails  a  high  mortality. 

Treatment. — Dujardin-Beaumetz  said  "The  best  treatment  for  typhoid 
is  a  good  physician."  The  treatment  concerns  {A)  prophylaxis;  (5) 
specific  treatment;  (C)  hygiene  and  rest;  (D)  the  question  of  intestinal 
antisepsis;  {E)  antipyretic  measures  (hydrotherapy);  {F)  diet;  (G) 
symptomatic  or  expectant  treatment;  {H)  treatment  during  conva- 
lescence. 

{A).  Prophylaxis. — Prophylaxis  has  as  wide  a  scope  in  medicine  as 
asepsis  and  antisepsis  in  surgery.  In  Chicago,  during  the  years  1889 
to  1892,  inclusive,  there  were  4,747  deaths  from  typhoid.  In  the  four 
years  after  the  drainage-canal  was  opened  there  were  2,235  cases;  that 
is,  per  population,  the  mortality  was  reduced  75  per  cent.  In  1905, 
typhoid  cases  were  rare.  General  prevention  is  difficult,  because  of  the 
ubiquity  of  the  germ  and  the  carelessness  of  individuals.  Systematic 
cooperation  regarding  sewage  regulation  and  water  supply  could 
efface  typhoid.  Koch  has  particularly  emphasized  this  point  lately 
and  succeeded  in  wiping  out  certain  typhoid  foci.  One  difficulty  lies 
in  the  infrequent  recognition  of  light  cases,  and  another  in  the  selfish 
carelessness  of  many  persons,  and  a  third  in  the  fact  that  some  individ- 
uals "carry  bacilli"  for  years.  It  is  easy  to  boil  water  for  home  use,  and 
yet  it  is  done  in  but  few  families,  even  in  those  of  physicians.  The 
traveler  should  avoid  unboiled  water  and  milk.  In  the  treatment  of  a 
case,  everything  with  which  the  germ  may  come  in  contact  must  be 
sterilized.  Next  to  the  fseces,  the  urine  is  the  most  important  conveyer 
of  the  bacillus.  They  are  the  usual  means  of  dissemination,  and  their 
proper  disinfection  in  every  case  would  surely  obliterate  typhoid.  The 
bacilli  may  persist  for  years  in  the  urine.  Chloride  of  lime  should  be 
placed  in  the  bottom  of  the  urinal,  or  bed-pan,  before  and  after  use. 
Acidulated  sublimate  (1  to  500)  or  10-per-cent.  crude  carbolic  solu- 
tion may  also  be  used;  but  neither  at  once  disinfects,  for  which  reason 
each  one  of  the  dejections  should  be  disposed  of  only  after  an  hour  or  two. 
Both  the  pans  and  urinals  must  then  be  sterilized.  The  same  urgent 
disinfection  is  indicated  in  the  case  of  thermometers  used  in  the  rectum, 
and  rectal  syringes  or  tubes.  The  perineum,  after  each  movement, 
should  be  sponged  witha  l-to-2,000  bichloride  solution,  and  also  the 
back  and  thighs,  when  there  are  involuntary  evacuations.  The  rubber 
draw-sheets  and  linen  should  be  sterilized  regularly  with  carbolic  acid 
or  bichloride  of  mercury,  and  the  sheets,  blankets,  pillows,  and  mattresses, 
steamed  when  taken  off  the  bed.  The  bath-tub  should  be  carefully 
cleaned  with  carbolic  solution,  as  the  patient's  soiled  skin  and  the 
urine  often  voided  during  the  bath  are  obvious  sources  of  danger.  It 
seems  superfluous  to  urge  cleaning  the  hands  of  the  nurse  or  physician 
after  examination  or  tubbing,  but  the  not  infrequent  direct  transmission 


48  THE  SPECIFIC  INFECTIONS 

of  the  disease  to  nurses,  orderlies,  and  doctors,  is  often  forgotten. 
Direct  infection  is  growing  in  clinical  importance.  In  the  Spanish- 
American  war  20  per  cent,  of  our  soldiers  were  directly  infected 
by  flies,  and  in  the  Boer  wai*  more  died  of  typhoid  than  were  killed  by 
bullets,  infection  being  carried  by  flies  and  sand.  The  few  cases 
among  the  Japanese  is  one  of  the  many  lessons  they  taught  us. 

In  convalescence  the  room  should  be  fumigated  with  formaldehyde, 
not  with  the  useless  sulphur  method  (see  Smallpox). 

(B).  Specific  Treatment. — Specific  treatment  awaits  the  furtherdevel- 
opment  of  serotherapy.  Chantemesse,  Widal,  Brieger,  Wassermann, 
Wright,  and  others,  have  obtained  some  results.  The  injection 
of  a  sterilized  culture  sufiiciently  strong  to  kill  a  guinea-pig  pro- 
duces local  reaction,  sometimes  nausea,  restlessness,  fever,  increased 
bactericidal  power  of  the  blood,  and  an  increase  in  its  agglutination 
properties.  Preventive  inoculation  in  India  and  South  Africa  reduced 
the  percentages  of  typhoid  morbidity  from  14  to  2  per  cent.,  and  the 
mortality  from  3  to  ^  per  cent.  The  injections  used  by  Chantemesse 
gave  him  a  mortality  of  but  4  per  cent.,  while  the  death-rate  at  that 
time  was  12  to  18  per  cent,  in  the  other  Paris  hospitals. 

(C).  Hygienic  Treatment. — Absolute  physical  and  psychical  rest 
is  imperative,  and  the  best  results  occur  in  cases  which  have  been  put 
to  bed  early.  Cases  of  the  ambulatory  type,  and  the  ones  which  for 
any  reason  are  not  put  to  bed  at  the  onset  of  the  typhoid,  never  fare 
as  well.  Typhoid  patients  should  not  be  entertained.  The  invariable 
use  of  the  bed-pan  and  urinal  should  be  insisted  upon,  as  every  pa- 
tient can  learn  to  use  them.  In  all  infections,  the  furniture,  carpets, 
and  hangings,  should  be  removed  from  the  room,  and  it  should  have 
free  ventilation, — fever  patients  do  not  catch  cold.  The  sunlight  should 
fall  across  the  bed  in  order  to  avoid  confusing  shadows.  The  nurse 
should  have  written  instructions.  The  stools,  baths,  etc.,  should  be 
watched  or  directed  by  the  physician,  especially  at  the  onset.  The 
single  bed  should  be  low,  should  have  a  firm  mattress,  rubber  draw- 
sheet,  and  perfectly  smooth  cotton  or  linen  sheets.  A  second  bed 
is  desirable  for  change  and  convenience. 

(D).  Antiseptic  Therapy. — Antiseptic  therapy  is  now  largely  of  his- 
torical interest,  as  typhoid  is  not  a  local  enteric  disease  but  a  septi- 
caemia or  bacillfemia.  Calomel  was  given  early  in  typhoid  by  von 
Ziemssen  and  Liebermeister,  who  thought  that  it  reduced  the  viru- 
lence of  the  attack  and  lessened  bowel  symptoms  and  complications; 
it  is  unnecessary,  and  at  the  acme  is  actually  harmful.  Beta-naphthol, 
grs.  V.  to  X.  every  four  hours,  is  given  by  Bouchard  and  Rossbach. 
Salol  (phenylis  salicylas)  is  the  least  objectionable,  since  it  is  mild; 
it  is  given  in  doses  of  grs.x.,  t.  i.  d.,  and  has  some  value  as  an  intes- 
tinal antiseptic.  The  urine  should  be  closely  watched  for  signs  of 
renal  irritation.  A  few  drops  of  hydrochloric  acid  (the  Swedish  fever- 
cure),  bichloride  of  mercury,  one-thirtieth  grain  every  eight  hours 
(Broadbent),  or  thymol,  two  grains  every  three  hours  in  a  soap  pill, 
are   also  advised.      No   one   of   this   group  of  agents  essentially  in- 


TYPHOID  FEVER 


49 


fluences  the  clinical  course.  They  are  used  not  against  the  Bacillus 
typhosus  but  solely  against  the  common  organisms  of  fermentation. 

{E).  Antipyresis. — (1).  Drug  Antipyretics. — Drug  antipyretics  in 
typhoid  are  not  often  indicated,  for  they  merely  reduce  fever  and  do 
not  eliminate  its  cause,  the  toxins.  Quinine  is  recommended  by  Lie- 
bermeister  and  Curschmann,  in  one  or  two  doses  of  fifteen  to  twenty 
grains,  given  before  the  fever  reaches  its  highest  point.  No  cardiac 
depression  results,  and  its  effects  last  from  eight  to  twelve  hours; 
the  fever,  however,  is  but  moderately  influenced  by  quinine.  Anti- 
pyrin  and  allied  products,  in  full  repeated  doses,  depress  the  brain, 
circulation,  respiration,  and  metabolism;  cause  vomiting  and  erup- 
tions; and  increase  the  danger  of  collapse.  They  are  not  indicated 
in  typhoid  as  they  are  in  the  fugitive  fevers.  Kryofine,  seven  to  fifteen 
grains,  is  a  good  febrifuge,  and  in  the  author's  experience  has  never 
caused  depression.  In  practically  all  cases,  drug  antipyresis  is  far 
inferior  to — 

(2).  Hydrotherapy,  which  is  the  only  logical  method  of  reducy 
ing  temperature,  since  it  alone  eliminates  the  fever-exciting  toxins. 
Nature's  method  of  reducing  temperature  by  sweating  should  not  be 
ignored.  Evaporation  from  the  moist  skin  should  be  helped  by  re- 
moval of  the  bed-clothing,  (a)  The  jull  cold  hath  of  Currie  (1787) 
and  Brand  is  given  with  water  at  64°  to  68°;    it  lasts  fifteen  to  twenty 

Fig.  6. 


Burr's  bed. 


minutes  and  is  repeated  every  three  hours  for  temperature  of  102° 
or  over.  Chilling  is  averted  by  vigorous  friction,  which  must  not 
abrade  the  skin;  by  cold  affusions  to  the  head;  or  by  administration 
of  alcoholic  stimulants.  The  apparent  brutality  of  the  Brand 
method  has  excited  considerable  popular  and  professional  prejudice, 
but  it  is  more  valuable  than  any  other  measure  in  typhoid.     As  Jiir- 

4 


50  THE  SPECIFIC  INFECTIONS 

gensen  remarks,  every  deviation  from  the  simple  principles  above  out- 
lined gives  less   satisfactory  results.     Early  resort  to  hydrotherapy 
gives  the  best  results.     When  the  portable  bath-tub  is  not  available, 
the  method  of  A.  H,  Burr  is  equally  good.    He  uses  a  wooden  frame, 
shaped  like  a  large  box;    the  base  fits  over  any  bed;    its  upper  part 
sustains  a  heavy  rubber  sheet,  which  passes  under  the  patient  and  con- 
stitutes the  sides  and  bottom  of  the  tub  (Fig.  6).     Its  use  obviates  the 
necessity  of  lifting  the  patient,  and  saves  excitement.    Water  is  poured 
over  the  patient  from  pails  and  is  removed  with  a  siphon.     The  ad- 
vantages of  Brand's  method  are:    (i)  The  mortality  is  lowered  6  to 
8  per  cent. ;    (ii)  toxaemia  is  lessened,  and  therefore  nervous  and  diges- 
tive symptoms,  heart  weakness,  and  pulmonary  complications,   are 
relieved;  fever  is  successfully  reduced,  and  there  is  less  visceral  degen- 
eration;   (iii)  the  renal  secretion  is  stimulated,  thereby   washing  the 
toxins  out  of  the  blood,  as  is  shown  by  a  five-  or  sixfold  increase  in  the 
urotoxic  coefficient;    (iv)  the  skin  becomes  more  active  and  bed-sores 
less  frequent,  although  furunculosis  is  seemingly  increased;    (v)  the 
clinical  course  is  shorter,  and,  on  the  whole,  fewer  complications  occur, 
although  the  percentage  of  hemorrhage  and  perforation  is  not  low- 
ered, and  relapses  seem  slightly  more  frequent.     Contra-indications  to 
the  use  of  Brand's  method  are  hemorrhage,  perforation,  great  pros- 
tration, alcoholism,  advanced  arteriosclerosis  or  cardiac  disease,  and 
marked  phlebitis.     Pregnancy,  nephritis,  and  pneumonia,  are  not  con- 
tra-indications.    Various  substitutes,  for  Brand's  method,  though  less 
effectual,  may  be  indicated  for  special  reasons,     (b)  The  gradually 
cooled  bath  (Ziemssen  and  Immermann)   is  identical  with  the  Brand 
method,  except  that  the  temperature  of  the  water  is  gradually  reduced 
from  90°  to  75°  or  65°.    It  is  adapted  to  cases  coming  under  treatment 
late  and  to  those  with  great  dyspnoea,  or  to  those  tending  to  collapse. 
(c)  The   protracted  tepid   bath    (Riess,   Eichhorst,   Unverricht).      (d) 
Cold  sponging,  first  with  warm  water  to  dilate  the  skin-vessels  and 
then  with  cold  water  to  abstract  heat.     Equal  parts  of  alcohol  and 
water  should  be  mixed,  to  aid  evaporation.     One  part  after  another  of 
the  body  is  exposed  and  sponged.     It  is  a  refreshing  and  quieting 
placebo,  but  enormously  inferior  as  an  antipyretic,     (e)  The  cold  pack 
is  also  much  less  successful.     In  sthenic  cases,  ice  applications  to  the 
head,  axilla,  spine,  etc.,  may  be  used,  or  the  body  may  even  be  ironed 
with  ice.     Ice-water  enemas  are  never  used  in  typhoid,  though  some- 
times employed  in  other  fevers. 

(F).  Diet. — Fifty  ounces  of  water  should  be  given  daily  at  definite 
intervals,  without  waiting  for  the  stuporous  patient  to  complain  of 
thirst.  This  flushes  the  kidneys,  lowers  temperature  by  increasing  the 
sweat  production,  and  lessens  parenchymatous  degeneration  of'  the 
viscera.  Pure  water  is  superior  to  barley-  or  albumin-water,  lemonade, 
etc.,  which  dull  the  appetite  and  often  derange  digestion.  Care  of 
the  mouth  may  be  considered  here.  The  mouth  and  pharynx  should 
be  carefully  cleansed  of  sordes  and  food  particles,  lest  infection  travel 
to  the  ears,  salivary  and  lymphatic  glands,  or  aspiration  pneumonia 


TYPHOID  FEVER  51 

result.  A  boric-acid  solution,  with  tincture  of  myrrh  or  tincture  of 
hydrastis,  meets  every  requirement.  The  cleansing  must  be  gentle,  in 
order  that  no  fresh  abrasions  may  be  inflicted.  The  diet  must  be  fluid, 
since  there  are  intestinal  lesions.  It  must  also  be  easily  digestible, 
since  fever  lessens  all  the  digestive  juices.  In  the  diet  no  reference 
is  usually  made  to  individual  symptoms,  as  there  is  no  correspond- 
ence between  the  clinical  symptoms  and  the  actual  anatomical  ulcer- 
ation of  the  intestines.  Graves  was  the  first  to  feed  fever  patients, 
who  up  to  that  time  had  been  starved,  but  there  is,  at  the  present 
time,  almost  equal  danger  of  overfeeding.  Milk  is  the  standard 
diet.  Six  to  eight  ounces  should  be  sipped  at  intervals  of  three  hours, 
day  and  night,  as  the  patient,  after  being  wakened,  readily  falls  to 
sleep  again.  It  is  best  given  diluted  with  half  an  ounce  of  lime-water 
or  with  a  little  carbonated  water,  which  should  not  be  cold,  since  the 
gas  expands  at  body  heat.  Though  milk  alone  is  said  to  contain  in- 
sufiicient  albumin  to  meet  the  tissue-waste,  there  is  risk  of  overfeeding; 
and  the  physician  himself  should  inspect  the  stools  for  curds,  for 
milk,  curdling  in  the  stomach,  practically  becomes  solid  food.  One 
pint  of  milk  is  equivalent  to  one  pint  of  oysters  or  a  good  chop.  Very 
few  patients  cannot  take  milk.  In  other  words,  it  can  be  forced  upon 
unwilling  patients.  Recalcitrant  patients  may  be  given  some  varia- 
tion, such  as  koumyss,  matzoon,  buttermilk,  whey,  or  certain  baby- 
foods.  If  the  digestion  is  peculiar  or  weak,  peptonized  milk,  given 
with  very  thin,  strained  gruels,  or  egg,  may  be  tolerated.  Carbohydrates 
are  theoretically  indicated  to  lessen  nitrogenous  waste,  and  well-boiled 
cornstarch  and  tapioca  are  allowed  by  some  clinicians.  They  are  per- 
missible if  no  tympany  results,  and  the  author  agrees  with  Hare  that 
taka-diastase  aids  their  assimilation.  Meat-juice  is  obtained  from 
freshly  slaughtered  beef,  by  a  meat-press.  If  its  taste  is  disagreeable 
to  the  patient,  a  few  drops  of  peppermint  oil  may  be  given  first.  It 
may  also  be  given  frozen  (meat-juice,  5  iij ;  sugar,  3  ij- ;  lemon-juice,  3  j- ; 
yolk  of  one  egg;  cognac,  ojO-  The  following  articles  afford  some 
variety:  Nutrose,  somatose,  eukasin,  Valentine's  meat-juice.  Brand's 
essence  of  beef,  Mosquera's  predigested  beef-jelly  (containing  pine- 
apple juice  and  over  50  per  cent,  soluble  albumin);  yolk  of  egg  in 
soup  or  wine,  and  white  of  egg  with  twice  its  weight  of  water.  Foods 
containing  gelatin  conserve  metabolism  (Senator)  but  may  irritate  the 
bowels.  Beef-tea  should  be  avoided,  as  it  contains  only  stimulating 
substances,  less  than  1  per  cent,  albumin,  and  no  fat  or  carbohydrates. 
Furthermore,  it  often  irritates  the  kidneys  and  intestines.  In  soporose 
patients  with  anaesthetic  throats,  food  may  enter  the  larynx  and  cause 
aspiration  pneumonia.  The  nasal  catheter  is  then  indicated.  To  its 
outer  end  a  funnel  is  attached,  through  which  food,  drink,  and  medi- 
cines, are  given.  A  safety-pin  across  its  outer  end  prevents  its  escape 
downward.  The  catheter  should  be  long  enough  to  pass  into 
the  oesophagus  beyond  the  larynx,  and  care  should  be  exercised 
that  it  does  not  enter  the  latter.  Rectal  feeding  is  sometimes 
indicated. 


52  THE  SPECIFIC  INFECTIONS 

(G).  Symptomatic  or  Expectant  Treatment. — 1.  Digestive  System. 

(a)  Vomiting. — It  must  be  ascertained  that  the  patient  has  been  given 
no  solid  food  by  solicitous  friends  and  that  perforation  has  not  taken 
place.  Rectal  feeding,  the  use  of  warm  carbonated  water,  cocaine  gr.  ^, 
or  tincture  iodine  w  i,  for  several  doses,  sinapisms  or  an  ice-bag  to 
be  placed  on  the  epigastrium,  are  indicated.  Bartholow's  formula  is 
very  serviceable : 

Acidi  carbolic! gr.  iv. 

Bismuthi  subnitratis 3iss. 

Cerii  oxalatis 3j. 

Sodii  bromidi 5ss, 

Sacchari  albi  ! 

Acaciffi  j ^^  1-^- 

Aquae  menthse  piperitse q.s.  ad   Bij. 

M.  et  ft.  emulsio. 

S. — One  teaspoonful,  undiluted,  every  15  to  30  minutes. 

(b)  Constipation  should  be  treated  with  enemas  of  water  or  sweet 
oil  every  other  day.  Typhoid  cases  with  constipation  do  better  than 
those  with  diarrhoea.  Cathartics  are  never  used,  as  they  cause  mete- 
orism.  (c)  Diarrhoea  is  most  frequently  due  to  toxsemia  and  is,  there- 
fore, most  efficaciously  treated  with  the  cold  bath;  curds  (prevented 
by  diluting  the  milk),  beef-tea,  or  solid  food,  may  be  its  cause.  Treat- 
ment is  indicated  when  there  are  more  than  four  movements  daily, 
and  when  there  is  colic  or  tenesmus,  unrest  or  weakness.  Cold  tea 
with  whiskey  and  pulv.  aromaticus  gr.  v.,  or  paregoric  and  bismuth 
each  5j-5  after  each  movement,  extr.  opii.  gr.  i.,  or  the  starch-and-laud- 
anum  enema  usually  give  relief  at  once.  Pepper  considered  silver 
nitrate  almost  specific  (gr.  i  to  ^). 

Bismuthi  subnitratis 3j. 

Morphinse  sulphatis gr.  j. 

M.  et  div.  in  pulv.  xij. 

S. — One  to  four  a  day.     (Alonzo  Clark). 

'^      .   . 

Acidi  tannici gr.  x. 

Tincturse  opii Wy'i- 

Spiritus  terebinthinae njjxv. 

Mucilaginis 3ij. 

Tincturse  chloroformi  compositae njjxx. 

Aquae  menthse  piperitae ad  oj. 

M.  f.  haust. 

S. — To  be  taken  every  two  hours.     (Murchison). 

^  .  .  .  ...  , 

Plumbi  acetatis gr.  iss  ad  iij. 

Opii  pulveris gr.  i  ad  ijss. 

Sacchari  albi     .    .    .    .  • gr.  Ix. 

M.  et  divide  in  pulv.  vj. 

S. — A  powder  every  three  hours.     (Yeo). 

(d)  Tympany. — This  is  sometimes  an  indication  that  the  patient  has 
been  given  solid  food.  In  severe  cases  albumin-water  must  be  sub- 
stituted for  milk.     The  cold  bath  often  gives  relief,  since  most  cases 


TYPHOID  FEVER  53 

of  meteorism  are  due  to  toxaemia.  The  turpentine  stupe  of  Jenner 
should  be  appHed  to  the  abdomen,  flannel  cloths  being  dipped  in 
a  mixture  of  warm  water  and  3ss  ol.  terebinthinse  and  pressed  hard 
together  to  spl-ead  the  oil  evenly  and  thus  avoid  blistering.  The  ice- 
coil  is  also  beneficial.  The  old  turpentine  emulsion  of  Wood  (ol. 
terebinthinse,  ttb.  iij.  to  v.)  is  excellent,  though  the  urine  must  be  watched 
carefully  for  signs  of  renal  irritation: 

01.  terebinthinse       oiss. 

01.  caryophylli gtt.  vj. 

Glycerini  _       {  --    «gg 

Mucilaginis  acacise    S       

Syrupi  et  aquae aa   oiss. 

M.  et  ft.  emulsio. 

S. — A  dessert  spoonful  every  3  or  4  hours. 

Whiskey  and  spices  are  effective.  Emulsio  asafoetidse,  Oj;  Spr. 
chloroformi,  3j- ;  and  ol.  terebinthinse,  5 ss;  as  a  warm  enema,  often  give 
relief,  (e)  Hemorrhage  necessitates  absolute  quiet,  mental,  physical, 
and  alimentary.  The  patient  should  not  be  moved  for  any  reason 
whatever.  In  severe  cases  he  should  lie  in  the  blood  which  has  been 
passed,  with  cotton  tucked  around  the  hips  and  between  the  legs  to 
catch  the  urine  and  fseces,  which  should  pass  into  it  without  his  being 
lifted  on  the  bed-pan.  No  food,  no  water,  no  enema,  no  bath,  should 
be  given.  Morphine  is  primarily  indicated.  It  quiets  the  excitement 
attending  hemorrhage,  lessens  peristalsis  and  enforces  bodily  quiet. 
It  should  be  given  in  sufficiently  large  amounts;  gr.  \  being  injected 
every  half-hour  for  three  doses,  and  then  a  quantity  sufficiently  large 
to  produce  its  full  physiological  effects,  for  the  dose  of  a  drug  is  not 
measured  in  grains  but  in  its  effect;  it  should  be  repeated  every  two, 
four,  or  six  hours  in  order  to  sustain  the  primary  indications  above 
named.  The  author  has  given  even  four  to  six  grains  in  the  first  day, 
when  the  greatest  danger  occurs,  but  in  such  cases  the  patient  must 
be  very  closely  watched.  The  author  considers  that  the  sole  valid 
objection  to  morphine  is  that  it  may  mask  coincident  perforation, 
which  occurs  once  in  every  five  cases  of  hemorrhage;  he  believes, 
however,  that  close  circumspection  invalidates  this  objection.  Opium 
or  styptics  by  the  mouth  are  dangerous  and  uncertain.  The  lead-  or 
iron-salts  probably  never  reach  the  bowel.  The  ice-coil  placed  on 
the  abdomen  may  be  beneficial.  Gelatin  may  be  injected  as  in  aneu- 
rysm {q.  v.).  The  question  of  stimulation  is  a  difficult  one.  On  the 
one  hand,  there  is  the  risk  of  forcing  blood  through  the  leak  by  stimu- 
lation; on  the  other  hand,  the  volume  of  blood  must  not  sink  too  low; 
but  first  the  heart  must  be  allowed  to  run  down, — nature's  own  and 
most  certain  method  of  hemostasis.  At  a  later  time  only,  should 
strychnine  or  digitalis  be  administered  hypodermatically,  or  saline 
transfusions  be  given ;  and  delay  in  their  use  is  better  than  haste.  (/) 
Perforation  necessitates  an  early  diagnosis,  which  is  often  difficult, 
and  immediate  operation,  often  without  general  anaesthesia.  Most 
reported  recoveries  were  operated  on  in  the  first  twenty-four  hours. 


54  THE  SPECIFIC  IXFECTIOXS 

Haggard,  Cazin,  and  Zezas,  collated  the  operations  up  to  1904-5. 
Recovery  occurred  in  30  per  cent,  of  358  operations  (Cazin).  In  twenty 
cases  operated  on  at  Johns  Hopkins  Hospital,  35  per  cent,  recovered. 

2.  Circulatory  System. — Heart  weakness  is  best  prevented  by  abso- 
lute rest,  and  hydrotherapy.  An  ice-bag  placed  over  the  heart  tends 
to  regulate  and  calm  its  action.  Strychnine,  gr.  3^5,  is  the  best 
heart  tonic,  and  may  be  given  two  or  three  times  a  day  as  a  vaso- 
motor tonic  in  cases  which  do  not  show  signs  of  heart-failure.  It  is 
best,  however,  to  await  definite  indications  for  stimulation.  Digitalis 
is  rarely  beneficial  in  fever  cases,  and  may  produce  urgent  signs  of 
cumulative  action  if  the  fever  should  fall.  The  author  has  seen  one 
case  in  which,  with  rather  sudden  defervescence,  the  pulse  dropped 
from  140  to  40.  Camphor,  gr.  ij.,  disagrees  when  given  by  the  mouth 
and  should  be  given  under  the  skin  in  1  to  10  parts  of  sterilized  olive 
oil.  Other  cardiants  are  considered  under  valvular  disease  and  pneu- 
monia. Sudden  dilatation  should  be  treated  by  venesection  and  stimu- 
lation. Alcohol  may  be  considered  under  this  head.  In  typhoid  it 
may  be  indicated  (a)  as  a  food,  with  milk  and  eggs,  thus  aiding  diges- 
tion: 3j-  to  i"^"-  of  whiskey  may  be  given  every  two  to  four  hours  in 
hot  milk.  Stokes's  mixture  contained  cognac,  oij-5  Vitelli  o\d.,  one; 
Syr.  aurantii,  5"^'-;  water  q.  s.  ad  §v.  Eggnog  is  valuable  as  a  food 
which  may  be  readily  absorbed,  (b)  As  a  cardiant  (though  phar- 
macologists hold  that  pure  alcohol  is  not  a  cardiant),  Meltzer  states 
that  it  equalizes  the  circulation.  It  is  indicated  especially  in  young 
alcoholics,  and  in  most  cases  over  forty  years  of  age.  Cognac  may  be 
given  by  the  mouth,  in  coffee;  or  by  rectum,  in  peptonized  milk 
with  two  drachms  of  tincture  of  valerian,  (c)  As  a  nervine  in  debility 
or  old  age,  as  whiskey,  champagne  (especially  for  vomiting),  sherry, 
or  port,  (d)  To  a  less  degree  as  an  antipyretic,  since  it  increases  the 
sweat  production.  Its  use  must  be  suspended  when  the  pulse  becomes 
bounding,  the  respiration  hurried,  the  skin  or  tongue  dry,  and  when 
there  is  restlessness,  or  the  odor  of  alcohol  appears  on  the  breath. 
Like  other  good  things,  alcohol  has  been  abused,  and  of  late  the  re- 
action against  its  use  is  in  part  sound  and  in  part  excessive.  With 
care  and  discretion  alcohol  is  invaluable  in  severe  cases. 

Thrombophlebitis  is  treated  by  quiet,  elevation,  warmth,  and  ban- 
daging from  the  toes  upward. 

3.  Respiratory  System. — Epistaxis  usually  ceases  spontaneously. 
If  the  blood  runs  into  the  throat  a  tampon  should  be  introduced. 
Laryngeal  complications  may  necessitate  early  tracheotomy.  Only 
2  per  cent,  of  severe  laryngeal  complications  recover  without  opera- 
tion. Bronchitis  is  treated  most  efficaciously  by  hydrotherapy,  or 
sometimes,  though  rarely,  by  codeine.  Expectorants  should  always 
be  avoided  since  they  are  likely  to  produce  gastric  disorder.  Hypo- 
stasis is  best  treated  by  hydrotherapy,  cardiants,  and  change  of  pos- 
ture every  two  hours,  for  which  written  orders  should  be  given. 

4.  Nervous  System. — The  initial  headache  may  be  relieved  by  hy- 
drotherapy, the  ice-cap,  ergotin  and  antipyrin,  each  gr.  v.,  for  several 


TYPHUS  FEVER  55 

doses.  Depression  is  relieved  by  valerian  and  whiskey.  For  delirium, 
and  insomnia,  hydrotherapy  is  the  most  useful  measure;  veronal,  gr. 
v.-vij.  in  warm  water,  produces  a  very  natural  sleep ;  alcohol ;  morphia, 
gr.  j;  codeine,  gr.  ^5  sodium  bromide,  3sstoj.;  and  hyoscine  hydro- 
bromate,  gr,  ilo  to  g'o ;  may  be  indicated. 

Morphinse  hydrochloridi gr.  J. 

Sodii  bromidi gr.  xxxxv. 

Syrupi  aurantii 3iij. 

Aquse  chloroformi ad   §ij. 

M.  f.  mist. 

S. — Half  to  be  taken  at  bed-time,  and  the  remainder  in  three  hours,  if  necessary. 
(Whitla). 

Typhoid  patients  should  never  be  left  alone,  lest  they  leave  the  bed 
or  leap  from  the  window.    Restlessness  may  suggest  a  full  bladder. 

5.  The  Skin. — Massage  with  alcohol  or  olive  oil  is  useful.  The 
skin  functions  are  helped  by  the  full  bath.  In  the  formation  of  bed- 
sores the  following  are  factors :  Local  heat,  pressure,  moisture,  mace- 
ration, or  filth.  All  of  these  can  generally  be  avoided  by  frequent 
changes  of  posture,  thick  pads  or  rubber  rings,  and  cleanliness.  In 
some  cases  great  debility  may  frustrate  prophylaxis.  The  least  ery- 
thema, papule,  abrasion,  or  pustule,  on  dependent  parts  is  a  matter 
of  solicitude.  If  bed-sores  have  already  developed,  the  simplest  treat- 
ment is  the  best,  since  antiseptics  and  powders  sometimes  only  aggra- 
vate. The  balsam  of  Peru  is  excellent.  Collodion  and  adhesive 
straps  are  always  to  be  avoided  as  far  as  possible. 

6.  Bacilluria. — Bacilluria  is  met  by  salol  and  urotropin,  each  gr.  x., 
t.  i.  d.     Special  care  is  necessary  in  the  use  of  catheters. 

{H).  Treatment  in  Convalescence. — The  convalescence  must  be  ac- 
tual, and  the  possibility  of  relapses  must  be  excluded  before  the  patient 
can  have  substantial  diet  or  be  allowed  to  sit  up.  It  is  best  to  err  on 
the  safe  side,  as  embolism  and  collapse  are  not  unknown  in  conva- 
lescence. Eggs,  toast,  gruels,  rice,  etc.,  may  be  given  after  one  week 
of  normal  temperature.  The  patient  should  not  leave  his  bed  for 
two  weeks.  Irregular  fever  lingers  in  some  cases  until  solid  food  is 
given.  In  other  cases,  nitrogenous  food  will  cause  a  higher  tempera- 
ture (febris  carnis).  Vegetables  and  fruits  should  be  postponed  for 
a  few   weeks.     An  excellent  tonic  in  convalescence  is  the  following: 

Strychninse  sulphatis gr.  j. 

Acidi  nitrohydrochlorici oj. 

Tr.  gentianse  co ov- 

M.  et  S. — One  teaspoonful  after  meals  in  half  a  glass  of  water. 


TYPHUS  FEVER 

Synonyms. — Typhus   fever;    exanthematous  typhus;    war,  prison, 
ship,  or  famine  fever. 


56  THE  SPECIFIC  IXFECTIONS 

Definition. — An  acute,  highly  contagious,  specific  infection  of  un- 
known causation;  mostly  epidemic,  with  a  sudden  onset  and  a  high 
temperature,  falling  by  crisis,  and  with  a  cyclic  curve,  a  character- 
istic eruption,  and  severe  nervous  symptoms.  Typhus,  first  described 
by  Corradi  (1083),  was  first  clearly  distinguished  by  Fracostorius,  in 
Verona  (1505). 

Etiology. — A\\  stages  of  the  disease  are  highly  contagious.  The  virus, 
which  is  as  yet  unknown,  exists  in  the  exhalations  from  the  skin  and 
lungs  (Murchison),  and  survives  for  a  long  time  in  clothing  and  fur- 
niture. Infection  is  usually  direct  from  person  to  person.  The  dan- 
ger to  attending  nurses  and  physicians  is  therefore  great,  especially  in 
severe  epidemics.  The  more  intimate  the  contact  the  greater  is  the 
danger  of  direct  infection.  It  is  also  communicable  indirectly  by  a 
third  person,  by  means  of  fomites,  etc.  The  point  of  entrance  to  the 
system  is  probably  the  lungs.  Cases  appear  from  time  to  time,  the 
history  of  which  cannot  be  traced.  Immunity  is  usually  conferred  by 
one  attack,  but  may  be  congenital.  Susceptibility  to  the  disease  is 
general. 

Geography. — Ireland,  Russia,  Galatia,  Hungary,  Italy,  and  Mexico, 
are  its  most  frequent  homes,  and  there  are  always  cases  in  China, 
Asia  Minor,  and  Hungary.  It  is  endemic  in  Berlin,  occurring  among 
the  lower  classes,  among  vagabonds,  and  in  the  unclean,  poorly-fed, 
closely-packed  and  unhygienic  population.  Typhus  was  one  of  the 
greatest  scourges  of  the  middle  ages,  with  its  wars  and  famines,  but 
it  has  decreased  in  the  past  century,  the  epidemics  in  Ireland  (1817 
and  1846)  and  in  the  Turko-Russian  war  (1877-78)  being  the  last 
general  outbreaks.  Its  most  recent  occurrence  in  this  country  was 
in  New  York  (1881-82  and  1893),  in  Philadelphia  (1883),  and  in 
Baltimore  in  1901  (Osier). 

Age. — Most  cases  occur  between  the  fifteenth  and  twenty-fifth  years. 
It  is  rare  in  the  young  or  aged,  though  it  has  been  observed  before  the 
first  year  and  after  the  eightieth.  It  may  occur  with  other  epidemics, 
such  as  typhoid,  recurrent  fever,  malaria,  and  smallpox.  The  bac- 
teriologv  of  tvphus  is  undetermined.  A  streptococcus  was  found  by 
Hlava  (1891)\nd  a  diplococcus  by  Dubieff  and  Bruhl  (1893). 

General  Clinical  Picture. — 1.  incubation. — The  incubation  lasts 
twelve  days  (seven  to  fourteen),  or  less  in  children,  and  is  usually 
unaccompanied  by  symptoms. 

2.  The  Stage  of  Invasion. — The  stage  of  invasion  is  sudden,  ex- 
hibiting one  or  more  chills  and  a  high  temperature  on  the  first  day. 
The  patient  therefore  comes  early  under  treatment.  Thirst  follows, 
with  anorexia,  coated  tongue,  nausea,  vomiting,  epigastric  oppression, 
suffusion  of  the  face,  conjunctivae,  nose,  and  pharynx;  dysphagia, 
apathy,  delirium,  epistaxis,  backache,  severe  pains  in  the  extremities, 
rapid  pulse,  and  early  splenic  intumescence. 

3.  The  Exanthematous  Stage. — The  exanthematous  stage  is  indi- 
cated on  the  third  or  fifth  day  by  a  roseolous  eruption,  at  first  pale- 
red  and  purely  hypersemic.     It  is  seen  first  on  the  abdomen,  and 


TYPHUS  FEVER  57 

chest,  extending  rapidly  to  the  back  and  extremities.  The  eruption 
then  develops  a  'petechial  character,  with  some  serous  infiltration  in 
the  centre  or  edge  of  the  flecks,  which  become  dirty  and  copper-col- 
ored. It  lasts  seven  to  ten  days.  In  this  stage  there  is  no  pain,  but 
often  apathy,  prostration,  delirium  or  mania.  The  tongue  and  mouth 
are  dry  and  dark.  Catarrhal  inflammations  of  the  pharynx,  larynx  and 
bronchi  develop,  with  hoarseness  and  cough.  The  fever  is  continuous. 
Coma-vigil,  rapid  respiration  and  pulse,  and  hypostatic  pneumonia 
may  end  the  case. 

4.  Defervescence. — ^The  crisis  usually  occurs  on  the  tenth  to  the 
fourteenth  day.  The  defervescence  may  occupy  two  or  three  days 
(lysis).  The  pulse  becomes  slower;  the  skin  often  desquamates  in 
dusky  scales;  profuse  sweats  are  common;  the  tongue  clears,  and 
convalescence  is  established  in  from  twelve  to  seventeen  days.  Long 
defervescence  is  suggestive  of  complications. 

Special  Sjrmptomatology. — 1.  Fever. — After  a  rigor,  the  tempera- 
ture rapidly  rises  to  103°,  105°,  or  even  107°,  on  the  first  or  second  day 
(Wunderlich).  No  other  acute  exanthematous  disease  produces  an 
equally  high  early  temperature.  Remissions  are  few  and  slight  in 
the  first  week,  and  the  maximum  temperature  is  observed  on  the 
fifth  day.  On  the  tenth  day  the  temperature  often  remits,  except  in 
the  most  severe  cases.  The  crisis  occurs  from  the  tenth  to  the  four- 
teenth day,  with  sweating,  exhaustion,  relief  of  symptoms,  and  often 
with  subnormal  temperature.  Curschmann  considers  that  lysis  is  as 
frequent  as  crisis.  Remissions  rarely  occur  in  this  disease.  Afebrile 
typhus  is  rare.  So  also  are  precritical  elevations  and  pseudo-crises. 
Death  occurs  either  with  a  preagonal  rise  or  with  collapse  of  temperature. 

2.  The  Skin. — The  eruption  consists  of  two  elements:  Roseolse 
changing  to  petechise,  and  a  fine,  dusky-red  mottling  under  the  skin. 
The  roseolce  are  seen  on  the  third  or  the  fifth  day;  they  increase  rap- 
idly and  abundantly,  though  never  in  recurrent  crops,  and  are  at  their 
height  within  two  days.  They  are  located  chiefly  on  the  lower  ab- 
domen, chest,  back  or  shoulders,  are  least  abundant  on  the  thighs, 
and  do  not  appear  on  the  face  except  in  women  and  children  whose 
skin  is  delicate.  The  palms  of  the  hands  and  the  soles  of  the  feet 
are  generally  exempt. 

The  roseolae  are  pale-red,  washed  in  outline,  round  or  oval,  the  size 
of  a  pin-head  or  a  lentil.  They  are  hj'-persemic,  and  therefore  dis- 
appear on  pressure  and  after  death.  They  are  easily  overlooked  at 
night.  They  last  one,  two,  or  at  the  most  three  days,  later  becoming 
dark,  livid,  or  copper-colored  petechioe  persisting  on  pressure  and  after 
death,  because  hemorrhagic.  The  petechiae  occur  mostly  on  the  back, 
or  in  the  folds  of  the  groin,  and  may  lie  between  the  roseolse.  The 
hemorrhage  may  extend  more  widely  either  into  the  skin  or  in  the 
subcutaneous  tissue.  Typhus  cases  presenting  no  rash  are  rare.  A 
great  multiplicity  of  petechise  is  an  ominous  feature,  especially  in 
cachectic  and  alcoholic  subjects.  A  morbilliform  eruption  on  the 
arms  and  legs  is  occasionally  observed  before  the  usual  typhus  rash, 


58  THE  SPECIFIC  INFECTIONS 

especially  in  thin-skinned  individuals.  The  skin  is  usually  dry,  but 
miliaria  may  appear  (in  6  to  10  per  cent,  of  the  cases),  notably  in  the 
young.  Icterus  without  decolorization  of  the  stools  is  frequent  and 
is  an  unfavorable  sign.  Desquamation  occurs,  and  is  sometimes  as 
profuse  as  in  scarlatina;  herpes  occurs  in  5  to  20  per  cent.,  and  bed- 
sores in  3  per  cent,  of  the  cases.  The  skin  has  a  peculiarly  pungent, 
offensive,  or  ammoniacal  odor. 

3.  The  Nervous  System. — This  is  markedly  involved,  toxaemia  be- 
ing profound.  Headache  is  constant  until  the  exanthem  appears; 
it  is  frontal  and  temporal,  infrequently  occipital,  and  radiates  into 
the  neck  or  shoulders.  It  is  associated  with  vertigo,  backache,  and 
hypersesthesia  of  the  fingers  and  toes.  The  sensorium  first  shows  de- 
pression, characterized  by  apathy,  insomnia,  incoherent  speech,  or 
disturbing  dreams,  which  increase  as  the  pains  disappear.  In  the  second 
week  coma-vigil,  low  delirium,  mania  and  hallucinations  often  de- 
velop. Suicidal  tendencies  may  be  noted,  especially  in  the  young  and 
robust.  Involuntary  evacuations  and  noisy  cerebral  respiration  also 
occur.  The  earlier  the  nervous  symptoms,  the  more  ominous  is  their 
significance.  Neuralgia  is  occasional  in  defervescence.  It  is  transient, 
and  exists  mostly  in  the  lower  extremities.  Tremor  of  the  forearms 
and  hands  is  almost  constant.  Convulsions  are  rare,  but  ominous. 
They  are  observed  chiefly  at  the  end  of  the  second  week  in  alcoholic 
or  very  irritable  subjects  and  in  children.  They  are  more  often  epi- 
leptiform than  partial,  tetanic,  or  trismic.  Paralysis  occurs  from  brain 
hemorrhage,  embolism,  etc.  Cases  of  paraplegia  and  aphasia  are 
recorded.     Meningitis  is  most  rare. 

Special  Senses. — There  is  conjunctival  catarrh  and  the  "pin-head 
pupil"  of  Graves.  The  ears  are  involved  in  32  per  cent,  of  the 
cases. 

4.  Circulation. — The  heart  and  vasomotor  system  suffer  greatly 
(Stokes).  The  pulse,  which  is  of  greatest  prognostic  value,  is  small 
and  greatly  increased,  reaching  100  to  120,  and  even  higher  in  women 
and  children.  It  is  slow  only  in  light  cases.  Dicrotism  is  rare.  It  is 
labile  and  often  slow  in  convalescence.  Acute  myocarditis  may  occur 
with  acute  dilatation,  which  is  highly  dangerous,  especially  in  alco- 
holics. Its  symptoms  are  those  described  under  Typhoid.  In  fatal 
cases  the  heart  muscle  is  granular  and  deep-red.  The  blood  is  dark 
and  fluid;  the  red  cells  and  haemoglobin  are  decreased,  and  the  white 
cells  are  increased. 

5.  Respiration. — Epistaxis  is  occasional.  Laryngeal  involvement 
varies  with  the  epidemic.  Hoarseness,  erosions,  fissures,  ulcerations, 
oedema,  and  perichondritis,  may  develop  and  may  possibly  lead  to 
secondary  abscess  of  the  lung  or  empyema.  Catarrh  of  the  upper 
air-passages,  bronchitis,  and  tracheitis,  are  part  of  the  disease.  They 
are  present  at  the  onset,  increase  with  the  fever,  and  are  evidenced  by 
a  cough,  with  a  slight  expectoration,  which  is  sometimes  streaked 
with  blood.  Catarrh  with  weak  heart  results  in  atelectasis,  hypostasis, 
and  lobular  pneumonia. 


TYPHUS  FEVER  59 

Pneumonia  occurs  in  15  per  cent,  of  typhus  cases,  usually  in  the 
second  week,  and  is  frequently  atypical. 

6.  Gastro-Intestinal  Tract. — The  tongue,  at  first  moist  and  white, 
becomes  dry  and  dark — the  "parrot  tongue."  Thirst  is  common. 
Nausea  and  vomiting  are  fairly  common,  and  meteorism  is  infrequent. 
The  epigastrium  only  is  tender.  The  liver  is  swollen,  soft,  and  grayish. 
There  is  usually  constipation  (90  per  cent,  of  the  cases),  although  diar- 
rhoea may  appear  at  the  crisis.  Gastro-intestinal  hemorrhage,  a 
hemorrhagic  diathesis,  diphtheritic  ulcerations,  parotitis,  ulceration  of 
the  oesophagus  and  pharynx,  phlegmons,  and  peritonitis,  are  infrequent. 

7.  Genito-Urinary  Tract. — The  urine  is  febrile.  The  urea  is  often 
decreased  but  may  be  increased  after  the  crisis.  The  chlorides  are  de- 
creased or  may  be  absent  entirely.  Albumin  frequently  appears  in 
the  second  week.  Nephritis  (in  6  per  cent,  of  the  cases)  is  dangerous. 
Uraemia  and  hsematuria  are  rare.  The  urine  will  frequently  show  the 
diazo  reaction.  Diacetone,  leucin,  and  tyrosin,  may  be  found.  Dys- 
uria,  orchitis,  and  menstrual  disturbances,  occasionally  occur. 

8.  Spleen  and  Glands. — An  early  splenic  tumor  is  palpable  in  33 
to  66  per  cent,  of  the  cases.  It  disappears  late  in  the  second  week.  The 
splenic  pulp  is  fluid  and  degenerated.  Rupture  has  been  described. 
The  lymphatic  glands  are  not  usually  enlarged,  though  adenitis  was 
noted  during  the  Crimean  and  Turko-Russian  epidemics. 

Recurrence. — ^This  is  very  rare  in  typhus.  It  happened  only  once 
in  5,000  cases  (Buchanan). 

Anomalous  Courses. — Light  forms  run  a  course  of  six  to  ten  days, 
with  less  fever,  fewer  nervous  symptoms,  and  less  rapid  pulse  than  in 
the  more  severe  types.  They  include  the  abortive  type  without  erup- 
tion, and  the  ambulatory  type.  Very  severe  forms  are  the  hyper- 
pyretic  (fatal  in  two  to  three  days),  or  the  adynamic  (in  which  the 
patient  dies  with  low  temperature,  hemorrhages,  etc.).  Complication 
with  other  diseases,  or  the  patient's  advanced  age,  may  intensify  the 
symptoms. 

DifEerentiation. — This  is  not  difficult  if  the  case  is  seen  from  begin- 
ning to  end,  or  during  an  epidemic.  There  are  no  absolute  pathologi- 
cal or  bacteriological  criteria.  Mistakes  in  the  diagnosis  of  sporadic 
cases  are  often  inevitable.  In  the  initial  stage  only  a  probable  diag- 
nosis can  be  made. 

In  smallpox  the  chills,  fever,  prostration,  severe  aches,  splenic 
tumor,  and  backache,  are  not  final,  since  they  are  less  marked  in 
mild  forms  of  the  disease.  The  initial  scarlatiniform  eruption  in  the 
angles  of  the  arms  and  groins  is  characteristic  of  smallpox.  The  mor- 
billiform eruptions  occur  also  in  typhus.  Smallpox  invades  the  face 
more  than  does  typhus,  and  the  relation  of  the  eruption  to  the  tem- 
perature remission  is  not  observed  in  typhus.  Even  at  postmortem 
examinations,  differentiation  between  the  hemorrhagic  form  of  typhus 
and  the  purpura  variolosa  is  frequently  impossible. 

In  recurrent  fever,  the  fever-curve  is  important,  but  the  diagnosis 
may  be  difficult  during  the  first  attack.     The  history,  the  lack  of  in- 


60 


THE  SPECIFIC  IXFECTIONS 


volvement  of  the  sensorium,  the  generally  favorable  condition  of  the 
patient,  the  absence  of  pain,  the  characteristic  anaemic  yellow-gray 
skin,  the  spirilla  and  successive  attacks,  indicate  recurrent  fever. 

In  irregular  epidemics,  meningitis,  with  chills,  fever,  nervous  symp- 
toms, coma,  and  headache  (without  rigid  neck  and  with  a  roseolous 
eruption),  at  first  presents  difficulties,  though  in  the  later  course,  it 
may  be  distinguished  after  lumbar  puncture  and  examination  of  the 
retinae.  The  eruption  is  at  first  roseolous  but  later  is  petechial.  If  the 
petechise  occur  first,  the  disease  is  not  typhus. 


Ttphus. 

Invasion:     sudden;     chill,   corj'za. 

Roseola:  ]\Iore  numerous  and  earlier, 
second  day  to  fifth  day. 

Never  in  crops. 

Distribution  on  body  and  extremities. 

Sparingly  on  face. 

Flat,    pale,    washed,    hypersemic,    not 

disappearing    upon    pressure    when 

they  become  petechial. 

Course:    more  rapid. 

Face  and  eyes  injected. 

Fever:  abrupt  rise,  higher,  less  remis- 
sion, if  any;  shorter;  crisis  or,  short 
lysis,  on  fourteenth  day. 

Soon  bedridden. 

Earlier  and  severer  nervous  symptoms. 

Pulse:  rapid  and  not  dicrotic. 

Spleen:  early  swelling,  but  less  frequent. 

Less  meteorism  or  none. 
Stools:  not  characteristic. 
Blood:  leukocytosis. 


Typhoid. 

Slower  and  more  gradual;  no  coryza. 

Usually  less  points  of  eruption  (are  ex- 
ceptions,— e.  g.  measles-like);  in  ex- 
tremities, as  in  Franco-German  war. 

In  successive  crops. 

On  body;   rarely  on  extremities. 

Almost  never  on  face. 

Papiilar,  pink,  sharply  outlined,  always 
hypersemic,  disappearing  upon  pres- 
sure. 

Slower. 

Paler;  conjunctivitis  rare. 

Slow  rise  and  regular  stages. 

Oftener  ambulato^5^ 

Second  week  or  later,  and  less  severe. 

Dicrotism  of  less  importance  than  slow- 
ness. 

Later,  but  lasts  longer;  two  or  three 
times  more  frequent. 

Meteorism. 

Ochre-stools. 

Leukopenia,  Widal  reaction;  bacteria 
in  blood,  urine,  roseolse. 


DiAzo  Reaction  in  Both. 

In  Measles  the  face  is  the  first  seat  of  eruption;  the  rash  is  rarely 
hemorrhagic;  catarrhal  symptoms  precede  the  eruption,  when  the 
fever  again  rises.    Typhus  is  rare  under  five  years  of  age. 

Prognosis. — The  prognosis  depends  upon  the  intensity  of  the  tox- 
aemia, the  fever,  the  nervous  symptoms,  and  on  the  complications — 
especially  pneumonia.     Death  from  toxaemia  usually  occurs  in  the 


RECURRENT  FEVER  61 

second  week  (twelfth  day);  from  pneumonia  in  the  third  week.  The 
mortahty  varies  between  6  and  20  per  cent.,  but  reaches  50  per  cent, 
in  virulent  epidemics  and  in  patients  over  fifty  years  of  age.  Children 
rarely  die  of  typhus. 

Treatment. — The  treatment  is  that  of  typhoid,  with  the  added  in- 
dication of  strict  isolation.  Open-air  treatment  in  tents  is  indicated, 
with  thorough  disinfection  of  everything  coming  in  contact  with  the 
patient.    Cardiac  stimulants  are  more  often  required  than  in  typhoid. 

RECURRENT  FEVER. 

Synonjons. — Relapsing  fever;  febris  recurrens;  typhus  recurrens; 
seven-day  fever;   famine  or  prison  fever;    bilious  typhoid. 

Definition. — A  specific  infectious  disease  caused  by  Obermeier's 
spirillum;  acquired  more  often  by  direct  personal  contact  than  by 
indirect  infection;  endemic  in  Ireland,  Russian  Poland,  and  India, 
though  sometimes  epidemic;  clinically  characterized  by  a  cyclic  course 
of  febrile  attacks  lasting  six  or  seven  days,  followed  by  an  equally 
long  apyretic  interval,  which  cycle  may  be  repeated  several  times. 

Etiology. — Recurrent  fever  has  been  known  for  nearly  two  cen- 
turies. It  was  first  described  by  Rutty,  of  Dublin,  in  1739.  It  ap- 
peared in  America  in  1844,  and  was  last  seen  in  1869.  Obermeier  in 
1873  described  a  specific  spirillum  or  spirochseta  (Spirillum  Ober- 
meieri).  Recurrent  fever  is  transmitted  not  by  the  spirillum  itself, 
but  by  its  spores,  since  the  disease  may  recur  after  the  spirillum  has 
been  killed  by  quinine.  The  spores  are  possibly  the  glistening  bodies 
sometimes  seen  in  the  blood  {q.  v.).  The  breath  and  exhalations 
are  infectious,  though  less  so  than  in  typhus.  The  secretions  are  ap- 
parently not  infectious.  The  disease  has  been  inoculated  in  monkeys 
and  in  man,  from  postmortem  cuts.  Bed-bugs  may  also  convey  it. 
Infection  is  carried  chiefly  by  vagabonds  and  emigrants.  Males  are 
especially  affected  (80  to  98  per  cent.).  Most  cases  occur  between  the 
twentieth  and  the  fortieth  years.  It  is  rare  after  forty-five,  and  has 
been  seen  in  the  foetus.  Epidemics  may  occur  with  typhus,  and  more 
rarely  with  typhoid,  malaria,  or  smallpox. 

Symptoms. — Incubation. — After  an  incubation  of  from  five  to  seven 
days,  the  invasion  occurs,  usually,  without  prodromes. 

The  Invasion. — The  invasion  begins  with  a  chill,  a  high  tempera- 
ture (reaching  possibly  104°  on  the  first  day),  a  throbbing  headache, 
and,  in  the  young,  convulsions  and  vomiting.  The  vertigo  and  cere- 
bral confusion  may  resemble  acute  alcoholism.  Because  of  the  severe 
neuralgic  pain  in  the  back,  legs,  and  calves,  the  patient  lies  motion- 
less. There  is  great  depression,  conjunctival  suffusion,  slightly  icteric 
sclerse,  a  pale  (even  cachectic)  facial  color,  epigastric  oppression  with 
or  without  vomiting,  and  tenderness  over  the  liver  and  spleen. 

The  Specific  Findings  are  in  (1)  the  blood;  (2)  the  spleen;  (3)  the 
bone-marrow. 


62  THE  SPECIFIC  IXFECTIOXS 

1.  The  blood  is  dark  and  reveals  the  pathognomonic,  motile,  cork- 
screw-shaped spirillum,  which  is  found  usually  with  the  appearance  of 
the  fever,  though  occasionally  a  few  hours  before. 

It  often  disappears  and  becomes  less  motile  before  the  fever  falls; 
and  is,  on  rare  occasions,  found  from  one  to  three,  or  even  fourteen  days 
after  the  fever.  It  appears  again  with  the  next  attack.  The  spirillum 
is  found  in  the  blood  only.  The  number  is  variable  and  not  propor- 
tionate to  the  severity  of  the  disease;  as,  for  instance  one  spirillum  in 
ten  to  seventy  fields  at  first,  and  twelve  to  thirty  spirilla  in  a  field  at  the 
acme.  Without  the  immersion-lens,  they  may  be  located  by  the  lashing 
about  of  the  red  cells.  They  always  lie  between  and  never  in  them, 
and  appear  as  fine  threads,  sixteen  to  forty  millimeters  in  length, 
with  five  to  ten  waves  in  each,  and  move  bv  undulation  along  their  ions: 
axes.  They  stain  best  with  fuchsin,  after  the  extraction  of  the  li:i'm> 
globin  by  acetic  acid.  Their  life  in  the  blood  is  usually  thirty-seven, 
days. 

The  white  blood-cells  are  increased.  Larcre,  fattv,  ofrauular  pioto- 
plasma-cells,  probably  from  the  spleen,  may  sometimes  be  seen. 

2.  The  spleen  is  nearly  always  enlarged,  painful,  and  palpable,  and 
varies  in  size  directly  with  the  temperature.  According  to  Leube,  in  no 
other  infectious  disease  is  the  spleen  so  large,  being  increased  five-  to 
sixfold  and  weighing  even  twenty  pounds.  The  capsule  is  tense, 
sometimes  with  perisplenic  adhesions,  and  the  pulp  is  a  fluid-red.  The 
Malpighian  bodies  are  increased,  and  necrotic  areas  and  infarcts  are 
common.  Suppuration  and  rupture  (6  per  cent,  of  the  cases)  may  occur, 
^licroscopically  there  are  hyperemia,  hyperplasia,  spirilla,  large  fatty 
cells  fin  the  portal  and  other  vessels),  and  fatty  desquamated 
endothelium  from  the  veins,  thus  explaining  the  spindle-cells  found  in 
the  blood-stream. 

3.  The  bone-marrow  resembles  the  splenic  follicles  and  contains 
many  granular  cells,  and,  occasionally,  aggregations  of  white  blood-cells. 

Other  Symptoms. — 1.  Nervous  System. — Headache  is  frequent. 
The  sensorium  is  usually  free,  delirium  and  insomnia  being  rare. 

2.  Temperature. — The  temperature  rises  abrupdy  to  103°  or  104,°  and 
remains  continuously  high  flOo.S"  to  107.6°),  from  five  to  seven  days, 
when  the  crisis  occurs.  In  no  other  disease  is  the  defervescence  so 
precipitate  (Leube).  The  fever  falls  5°  to  13°  (even  16°).  In  from  five 
to  seven  days  the  patient  is  well,  when  in  99  per  cent  of  cases  the  cycle 
is  repeated.  In  the  second  or  following  attack  there  may  be  no  chill. 
There  are  usually  but  two  or  three  relapses,  though  as  many  as  seven 
have  been  recorded,  each  successive  one  being  shorter  by  one  to  one 
and  one-half  days.  The  temperature-curve  is  diagnostic.  Lysis  is  rare 
(1  to  2  per  cent,  of  the  cases).  The  crisis  is  followed  by  rapid  convales- 
cence, sweats,  shrinkage  of  the  spleen,  and  disappearance  of  the  spiril- 
lum;  sometimes  post-critical  diarrhoea  and  collapse  develop. 

3.  Circulatory  System. — -The  pulse  is  rapid  (120  to  140).  Compared 
with  the  temperature,  it  is  full  and  hard,  seldom  dicrotic,  sometimes 
irregular,  and  often  slow  after  the  crisis. 


RECURRENT  FEVER 


63 


4.  Respiratory  Tract. — Bronchitis  (20  to  47  per  cent,  of  the  cases)  and 
increased  respirations  (thirty  or  more)  have  been  observed.  In  fatal 
cases  atelectasis,  hypostasis,  pneumonia  (40  per  cent.),  glottis  oedema 
(31  per  cent.),  and  pleurisy  (2  to  3  per  cent.),  have  been  found. 


Fig 

.  7 

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4 

5 

G 

7 

8 

9 

10 

11 

IX 

13 

14 

15 

la 

17 

18 

19    20 

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23 

24 

2.'. 

20 

.!' 

TEMP. 

105 

i 

104 

li 

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103 

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v 

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K 

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102 

A 

I      ' 

m 

101 

, 

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100 

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97 

l\ 

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90 

i 

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93 

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V 

94 

^ 

Fever  chart  in  recurrent  fever. 

5.  Gastro-Intestinal  Tract. — The  tongue  is,  at  first,  white  and  later 
becomes  yellow-brown.  The  appetite  may  be  unimpaired.  Hsemate- 
mesis,  a  tender  and  swollen  liver,  icterus  (S  to  2.5  per  cent,  of  the  cases), 
gall-bladder  distention,  bloody  effusions  in  the  alimentary  mucosa,  and 
hyperplasia  of  the  lymphatics,  may  be  observed. 

6.  Genito-Urinary  Tract. — The  urinary  findings  resemble  those  of 
typhoid.  Nephritis  is  infrec[uent  (2  to  4  per  cent,  of  the  cases),  and 
abortion  occurs  in  66  to  100  per  cent. 

7.  Skin. — The  skin  is  usually  subicteric,  yet  the  stools  remain 
colored.  Herpes  (2  to  32  per  cent,  of  the  cases),  oedema,  erythema, 
petechia,  urticaria,  desquamation,  and  even  roseolse,  have  been  noted. 
The  hot  and  dry  skin  becomes  drenched  at  the  crisis. 

Diagnosis. — The  specific  points  are:  A  prevailing  epidemic ;  onset 
with  chill  and  fever;  swelling  and  tenderness  of  the  liver  and  spleen; 
muscular  pains;  an  abrupt  crisis;  an  apyretic  interval  with  recurrence 
of  the  cycle,  and  the  spirilla  foimd  by  blood  examination. 

Loeventhal  has  found  that  the  serum  acts  as  a  bactericide  on  the 
spirochfetae.  In  the  bilious  type  (bilious  typhoid  or  septic  recurrent 
fever),  there  is  severe  icterus,  destruction  of  the  red  corpuscles,  and 


64  THE  SPECIFIC  INFECTIONS 

pathological  liver-findings  wliicli  are  suggestive  of  acute  yellow  atrophy. 
Hemorrhages,  involvement  of  the  sensorium,  and  death  from  collapse 
in  the  first  attack  (60  per  cent,  of  the  cases),  are  common.  The  colored 
stools,  rapid  pulse,  severe  bronchitis,  and  enlarged  spleen,  are  significant. 
Malaria,  typhoid,  typhus,  yellow  fever,  acute  yellow  atrophy  of  the 
liver,  and  Weil's  disease,  are  excluded  by  one  examination  of  the  blood. 

Complications  of  recurrent  fever  include  pneumonia  and  other 
lesions  already  mentioned.  ^Meningeal  hemorrhages,  psychopathies, 
paralysis,  neuritis,  and  eye  complications,  are  very  infrequent. 

Convalescence. — Convalescence  is  rapid,  after  four  or  five  weeks. 
Death  may  occur  from  toxaemia,  heart  collapse,  or  from  complications. 
The  prognosis  is  good,  the  mortality  averaging  2  to  10  per  cent.,  although 
reaching  60  per  cent,  in  the  bilious  type.  One  attack  is  not  certain  to 
confer  immunity. 

Treatment. — The  treatment  is  that  of  typhoid,  as  no  drug  has  any 
effect  on  the  parasites.  Pain  often  necessitates  the  use  of  opiates.  The 
heart  weakness  is  treated  as  it  is  in  typhoid. 


SMALLPOX    AND  VARIOLA.     VACCINATION. 

Definition. — -Smallpox  is  an  acute,  highly  infectious,  specific  disease. 
It  begins  suddenly  with  a  chill,  headache,  vomiting,  and  intense 
epigastric  and  lumbar  pain,  and  is  characterized  by  a  typical  fever- 
curve  and  by  an  eruption  on  the  skin  and  contiguous  mucous  sur- 
faces consisting  of  papules,  vesicles,  pustules,  and  crusts  in  successive 
stages. 

History. — Smallpox  is  said  to  have  prevailed  in  China  many  cen- 
turies before  the  Christian  era.  Galen's  pesta  magna  of  the  second 
century  is  thought  to  have  been  variola.  Epidemics  occurred  in  the 
sixth  century,  and  during  the  crusades.  Rhazes  (Arabia,  ninth  cen- 
tury) gave  us  the  first  accurate  clinical  description  of  the  disease. 
Smallpox  was  introduced  into  Mexico  in  1520,  by  the  Spaniards,  and 
three  and  a  half  million  persons  contracted  the  disease.  Sydenham's 
classic  of  the  seventeenth  century  is  most  accurate  and  reliable.  In  1718, 
Lady  INIontague  introduced  into  England  preventive  inoculation, 
which  had  been  practiced  for  centuries  in  Asia,  and,  though  she  reduced 
the  mortality  by  this  means  to  1  per  cent,  or  less,  she  only  disseminated 
the  disease  in  a  mitigated  form.  Jenner's  discovery  of  vaccination,  in 
1796,  has  greatly  lessened  the  terrors  of  variola,  which  in  Europe 
alone  carried  off  nearly  half  a  million  persons  yearly,  and  in  Iceland 
cost  the  lives  of  36  per  cent,  of  the  population. 

Etiology. — The  virus  is  still  imperfectly  known.  Weigert  and  others 
have  found  pyogenic  organisms,  although  suppuration  is  due  to  a  later 
mixed  infection.  Protozoa  were  first  mentioned  by  Van  der  Loeff,  in 
1886.  The  cytorytes  variolce  of  Guarnieri  (1892)  is  an  amoeba  found  in 
the  blood  in  the  incipient  stage,  in  that  of  vaccinated  children  and  of 


SMALLPOX  AND   VARIOLA.      VACCINATION  65 

calves,  and  in  the  exanthem.  Pfeiffer,  Roger,  Weil,  Funck,  Copeman, 
Councilman,  Mallory,  Calkins,  Howard,  and  Perkins,  have  found 
similar  structures.  Small  bodies  are  found  in  the  lower  epithelial  lay- 
ers. These  bodies  are  structureless,  measure  one  to  four  microns,  and  lie 
in  vacuoles  in  the  cells.  They  enlarge  and  become  granular  and  seg- 
mented. 

The  virus  causes  constitutional  infection  before  the  eruption  appears. 
The  greatest  infectiousness  is  noted  during  the  eruption.  Its  chief 
sources  are  the  dried  pustules  in  which  the  virus  localizes.  That  the 
blood  is  infectious  at  an  early  stage  was  demonstrated  by  the  devel- 
opment of  the  disease  in  an  individual  on  whom  skin  had  been 
transplanted  from  a  person  in  the  early  stages  of  smallpox.  Variola 
without  eruption  is  contagious,  and  it  therefore  seems  that  the  secre- 
tions, excretions,  and  exhalations,  convey  the  virus.  The  virus  adheres 
to  objects  having  rough  surfaces,  such  as  bedding,  clothing,  public  con- 
vevances,  and  money.  The  disease  persists  in  infected  communities 
for  years,  becoming  quiescent,  and  afterwards  breaking  out  anew. 
Infection  may  be  direct  from  person  to  person,  or  indirect  by  a  third 
party  or  by  fomites.  Cadavers  of  variola  victims  are  dangerous.  In 
short,  every  new  case  comes  directly  or  indirectly  from  a  patient  with 
variola.  The  virus  is  very  penetrative,  and  infection  may  exist  beyond 
the  room,  the  building,  or  the  area  of  the  isolated  case. 

The  chief  factor  in  dissemination  is  human  intercourse,  and  not 
telluric,  atmospheric,  or  clinical  conditions.  vSusceptibility  to  smallpox 
is  almost  universal,  although  individual  disposition  plays  a  great  role. 
Only  1  per  cent,  of  people  are  immune.  Some  can  never  be  successfully 
vaccinated.  Individual  immunity  was  noted  by  Morgagni,  Boerhave, 
and  Diemerbroeck.  The  author  knows  two  persons  in  whom  vaccination 
has  never  been  successful.  Temporary  immunity  is  more  frequent 
than  congenital,  which,  however,  has  been  observed.  Ordinarily  and 
practically,  immunity  is  only  acquired  by  vaccination  or  a  previous 
attack.  In  prehistoric  times,  inoculation  was  practiced  to  afford  immu- 
nity. Second  attacks  are  infrequent.  Either  sex  and  all  ages  may  be 
affected.  Mothers  with  the  disease  may  deliver  babes  with  the  florid 
eruption  or  with  scars.  Some  children  born  in  pest-houses  escape  if 
vaccinated,  but  most  of  them  die.  The  virulence  of  the  virus  is  great 
in  aboriginal  and  colored  races  (Indians  and  Mexicans),  and  in  preg- 
nant or  menstruating  women.  Though  it  varies  in  different  epidemics, 
vaccination  is  more  important  than  virulence  per  se.  Severe  cases  may 
follow  mild  infection,  as  shown  in  Osier's  description  of  the  Montreal 
epidemic,  in  which  3,164  persons,  infected  by  a  mild  case  in  a  Pullman- 
car  conductor,  died  among  the  French  Canadians,  who  oppose  vaccina- 
tion.   It  is  frequently  conveyed  by  vagrants. 

Point  of  Entrance. — Smallpox  infection  unquestionably  occurs 
through  the  respiratory  tract,  and  perhaps  also  through  the  digestive 
tract.  Variola  may  coexist  with  or  closely  follow  measles,  scarlatina, 
syphilis,  erysipelas,  pemphigus,  typhoid,  malaria,  and  tuberculosis. 
Variola  occurs  sporadically,  epidemically,  or  panepidemically. 


66 


THE  SPECIFIC  INFECTIONS 


Symptoms. — Forms : 

I.  Variola  Vera     — 1. 

—2. 

II.  Variola  —3. 
IIemorrhag:ica     — 4. 

III.  Varioloid         — 5. 


Discreta,  discrete. 

Confluens,  confluent. 

Purpura  variolosa  (black  smallpox). 

Variola  hemorrhagica  pustulosa. 

Smallpox  modified  by  vaccination. 


1.  Variola  Vera  Discreta. — Pfeiffer's  Table,  with  fever-curve. 


Fig.  8. 


TEMP. 

104 

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103 

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102 

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101 

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100 

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A 

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7 

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IN 

CUB 
2  D 

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STA 

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AND 

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ACU 
3  D* 

LES 
YS 

ERUPTION  OF    SUPPURATION 
VESICLES                3  DAYS 

EXSICCATION  & 
3ECRUSTATI0N 

Temperature  chart  and  stages  of  smallpox  (Pfeiffer.) 

{A).  The  Incubation. — The  incubation,  or  period  of  latency 
ranges  from  five  to  twenty  days,  and  averages  twelve  days.  It  lasts 
eight  days  after  inoculation,  and  usually  presents  no  symptoms,  though 
sometimes  there  may  be  headache,  anorexia,  and  pharyngitis. 

(jB).  The  Prodromal  Stage. — The  prodromal  stage,  (initial  stage, 
or  stage  of  invasion,)  dating  from  the  first  symptom  to  the  cutaneous 
eruption,  is  the  same  in  all  types,  and  its  duration  averages  three 
days  (rarely  six  to  fourteen).  It  is  shorter  in  children  (Rilliez  and 
Barthet)  and  in  the  confluent  type  of  the  disease;  the  longer  it  is,  the 
more  severe  is  the  infection  (Trousseau).  Its  intensity  bears  no  in- 
variable relation  to  prognosis,  for  varioloid  (mild  smallpox),  may 
present  a  severe  onset;  if  the  onset,  however,  is  mild,  the  disease  will 
not  be  confluent  or  hemorrhagic  in  form.  Prodromal  symptoms  are 
absent  in  rare  instances. 

The  invasion  begins  acutely  with  chill,  fever,  rapid  pulse  and  respira- 
tion, nervous  toxsemic  symptoms,  intense  headache,  and  backache, 
vomiting,  and  other  symptoms,  all  of  which  will  be  considered  in 
detail:  (a)  The  chill  is  usually  severe,  and  is  frequently . repeated. 
It  may  follow  one  or  two  days  of  fever  (Jaccoud).  In  children  it  is 
often  absent.  (6)  The  initial  fever  is  almost  invariably  high,  rising 
suddenly  to  103°  or  104°,  and  reaching  its  maximum  on  the  second  or 
third  day.  In  rare  instances  there  is  no  fever,  (c)  The  'pulse  is  rapid 
(120),  full,  and  not  often  dicrotic  except  in  severe  cases.  The  more 
frequent  respiration  (30  to  36)  is  somewhat  characteristic,  constituting 
the  so-called  toxsemic  or  "cerebral  respiration."  {d)  The  skin  is  red, 
excessively  hot  {calor  mordax),  and  usually  dry,  but  there  may  be 
sweating  in  the  discrete  variety  (Sydenham)  and  in  favorable  cases 
(Trousseau).    The  face  is  flushed  but  the  eyes  are  clear,    (e)   Nervous 


SMALLPOX  AND   VARIOLA.      VACCINATION  67 

toxGemia  is  evidenced  by  the  benumbed  sensorium,  depression,  restless- 
ness, insomnia,  delirium  (especially  in  alcoholics),  or  convulsions  and 
meningeal  symptoms  in  children.  Coma  is  rare.  Headache  is  almost 
constant,  usually  appearing  with  or  just  before  the  chill.  It  is  fre- 
quently frontal  or  temporal,  and  may  be  generalized,  occipital,  or 
neuralgic.  When  severe  or  agonizing  in  character,  it  may  be  suggest- 
ive of  meningitis,  especially  when  accompanied  by  delirium,  hard 
vomiting,  and  neckache.  (/)  Backache  appears  with  the  chill,  and 
lasts  one  or  two  days.  It  occurs  in  nearly  all  cases  (certainly  in  over 
50  per  cent.),  though  it  is  rather  less  frequent  than  headache  and 
vomiting.  It  is  severe  like  lumbago,  or  actually  agonizing.  The 
"veritable  paraplegia"  described  by  Trousseau  is  usually  only  immo- 
bility due  to  pain  caused  by  toxins  or  by  intense  congestion  (Jaccoud) 
of  the  kidneys,  spinal  muscles,  or  meninges.  It  is  rare  in  other  fevers 
likely  to  be  confused  with  variola.  Pain  is  sometimes  observed  in  the 
pharynx,  larynx,  or  heart,  and  produces  a  sensation  of  constriction; 
in  the  chest  it  results  in  oppression  or  actual  dyspnoea ;  it  may  occur  in 
the  intercostal  nerves,  sciatics,  colon,  bladder,  muscles,  and  joints. 
ig)  Vomiting  and  early  epigastric  pain  (especially  constant  in  chil- 
dren) occur  with  other  febrile  digestive  symptoms.  The  spleen  is  not 
often  enlarged  in  the  initial  period.  It  is  often  tender,  as  are  the  liver 
and  epigastrium.  Qi)  The  initial  or  'prodromal  eruptions,  studied 
especially  by  Sydenham,  Simon,  Osier,  Knecht,  and  Scheby-Busch,  are 
present  in  10  to  16  per  cent,  of  the  cases.  They  vary  with  the  epidemic 
and  have  considerable  diagnostic  value.  They  may  be  general  but  are 
more  commonly  limited  to  the  lower  abdomen,  the  inside  of  the  thighs, 
the  sides  of  the  thorax,  the  axillse,  and  sometimes  to  the  extensor  sur- 
faces of  the  knees  and  the  elbows  (Simon).     There  are  two  varieties: 

1.  The  morbilliform  variety  (measles-like,  roseola  variolosa),  which 
appears  during  the  second  day  on  the  face  and  body  as  small  maculse. 
These  are  sometimes  crescentic,  disappear  upon  pressure,  and  usually 
have  a  life  of  one  day  with  complete  involution,  although  in  exceptional 
cases  they  remain  until  the  smallpox  papules  appear.  They  are  due 
to  hypersemia  but  are  often  purpuric,  occurring  without  the  measles 
catarrh.  They  are  seen  most  often  in  varioloid,  and  therefore  have  a 
favorable  prognostic  import. 

2.  The  scarlatinal  form  (erythema  variolosum)  is  more  rare  than  the 
morbilliform  variety  and  occurs  earlier,  either  on  the  first  day,  or 
before  any  other  symptoms.  It  is  less  punctate,  extensive,  and  bright, 
than  it  is  in  scarlet  fever.  If  it  is  purple  in  color  and  purpuric,  it  is 
almost  always  variolous.  It  occurs  on  the  lower  abdomen,  and  on  the 
thighs  (forming  a  triangle  with  base  upwards  when  the  legs  are  to- 
gether), but  may  even  reach  the  knees.  Sometimes  it  is  found  on  the 
axilla  or  over  the  shoulders,  and  is  seen  in  women  more  frequently 
than  in  men.  These  areas  are  rarely  invaded  by  the  pustular  eruption 
(Trousseau  and  Hebra;  though  denied  by  Eichhorst).  Some  writers 
(Gigon,  Barthelemy)  speak  of  an  erysipelas-like  prodromal  rash,  and 
Osier  and  others  have  observed  prodromal  urticaria. 


68  THE  SPECIFIC  IXFECTIOXS 

(C).  The  Eruptive  Stage. — The  eruptive  stage  consists  of  several 
serial  sub-stages: 

1.  The  stage  of  macules  and  fa-pules  {stadium  macidosum  et  papu- 
losum)  occurs  on  the  fourth  day,  and  advances  for  three  days.  The 
eruption  begins  on  the  forehead  near  the  hair  and  on  the  cheek,  T\dth 
itching  and  burning  macules,  resembling  flea-bites,  which  soon  become 
papules  (like  those  of  prurigo  or  lichen.  Trousseau).  The  papules  are 
reddish,  discrete,  circular,  elevated,  and  hard  or  "shotty."  They  may 
be  observed  in  photographs  taken  a  number  of  hours  before  they  can 
be  seen  by  the  naked  eye.  A  day  after  their  eruption  on  the  face  and 
head,  they  appear  on  the  body,  and  on  the  next  succeeding  day  they 
"appear  on  the  extensor  aspects  of  the  extremities;  i.  e.,  the  papular 
eruption  advances  for  three  days,  and  is  descending.  In  children  the 
papules  may  develop  first  near  the  groin.  The  papules  are  thickest  on 
the  face  and  trunk.  Sometimes  they  are  very  thick  on  the  neck.  The 
eye-lids  are  oedematous.  According  to  Stokes,  the  amount  of  the 
eruption  depends  on  the  vascularity  of  the  part.  Trousseau  and 
Sydenham  maintained  that  if  the  eruption  appeared  on  the  second  day 
of  the  disease,  the  confluent  type  might  be  expected;  if  on  the  third  or 
fourth  (or  even  the  fifth)  day,  the  discrete  type  might  be  anticipated. 
If  the  eruption  ceases  at  this  point,  the  disease  is  called  variola  cornea, 
or  verrucosa. 

Weigert  holds  that  the  first  skin  changes  are  not  inflammatory  but 
necrobiotic  or  diphtheroid,  and  that  inflammation  begins  later  with 
exudation  into  and  about  the  necrotic  areas  in  the  rete  Malphigii. 
Other  authorities  consider  inflammation  the  primary,  and  necrosis  the 
secondary  process. 

Unlike  measles  and  scarlatina,  the  fever  remits  when  the  eruption 
appears,  and  the  backache,  and  headache  improve.  In  two  or  three 
days  the  fever  reaches  normal  by  irregular  steps.  The  lower  the  fever 
falls  in  this  remission,  the  lighter  is  the  type  of  smallpox. 

2.  In  the  stage  of  vesiculation  {stadium  vesiculosum),  lymph  gathers 
in  many  but  not  in  all  of  the  papules.  This  occurs  on  the  seventh  day 
of  the  disease  and  lasts  about  two  days.  The  vesicles  are  multilocular, 
since  they  occur  in  the  cells  of  the  rete  Malpighii  (Weigert).  Umbilica- 
tion  occurs  in  the  centres  of  many  vesicles,  caused  by  elevation  of  their 
edges  by  infiltration  and  by  the  follicles  in  their  centers.  It  corresponds 
to  the  area  of  primary  necrosis  and  is  suggestive  but  not  pathognomonic 
of  smallpox  (Jaccoud,  Eichhorst).  On  the  soles  of  the  feet  and  the 
palms  of  the  hands  the  fluid  is  situated  deep  in  the  resistant  tissues. 
(If  the  changes  stop  short  of  pustulation,  the  disease  is  called  variola 
crystallina.)  The  mucous  membranes  may  be  the  seat  of  simple 
inflammation,  specific  eruption,  or  pseudomembrane. 

3.  The  stage  of  suppuration  {stadium  pustulosum)  or  maturation 
begins  on  the  ninth  day  witli  clouding  of  the  vesicles  and  with  inflam- 
matory congestion  (areola)  about  them.  It  advances  for  usually  three 
and  rarely  more  than  five  days.  Increased  mucous  membrane  catarrh, 
develops  simultaneously  with  the  cutaneous  eruption.     The  pustules 


SMALLPOX  AND   VARIOLA.      VACCINATION  69 

become  opaque,  then  yellow,  and  the  thick  pus  obliterates  the  umbilica- 
tion  and  renders  the  eruption  globular.  The  areola,  or  halo,  becomes 
more  \avid  and  inflammatory  oedema  may  result  from  fusion  of 
the  areolae,  'l^his  causes  increased  tension,  deformity  (especially  in  the 
face  and  parts  where  the  skin  is  most  loose),  closure  of  the  eyes,  occlu- 
sion of  the  nose  (of  particular  moment  in  children),  and  great  tender- 
ness and  pain.  Pustulation  follows  the  descending  order  of  the  initial 
eruption  and  the  pustules  are  less  thick  on  the  trunk  than  on  the 
extremities  and  head.  On  the  volar  and  plantar  surfaces  they  are  less 
prominent  and  there  is  less  oedema.  The  pustules  evacuate  spontane- 
ously, especially  on  the  face,  but  may  dry  without  rupture.  Various 
stages  of  the  eruption  may  be  observed  in  different  parts  of  the 
body  at  the  same  time;  not  all  vesicles  become  pustules.  The  skin 
exhales  a  peculiar,  penetrating,  offensive  odor,  and  bed-sores  may 
develop. 

(Anomalies  are  variola  ahortiva,  in  which  the  pustular  stage  is  not 
reached;  variola  siliquosa, — air  in  the  vesicles  or  pustules;  and  very 
large  eruptions  three  quarters  of  an  inch  in  diameter.) 

Pathologically,  the  pus  originates  from  the  vessels  of  the  papillae, 
which  may  undergo  much  pressure,  atrophy,  or  even  necrosis. 

The  mucous  membranes  are  involved  in  various  ways,  but  the  pock 
eruption  occurs  mostly  in  the  upper  mucosae  (mouth  and  nasopharynx), 
and  therein  resembles  its  cutaneous  distribution;  the  successive 
stages  of  papulation,  vesiculation,  pustulation,  and  crustation,  may 
develop,  but  they  are  less  typical  than  in  the  cutaneous  eruption; 
erosions  often  result  with  diffuse  catarrhal  stomatitis,  and  sometimes 
with  glossitis,  phlegmonous  angina,  etc.  The  eruption  has  been  found 
in  very  rare  instances  in  the  external  ear.  Eustachian  tube,  eye,  oesopha- 
gus, larnyx  (with  oedema  or  perichondritis),  trachea  and  bronchi 
(mostly  erosions),  stomach  and  intestines  with  swelling  of  Peyer's 
patches,  rectum,  bladder,  cervix,  prepuce,  distal  end  of  the  urethra, 
vulva,  and  vagina,  with  appropriate  symptoms  of  local  irritation. 
Pathologically,  the  changes  resemble  those  in  the  skin,  but  they  have 
been  less  thoroughly  studied. 

With  pustulation  there  is  in  most  cases  a  gradual  rise  in  temperature, 
secondary  fever,  the  fever  of  suppuration.  It  is  never  sudden,  is  some- 
times associated  with  chills,  especially  in  women  and  children  and  in 
nervous  patients,  and  is  due  to  the  smallpox  virus  and  mixed  pyogenic 
infection.  The  duration  of  the  rise  is  proportionate  to  the  degree  of 
pustulation  and  of  dermatitis.  In  variola  discreta  the  temperature 
does  not  remain  high  more  than  twenty-four  to  thirty-six  hours,  with 
morning  remissions.  A  marked  leukocytosis  attends  the  fever,  or  it  may 
even  precede  suppuration  by  one,  two,  or  three  days.  It  parallels  the 
degree  of  infection  and  may  even  attain  30,000  to  34,000  cells  per 
cubic  millimeter.  It  ceases  with  involution  unless  complications  inter- 
vene. The  lymphocytes  are  increased  (to  50  or  66  percent.),  the  eosin- 
philes  are  decreased  (to  50  or  33  per  cent.),  and  the  myelocytes  may 
reach  10  to  12  per  cent. 


70  THE  SPECIFIC  INFECTIONS 

The  red  cells  occur  in  clumps  rather  than  in  rouleaux,  and  some 
deglobulization,  even  as  low  as  2,000,000,  is  observed.  The  fever  may 
show  a  preagonal  increase  or  collapse.  Hyperpyrexia  may  occur. 
Repeated  rises  in  temperature  are  very  dangerous.  Cerebral  symptoms 
occur,  such  as  great  excitement,  or  delirium  with  suicidal  tendencies, 
as  happened  in  the  case  of  one  of  the  author's  classmates.  Albuminuria 
(33  per  cent,  of  the  cases),  acute  exhaustion,  and  heart  paralysis, 
especially  in  the  aged,  may  develop. 

(D).  The  Stage  of  Involution. — The  stage  of  involution  {exsicca- 
tion, decrustation) ,  begins  on  the  twelfth  day.  It  occurs  in  the  same 
descending  order  as  the  florition  and  suppuration,  first  on  the  head, 
then  on  the  body,  etc.,  with  decrease  in  the  oedema,  in  the  redness,  and 
in  the  pain.  As  the  pain  decreases,  there  is  an  intolerable  itching  and 
some  pigmentation.  Crusts  form,  and  remain  longest  on  the  soles  of 
the  feet  and  palms  of  the  hands  where  they  may  form  complete  casts 
of  the  part.  Mucous  erosions  heal  more  readily  than  crusts.  The 
hair  falls  out,  and  by  the  end  of  the  second  week  the  fever  reaches 
normal.  There  is  no  desiccation  fever,  as  claimed  by  some  writers, 
and  fever  at  this  stage  indicates  some  complication.  Scars  result  from 
the  granulations,  and  the  higher  the  granulating  surface,  the  deeper  is 
the  cicatrix.  Scars  occur  when  the  true  skin  has  been  involved,  and 
are  seen  chiefly  on  the  face,  scalp,  palms  of  the  hands,  and  soles  of  the 
feet.  Sydenham's  statement,  that  discrete  smallpox  rarely  leaves  its 
mark,  holds  good  in  most  cases,  according  to  Osier.  Others  hold  that 
variola  vera  implies  suppuration  with  fever  and  cicatrices  as  necessary 
stigmata.  Complete  convalescence,  according  to  Jaccoud,  follows  the 
disappearance  of  the  last  crust.  Scar  formation  lasts  three  or  four 
weeks. 

2.  Variola  Vera  Confluens. — This  is  a  malignant  type,  which  was 
more  frequently  observed  in  prevaccination  days,  and  is  now  seen 
largely  in  unvaccinated  persons  or  in  those  vaccinated  but  once. 
Personal  tendency,  the  genius  epidemicus,  and  propagation  per  con- 
tinuum, further  the  development  of  this  type.  The  initial  stage  is 
violent.  The  headache  and  backache  are  agonizing.  The  status 
typhosus  and  gastric  symptoms  are  marked,  the  fever  remission  is  slight 
or  absent,  and  there  is  little  or  no  improvement  in  the  symptoms  when 
the  fall  in  temperature  occurs.  The  exanthem  is  precipitate  both  in 
its  development  (on  the  second  or  third  day),  and  in  its  extension.  The 
earlier  the  exanthem  in  variola  (e.  g.,  on  third  day),  the  greater  is  the 
probability  of  confluent  smallpox.  The  patient  usually  dies  if  the 
eruption  does  not  appear.  The  eruption  becomes  confluent  especially 
on  the  face  and  head,  and  sometimes  also  upon  the  hands  and  feet; 
whereas  on  the  body  and  limbs  it  is  largely  discrete.  With  fusion  of  the 
eruption,  great  inflammatory  oedema  appears,  the  symptoms  increase, 
swelling  and  erosion  of  the  mucous  membranes,  closure  of  the  eyes, 
keratitis,  and  obstruction  of  the  nose,  develop. 

The  general  aspect  is  desperate.  Pligh  fever,  high  pulse,  rapid, 
noisy,  even  irregular  or  stertorous  breathing,  delirium,  albuminuria, 


SMALLPOX  AiSD   VARIOLA.      VACCINATION  71 

persistent  nausea  and  vomiting,  great  thirst,  salivation  in  adults  and 
diarrhoea  in  children  (Sydenham),  husky  voice,  enlarged  cervical 
glands  and  often  parotitis,  are  present.  This  type  is  severe  from  the 
onset  and  the  prognosis  depends  upon  the  number  of  pustules  upon  the 
face.  Sydenham  says  that  "if  upon  the  face  they  are  as  thick  as  sand, 
it  is  no  advantage  to  have  them  few  and  far  between  upon  the  body." 
Death  occurs  from  acute  toxaemia  {variola  typliosa  seu  adynamica), 
with  hyperpyrexia  and  cardiac  asthenia,  or,  if  the  patient  lives  longer, 
from  septicopysemia,  phlegmon,  erysipelas,  gangrene,  pneumonia, 
pleurisy,  and  nephritis.  Recovery  from  variola  confluens  is  infrec|uent; 
in  convalescent  cases  permanent  deformity,  such  as  ectropion,  is  prob- 
able.   These  cases  run  a  course  of  three  or  more  weeks. 

3.  Purpura  Variolosa. — This  is  the  black  smallpox-^smallpox  with 
primary  hemorrhage  in  the  initial  stages.  It  is  the  worst  type,  and 
results  almost  uniformly  in  early  death.  It  was  frequent  in  the  great 
pandemic  of  1870-72.  It  is  also  important  because  of  the  difficulty  in 
its  diagnosis.  It  is  seen  most  frequently  in  the  unvaccinated,  but  may 
occur  in  the  vaccinated,  in  women  during  the  puerperium,  in  the  young, 
and  in  robust  males.  The  incubation  is  short  (six  to  eight  days),  the 
invasion  is  stormy,  with  agonizing  lumbar  pain,  great  prostration,  a 
rapid,  small,  soft,  and  sometimes  dicrotic  or  irregular  pulse,  and 
disproportionately  increased  respiration.  The  initial  epigastric  pain 
and  vomiting  may  last  until  death. 

On  the  second  day  (or  even  on  the  first),  there  appears  a  dark  scarlet 
or  plum-colored  eruption,  with  brick-red,  purple,  or  inky  ecchymoses, 
which  appear  especially  about  the  eyes.  The  aspect  of  the  discolored 
and  swollen  face,  and  ecchymotic,  sunken  and  intelligent  eyes,  is  des- 
perate. Hsematuria  is  the  most  common  of  internal  or  visceral  hemor- 
rhages. Other  forms  are:  Hsematemesis,  enterorrhagia,  epistaxis, 
metrorrhagia,  and  hemorrhage  from  the  gums,  ears,  and  bronchi, 
sometimes  accompanied  by  gangrene  of  the  pharynx.  Tympanites 
and  genuine  albuminuria  may  be  noted.  Miscarriage  is  frequent.  The 
spleen  is  not  enlarged.  The  disease  does  not  usually  reach  the  real  erup- 
tion of  variola,  or,  at  the  most,  only  the  papules  are  observed,  because, 
as  Rhazes  observed,  the  course  is  almost  invariably  fatal  in  four  or  five 
days.  The  mind  often  remains  lucid  to  the  end.  In  the  majority  of 
cases  the  fever  is  not  high,  but  in  the  most  fulminant  type  it  reaches 
105°  or  106°,  with  delirium,  collapse,  and  coma.  Death  results  in  a  few 
hours,  even  before  cutaneous  hemorrhage  is  seen,  although  internal 
hemorrhages  are  found  at  autopsy.  According  to  Unna,  the  "blood 
dissolution"  of  the  older  writers  is  a  mycotic  coagulation  thrombosis. 

4.  Variola  Pustulosa  Hemorrhagica. — This  is  more  common  than 
Purpura  Variolosa  (primary  hemorrhage).  In  this  type  of  smallpox 
hemorrhage  occurs  after  the  eruption  appears  (secondary  hemorrhage). 
This  form  occurs  in  weakly  or  alcoholic  subjects.  The  initial  stage  is 
severe,  and  secondary  hemorrhages  occur  into  the  vesicles  or  pustules, 
or  into  the  lower  parts  of  the  body  if  the  delirious  patient  has  left  his 
bed,  or  there  may  be  "blood  dissolution,"  epistaxis,  hsematuria,  and 


72  THE  SPECIFIC  INFECTIONS 

metrorrhagia.  Adynamic  manifestations  are  usual,  and  the  outcome 
is  almost  always  fatal,  though  in  one  type,  hemorrhage  at  the  vesicular 
stage  may  be  followed  by  rapid  abortion  of  the  rash  and  speedy  recov- 
ery (Osier). 

5.  Varioloid. — ^'arioloid  (variola  modificata  s.  mitigata,  variolois) 
is  variola  mitigated  by  vaccination.  The  more  marked  the  initial 
eruption,  w^hich  is  often  morbilliform,  the  less  the  number  of  pustules. 
Varioloid  begins  suddenly.  The  fever  is  atypical.  It  may  reach  103° 
and  usually  falls  with  the  specific  eruption,  reaching  normal  on  the 
fourth  day.  Secondary  suppuration  fever  is  rare  and  euphoria  is 
common.  The  eruption  is  superficial,  and,  according  to  French  clini- 
cians, there  is  no  suppuration.  The  eruption  varies  in  amount,  being 
present  on  the  trunk  only,  or  being  typical  chiefly  on  the  hands  and 
feet.  It  may  be  absent  entirely.  It  may  not  be  umbilicated  and  may 
desiccate  rapidly  without  rupture.  The  exanthem  is  usually  small  and 
scars  are  rare.  The  mucous  surfaces  are  little  involved,  and  are  entirely 
unaffected.  The  entire  course  is  shorter,  more  irregular,  and  rudi- 
mentary', and  more  benign  than  in  variola  vera. 

Complications  and  Sequelae. — The  complications  and  sequelne  of 
variola  are  many,  occurring  chiefly  in  the  more  severe  forms  and  during 
the  stage  of  suppuration. 

1.  The  Nervous  System. — Nervous  complications  are  very  frequent. 
Delirium  is  caused  by  brain  byperpemia,  which  results  from  swelling  of 
the  face  and  scalp  (Curschmann);  Jaccoud's  tA^es  of  nervous  com- 
plications are  (a)  simple  toxic,  in  nervous  individuals,  (b)  alcoholic,  (c) 
hyperpyretic.  Convulsions  are  frequent  in  children.  In  adults  they 
render  the  prognosis  uncertain.  Psychoses  are  usually  asthenic 
(Kraepelin)  and  less  frequent  than  they  are  after  typhoid.  ^Meningitis 
suppurativa  is  unusual  and  is  seen  most  often  in  children  (Gregory); 
encephalitis,  aphasia  in  children,  hemiplegia,  embolism,  cerebral  soften- 
ing, phlebitis,  and  abscess,  are  occasional  complications.  Old  writers, 
such  as  Trousseau,  spoke  of  paraplegia,  to  which  reference  has  already 
been  made  under  backache.  True  motor  paraplegia  undoubtedly  may 
occur,  and  also  monoplegia,  both  caused  by  myelitis.  Landry's  paraly- 
sis has  been  recorded,  as  well  as  neuritis  in  the  trunk  and  extremities, 
such  as  acute  ataxia,  or  paralysis  in  the  brachial,  pharyngeal,  oesopha- 
geal, bulbar,  facial,  and  optic  nerves. 

2.  The  Vascular  System.— Vascular  changes  are  more  rare.  The  heart 
muscle  may  degenerate,  becoming  soft  and  relaxed,  and  microscopic- 
ally revealing  segmentation,  and  cloudy  and  fatty  conditions.  Dilata- 
tion may  occur.  French  writers  speak  of  a  coronary  endarteritis  and 
myocarditis  (Desnos,  Huchard).  A  systolic  bruit  may  be  heard  at  the 
apex,  with  weak  first  tone,  and  tachycardia,  as  is  the  case  in  typhoid. 
Aortitis  with  brain  embolism  (Potain)  has  been  noted.  Pericarditis  and 
ulcerative  endocarditis  are  rare.  Marantic  thrombosis  occurs  occa- 
sionally. 

3.  The  Respiratory  Tract. — (Edema  of  the  larynx  and  perichon- 
dritis are  usually  fatal,  for  laryngeal  anaesthesia  promotes  inhalation 


SMALLPOX  AND   VARIOLA.      VACCINATION  73 

pneumonia.  Obstruction  of  the  larynx  by  submucous  hemorrhage  is 
an  uncommon  complication.  Bronchitis  is  invariable  in  severe  cases. 
Pneumonia,  usually  lobular,  occurs  in  40  to  100  per  cent,  of  fatal 
cases  (confluetit  and  hemorrhagic  variola);  lobar  pneumonia  is  rare. 
Lung  abscess,  embolism,  and, gangrene,  are  uncommon.  Pleurisy  is 
present  in  some  epidemics,  is  quite  common  according  to  Quinquad, 
occurs  chiefly  in  the  stage  of  suppuration,  and  is  especially  and  rapidly 
fatal  in  children  (E.  Smith). 

4.  The  Digestive  System. — Glossitis  is  rare  and  is  observed  chiefly 
in  smallpox  of  the  confluent  type.  Retropharyngeal  abscess,  gan- 
grene, parotitis,  noma,  phlegmonous  oesophagitis,  and  hemorrhage, 
or  membrane  formation  in  the  throat,  are  ominous  though  uncommon 
complications.  The  early  vomiting  rarely  persists.  Diarrhoea  is  not 
common,  but  a  simple  form  is  seen  in  children  (Trousseau,  Syden- 
ham), and  a  dysenteric  form  is  occasionally  seen  in  adults.  Peri- 
tonitis and  perineal  abscess  are  infrequent.  The  alimentary  tract, 
with  the  exception  of  the  rectum,  is  usually  considered  exempt  from 
the  eruption.  Isolated  cases  of  retroperitoneal  cellulitis  and  medi- 
astinitis  occur.  The  liver  may  sufi^er  cloudy  or  fatty  change,  focal 
necrosis,  or  difl'use  hepatitis.  The  spleen  is  usually  swollen  and  soft; 
but  is  sometimes  firm  and  hard. 

5.  The  Genito-urinary  Tract. — This  is  not  often  involved.  Al- 
buminuria may  occur  early  (Trousseau)  in  25  to  33  per  cent,  of  the 
cases.  It  may  also  occur  during  the  eruption  (Jaccoud),  during  sup- 
puration, or  in  convalescence  (Cartaz,  Bourgin,  2  to  10  per  cent.). 
Nephritis  is  not  frequent,  but  may  develop  during  the  fever  or  in 
convalescence;  it  is  often  glomerular.  Focal  necrosis  may  be  noted. 
Pyelitis  from  cystitis  or  myelitis,  diabetes  mellitus,  ovaritis,  and  vul- 
var gangrene,  have  been  observed.  Menorrhagia  is  common  in  the 
early  stages  of  onset  or  in  hemorrhagic  forms,  and  abortion  from 
hemorrhagic  endometritis  is  the  rule  in  pregnant  women.  Orchitis 
variolosa  (Trousseau,  Chiari,  Velpaux),  is  very  frequent,  the  inflam- 
matory foci  being  multiple.  They  lie  mostly  in  the  connective  tissue, 
but  are  rarely  suppurative,  or  associated  with  focal  necrosis. 

6.  The  Special  Senses. — The  eye  is  involved  in  1  per  cent.  (Hebra). 
Pox  in  the  conjunctiva  are  rare,  as  are  conjunctivitis,  keratitis,  diph- 
theria of  the  conjunctiva,  iridochoroiditis,  neuroretinitis,  metastatic 
panophthalmitis,  and  retinal  hemorrhage.  Otitis,  mastoid  caries,  and 
suppurative  thrombophlebitis,  may  occur. 

7.  The  Locomotor  System. — Muscular  abscess  or  hemorrhage  and 
arthritis,  especially  in  the  knee  and  shoulder,  may  occur  during  desic- 
cation. Arthritis  is  more  often  suppurative  than  serous,  and  is  a 
feature  of  the  secondary  sepsis.  In  the  bones  there  are  almost  invar- 
iably hemorrhage  into  the  marrow,  hyperplasia  of  the  marrow  cells, 
and  multiple  foci  of  necrosis  or  nonsuppurative  osteomyelitis  (in  72 
per  cent,  of  the  cases  [Chiari] ). 

8.  The  Skin. —  Decubitus,  erysipelas,  phlegmon,  furuncles,  ab- 
scesses  (local  or  pytemic),  post-variolous  eruptions,  erythema,  pus- 


74  THE  SPECIFIC  INFECTIONS 

tules,  impetigo  contagiosa,  bullae,  great  desquamation,  acute  gangrene 
(especially  of  the  scrotum,  and  usually  fatal),  may  develop  in  severe 
cases.  In  purpura  variola,  superficial  hemorrhages  occur  in  the  skin 
in  addition  to  subcutaneous  hemorrhagic  infiltration.  Hemorrhage 
into  existing  exudates,  and  less  often  hemorrhage  in  the  heart,  spleen, 
kidney,  liver,  stomach,  intestines,  cellular  tissue  of  the  thoracic  and 
abdominal  cavities,  braiu,  and  spine,  also  occur. 

Diagnosis. — The  diagnosis  of  smallpox  is  usually  easy  when  chill, 
fever,  headache,  backache,  and  vomiting,  occur  in  the  presence  of  an 
epidemic  or  after  exposure  to  infection.  A^'accination  and  revaccina- 
tion  are  factors  and  their  scars  must  be  searched  for.  It  is  often  im- 
possible to  avoid  mistakes  in  the  diagnosis  of  the  first  cases  of  an 
epidemic.  In  abortive  or  purpuric  cases  a  diagnosis  is  also  difficult 
or  impossible.  Hemorrhagic  scarlatina  or  measles  sometimes  cause 
difficulty.  In  the  former  the  mucous  hemorrhages  are  less  frequent 
than  in  smallpox.  Differentiation  between  smallpox  and  virulent  hem- 
orrhagic or  fulminating  purpura  may  be  difficult.  The  initial  sug- 
gestive scarlatiniform  eruption  is  important  but  it  has  been  unduly 
emphasized;  the  prodromal  eruptions  flus  purpura  are  highly  sug- 
gestive. Exposure  to  infection  followed  by  an  acute  onset  and  high 
temperature  is  significant,  although  acute  onset  and  high  fever  may 
occur  in  typhus  (chill,  macular  and  petechial  rash,  especially  on  the 
body,  and  persistently  high  fever),  in  pneumonia  (chill,  vomiting, 
herpes,  pain  in  the  chest,  and  rusty  sputum),  in  scarlatina  and 
influenza,  with  an  initial  rash,  and  in  meningitis  (joint  involvement, 
headache,  or  vomiting).  Lumbar  and  sacral  pain  is  more  common  in 
smallpox  than  in  typhus  fever,  pneumonia,  or  scarlatina.  Intense 
frontal  headache,  severe  backache,  vomiting,  chill,  and  fever,  are  suf- 
ficient grounds  for  a  tentative  diagnosis,  and  are  important  enough  to 
necessitate  isolation.  Nevertheless,  the  diagnosis  is  uncertain  until 
the  eruption  is  seen.  In  the  variola  sine  exanthemate  (the  febris  vari- 
olosa of  Rhazes  and  Sydenham,  the  variola  sine  variolois  of  de  Haen, 
the  varioles  frustes  of  Costes)  the  diagnosis  must  be  made  from  the 
history  of  exposure,  the  presence  of  an  epidemic,  fever,  pain,  delirium, 
possibly  the  initialr  ash,  (Sydenham,  Frank,  de  Haen,)  and  the  ab- 
sence of  secondary  fever  because  there  is  no  suppuration.  An  eruption 
which  appears  on  the  third  day  of  the  affection,  accompanied  by  a 
fall  of  the  fever  and  euphoria,  is  most  important. 

Varicella vs. Variola. 

Etiology    different.      Vaccination    and         Smallpox  may  closely  resemble  chicken- 
smallpox  do  not  protect,  pox  (epidemic  of  Lee);  very  mild  cases 

are  especially  misleading. 

Age:  is    not    distinctively    differential;         Usually  after  puberty,  with  mmierous 
varicella   usually   occurs   before   pu-  exceptions, 

berty;  it  may  occur  in  adults. 

An  initial  stage  is  practically  absent.  It  is  severe,  even  in  mild  cases. 

(Concluded  on  next  page.)  i 


SMALLPOX  AND   VARIOLA.      VACCINATION 


75 


Varicella- 


-  Variola. 


Temperature:  no  remission  with  out- 
break of  rash. 

Prodromal  rash:  very  exceptional. 

Vesicles  and  roseolse  (maculae)  occur  in 
crops  and  are  simultaneous;  very 
rarely  shotty. 

Rash  evolution:  is  much  more  rapid; 
vesicles  in  the  first  or  second  day. 

Eruption  is  universal,  although  succes- 
sive crops  may  occur;  most  abundant 
and  characteristic  (denied  by  Thomas) 
on  back;  begins  on  body;  less  on  face, 
hairy  scalp,  mucosae,  hands,  and  feet. 

The  vesicle  is  superficial,  and  the  trans- 
parent fluid  shines  through.  (Wyss 
has  observed  confluent  eruption  and 
umbilication). 

Areola  (halo)  is  usually  absent. 

Involution  is  rapid. 


Typical  remission  with  secondary  fever 
(except  in  varioloid). 

Frequent  (10  to  16  per  cent.). 

Never  in  crops;  first  macules,  then 
hard,  shotty  papules,  followed  by 
vesicles,  etc. 

Much  slower;  vesiculation  on  the  sev- 
enth day  (see  Pfeiffer's  table). 

Note  place  of  first  development;  de- 
velopment progresses  downward — 
face  first,  then  hands  and  feet;  less  on 
trunk. 


The  fluid  is  pearl-colored,  not  transpar- 
ent, and  has  a  thicker  covering. 


Marked. 
Tardy. 


Mistakes  may  occur  among  smallpox  experts,  but  attention  to  the 
history,  somatic  findings,  and  course,  rather  than  to  the  eruption,  pre- 
vents many  disastrous  results. 


Measles- 


-Variola. 


Both  present  the  same  prodromal  duration;  in  each  the  eruption  begins  on  the  face; 
according  to  some  observers,  simultaneously  on  face  and  trunk. 


Age:  eminently  a  childhood  affection. 
Catarrhal  stage  characteristic. 

Fever:  present  in  catarrhal  stage,  but 
low  before  exanthem,  and  rises  with 
its  appearance 

Exanthem:  Koplick's  spots  on  buccal 
and  labial  mucosa;  bluish-white  sur- 
rounded by  red. 

Eruption  later  with  rise  of  fever. 

Papules  "grouped,"  crescentic. 

Papules  remain  relatively  flat,  smooth, 
velvety. 

Grisolle's  sign  absent  (the  eruption  dis- 
appearing under  pressure). 

Areola  (halo)  absent. 


Chiefly  in  adults. 

Catarrh  present,  if  at  all,  in  rudimentary 
form. 

High  before  eruption,  and  falls  with 
florition  of  the  exanthem  even  in 
severe  cases. 

Absent.  Early  papular  eruption  on 
palate,  etc. 


Initial  morbilliform  eruption  with  the 
primary  fever. 

Never  so. 

Change  into  vesicles,  pustules,  crusts, 
scars;    hard  and  shotty. 

Grisolle's  sign  present;  i.  e.,  persistence 
in  smallpox  of  the  papule  on  stretch- 
ing the  skin,  which  distinguishes  its 
eruption  from  scarlatina,  varicella,  etc. 

"Halo"  present. 


76  THE  SPECIFIC  INFECTIONS 

Scarlatina vs. Variola. 

Rash  on  the  second  day,  angina,  straw-         Rash  later;  slow  evolution  of  different 
berry  tongue,  desquamation,  glands,  phases.    No  angina  (or  late,  at  least), 

nephritis,  etc.      (See  cardinal  symp-  no    glands,    no    strawberry    tongue; 

tomsof  scarlet  fever).  the  initial  scarlatinal  eruption  is  not 

punctate,  less  extensive  and  bright, 
and  does  not  desquamate. 

No  double  elevation  of  fever-curve.  Double  summit  to  curve. 

In  drug  rashes  (copaiba,  etc.),  the  pustules  occur  largely  on  the 
face,  head,  arms,  and  forearms,  and  much  less  frequently  upon  the 
trunk  or  legs.  In  syphilis  the  initial  lesion,  the  glands,  the  polymorph- 
ism of  the  rash,  and  the  absence  of  fever,  or  its  presence  in  moder- 
ate form,  are  easily  distinctive. 

The  lumbago  form  of  acute  nephritis  (Robin),  acute  myelitis  or 
rheumatism,  erythema,  menstrual  rashes,  septicfemic  rashes,  acne 
(cachectic  and  vulgar),  and  lichen,  only  superficially  resemble  variola. 

Glanders  may  cause  more  difficulty  in  making  a  diagnosis.  Its 
features  are  malaise,  pyrexia,  pains,  papules,  pustules,  nasal  dis- 
charge, considerable  exudation,  and  the  proper  bacteriological  find- 
ings. Its  general  symptoms  are  more  severe  than  the  degree  of  skin 
eruption  would  indicate. 

Prognosis. — The  prognosis  depends  on  (a)  previous  vaccination, 
the  disease  being  very  fatal  (40  to  50  per  cent,  mortality)  in  those  un- 
protected by  vaccination  and  revaccination.  Smallpox  is  rarely  fatal 
in  persons  who  have  been  vaccinated  within  five  or  six  years ;  only 
8  per  cent,  of  those  vaccinated  once,  die  and  only  4  per  cent,  of  those 
vaccinated  twice.  (6)  On  the  genius  epidemicus:  In  our  last  epi- 
demic the  death  rate  was  but  3  per  cent,  (c)  On  the  type,  being  (i) 
practically  100  per  cent,  in  purpura  variolosa;  (ii)  nearly  100  per  cent, 
in  variola  pustulosa  hemorrhagica;  (iii)  60  per  cent,  in  variola  con- 
fluens — especially  fatal  in  the  first  decade  of  life;  (iv)  25  per  cent. 
(15  to  35  per  cent.)  in  variola  discreta, — particularly  dangerous  in 
those  over  fifty  or  under  ten  years,  in  pregnancy,  in  the  puerperium, 
in  weakly  and  in  alcoholic  subjects;  (v)  1  percent,  in  varioloid;  (vi) 
recovery  usual  in  variola  sine  exanthemate. 

The  prognosis  also  depends  upon  individual  symptoms:  1.  In- 
cubation is  short  in  unfavorable  forms,  especially  in  purpura  variolosa. 

2.  Initial  symptoms  are  mild,  chiefly  in  varioloid,  but  may  be 
severe  in  both  the  benignant  and  malignant  forms.  Very  severe  head- 
ache indicates  the  hemorrhagic  form. 

3.  The  initial  rash  is  usually  a  partial  erythema  in  mild  forms 
of  smallpox;  and,  in  general,  morbilliform  eruptions  occur  in  vario- 
loid. Scarlatiniform  eruptions  occur  in  rather  severe  forms,  and  a 
universal  scarlatinal  hemorrhagic  eruption,  especially  in  the  groins, 
occurs  particularly  in  purpuric  types. 

4.  The  danger  is  proportionate  to  the  amount  of  the  eruption  on 
the  face  and  hands  (Sydenham).  A  slow  typical  exanthem  indicates 
variola  discreta,  and  a  precipitate  atypical  eruption  is  a  symptom  of 
variola  confluens. 


SMALLPOX  AND   VARIOLA.      VACCINATION  77 

5.  A  prompt  fall  in  temperature  after  the  eruption  is  favorable. 
A  slow,  complete  fall  occurs  chiefly  in  the  severe  forms.  Persistent 
apyrexia  after  florition  and  early  desiccation  indicate  a  mild  type. 
Accession  of  •^ever  after  pustulation  is  ominous  (Rhazes).  There  are 
fewer  complications  with  an  early  fall  of  temperature.  Hyperpyrexia 
or  temperature  collapse  during  suppuration  is  a  sign  of  imminent 
death. 

6.  In  the  stage  of  suppuration  the  danger  is  parallel  to  the  height 
of  the  fever  and  the  amount  of  cutaneous  and  mucous  efflorescence. 
Enlargement  of  the  spleen  is  ominous. 

Treatment. — I.  Prophylactic  Vaccination. — Protection  from  small- 
pox by  cowpox  vaccination  was  discovered  by  Jenner,  who  published 
his  results  in  1798,  although  he  was  practically  certain  of  his  evidence 
twenty  years  earlier.  The  idea  had  been  long  prevalent  among  farm- 
ers that  cowpox  afforded  immunity  to  smallpox.  Professor  Water- 
house,  of  Harvard,  in  1800,  introduced  vaccination  into  this  country, 
and,  among  others,  President  Jefferson  was  instrumental  in  dissemi- 
nating its  practice. 

The  nature  of  cowpox,  or  vaccinia,  is  still  bitterly  disputed.  The 
most  probable  view  is  that  cowpox  and  horsepox  are  human  small- 
pox modified  by  transmission  through  animals.  Copeman  suggests 
that  vaccinia  and  variola  have  descended  from  a  common  stock. 
Variola  inoculated  in  the  cow  produces  typical  vaccinia.  The  other 
view,  held  largely  by  the  French,  is  based  upon  Chauveau's  experi- 
ments, which  conclude  that  the  two  affections  are  distinct.  The  bac- 
teriology of  vaccinia  is  also  uncertain.  Micrococci  (Quist,  Martin, 
and  Ernst),  bacilli  (Klein  and  Copeman),  and  amoebse  (Guarnieri's 
cytorytes  vaccinice,  Pfeiffer,  Ruffer,  and  Reed),  have  been  found. 

Usual  Symptoms. — The  incubation  period  is  three  days,  during 
which  there  may  be  slight  traumatic  local  reaction.  The  eruption 
occurs  on  the  third  day  as  a  hard  papule  surrounded  by  a  delicate 
halo.  The  papule  enlarges,  and  on  the  fifth  (or  sixth)  day  shows 
Jenner's  vesicle  filled  with  clear  serum,  and  umbilicated  in  the  centre. 
It  merges  peripherally  into  the  already  indurated  and  painful  skin, 
in  which,  by  the  eighth  day,  the  magnifying  lens  shows  many  minute 
vesicles.  By  the  tenth  day,  the  serum  of  the  vesicle  has  become  puru- 
lent and  the  surrounding  tissues  are  very  hard  and  painful.  By  the 
eleventh  day,  a  small  central  crust  appears,  which,  by  the  end  of  the 
second  week,  covers  the  entire  vesicle  and  is  accompanied  by  a  reces- 
sion of  the  adjacent  cellulitis.  In  one  or  two  weeks,  the  ulceration, 
decrustation,  and  granulation,  are  usually  complete,  and  a  scar  or  pit 
remains,  which  pales  with  time.  Constitutional  reaction  is  greatest  in 
children.  The  fever  in  most  cases  appears  on  the  fifth  day,  and  some- 
times lasts  four  or  five  days,  with  leukocytosis,  restlessness,  headache, 
or  backache.  A  swelling,  depending  on  the  site  of  inoculation,  occurs 
in  the  axillary  or  inguinal  glands. 

Unusual  Symptoms. — The  vesicles  may  develop  early  and  run  a 
course  which    may  be  shorter  by  half  than  the  usual  one.     Crusts 


78  THE  SPECIFIC  IXFECTIONS 

may  form  in  a  week.  In  other  cases  the  eruption  may  be  tardy  and 
atypical.  In  both  instances  revaccination  is  indicated.  The  eruption 
may  recur  as  many  as  four  times  (Sutton),  and  in  rare  cases  may  be 
hemorrhagic,  'or  even  fatal. 

CoMPLiCATioxs. — These  are  rarely  fatal.  In  Germany,  in  189.5,  two 
deaths  (from  erj'sipelas)  occurred  in  two  and  a  half  million  vaccina- 
tions. To  offset  this  theoretical  risk  there  is  the  almost  universal 
susceptibility  to  smallpox  in  all  unvaccinated  indi^-iduals.  (1)  Ery- 
thema, urticaria,  roseoli]e,  or  erysipelas  (third  to  eighth  day). 
(2)  Accessory  vaccinia  near  the  original  inoculation,  or  generalized 
vaccinia,  which  develops  about  the  eighth  day  on  the  trunk  or  extrem- 
ities, and  often  on  the  wrists;  bullous  or  miliary  vesicles  sometimes 
continue  to  develop  for  over  a  month,  and  in  weakly  subjects  are  very 
exceptionally  fatal.  (3)  Secondary  infection  in  the  first  week  or  two, 
either  local  (deep  ulceration,  gangrene,  lymphangitis,  or  lymphadenitis), 
or  systemic  (sepsis,  pericarditis,  meningitis,  and  parotitis).  Very  few 
cases  of  tetanus  have  occurred;  McFarland  (1903)  collected  68  cer- 
tain cases,  the  majority  of  which  occurred  in  Philadelphia.  Albumin- 
uria is  infrequent.  (4)  Later  infections,  such  as  tuberculosis  or 
syphilis.  Tuberculosis  is  but  seldom  inoculated,  because  it  is 
rare  in  calves.  Its  inoculation  can  easily  be  prevented  by  the  Belgian 
method  of  not  using  the  lymph  until  the  animal  has  been  killed  and 
found  healthv.  In  some  cases  a  latent  tuberculosis  in  the  patient 
may  be  awakened  by  vaccination,  which  seems  to  act  like  tuberculin. 
The  dancer  of  inoculating  syphilis  is  far  less  now  than  when  human 
virus  was  used.  Fifteen  days  are  necessary  for  the  development  of 
a  chancre,  and  after  about  eight  weeks  more  the  secondaries  appear. 
These  are  the  chief  diagnostic  criteria.  Syphilis  may  be  inoculated 
accidentally  and  also  intentionally,  as  in  the  oft-cited  case  of  Dr. 
Cory.  In  exceptional  cases  syphilis  already  in  the  system  may  be 
aroused  bv  vaccination.  There  are  no  clear  cases  of  inoculation  of 
leprosy. 

Age. — Children  should  be  vaccinated  in  the  third  or  fourth  month, 
and  it  should  never  be  delayed  beyond  the  first  year. 

Technique. — The  arm  (or  leg,  in  the  case  of  girls),  should  be  washed, 
but  no  antiseptics  should  be  employed,  lest  they  neutralize  the  ^^rus. 
A  fold  of  skin  should  be  raised  and  either  rubbed  \\-ith  a  piece  of 
sterile  gauze  or  scraped  \s^th  a  knife  held  almost  parallel  to  the  skin, 
until  the  epidermis  is  removed  and  slight  oozing  of  lymph  appears. 
The  virus  must  reach  the  lymph  stream,  and  therefore  blood  should 
not  be  drawn,  as  coagulation  somewhat  inhibits  "taking."  The  vac- 
cine should  be  slowly  rubbed  over  and  into  the  abraded  skin.  The 
spot  should  be  covered  with  a  sterile  dressing  or  cloth  held  in  place 
by  adhesive  plaster,  only  after  the  virus  has  thoroughly  dried.  Boric, 
carbolic,  or  bichloride  gauze  must  not  be  used. 

Lymph. — Vaccinia  virus  is  harmless  if  it  is  pure  and  has  been  col- 
lected in  the  vesicular  and  not  in  the  pustular  stage.  It  can  best  be 
preserved  in  the  fluid  form,  in  sealed  sterile  tubes  with  three  or  four 


SMALLPOX  AND   VARIOLA.      VACCINATION  79 

parts  of  glycerin.  This  obviates  pyogenic  infection,  preserves  the  virus 
longer  (four  months),  and  is  more  economical  than  any  other  method; 
as  twenty  to  twenty-five  times  as  many  vaccinations  are  possible  with 
the  same  amount  of  virus  when  preserved  by  this  method.  When 
human  virus  must  be  used  it  should  be  taken  from  a  perfectly  sound 
child  which  has  been  carefully  examined  for  tuberculosis  and  syphilis. 
It  should  be  taken  from  the  clear  and  unbroken  vaccinia  vesicle  on 
the  seventh  or  eighth  day.  No  blood  should  be  withdrawn,  and  the 
vesicle  must  be  free  from  pus. 

Results. — The  successful  vaccination,  accompanied  by  typical  papu- 
lation, vesiculation,  pustulation,  crustation,  cicatrization,  and  by  local 
and  often  general  reaction,  confers  immunity  in  almost  all  cases, 
though  there  are  isolated  instances  when  variola  has  closely  followed 
successful  vaccination.  Although  immunity  is  not  absolutely  infal- 
lible, vaccination  is  the  greatest  triumph  of  prophylaxis  yet  achieved. 
Immunity  is  not  as  a  rule  life-long,  as  Jenner  thought.  In  some  few 
cases,  the  individual  is  permanently  protected  by  one.vaccination,  and 
revaccination  is  unsuccessful.  Protection  lasts  on  an  average  ten 
years,  after  which  60  (or  90)  per  cent,  can  be  once  or  twice  revac- 
cinated.  Conversely,  the  child  should  be  revaccinated  in  his  tenth 
to  twelfth  year,  and  if  the  vaccination  does  not  "take,"  it  should  be 
repeated.  The  reaction,  fever,  induration,  and  size  of  the  vesicle  and 
scar,  are  less  in  revaccination.  It  is  also  held  that  immunity  is  more 
certain  and  enduring  when  more  than  one  inoculation  has  been  made; 
the  Germans,  especially,  vaccinate  two  areas,  and,  sometimes,  even  four 
or  six.  The  nature  of  the  immunity  conferred  is  still  disputed,  but, 
unlike  the  immunity  of  diphtheria,  it  is  probably  due  to  actual  tissue 
change.  Pfeiffer  advances  the  idea  that  in  smallpox  the  germ  endures 
in  the  tissues,  and  in  this  way  maintains  the  usually  permanent  im- 
munity. Vaccination  immediately  after  exposure  is  also  thought  to 
prevent  or  modify  an  impending  attack.  Partial  immunity  is  evi- 
denced by  mild  varioloid  (smallpox  mitigated  by  vaccination).  The 
general  beneficence  of  vaccination  needs  no  multiplied  statistics.  In 
general,  epidemics  prevail  in  communities  which  are  least  protected, 
and  conversely,  they  disappear  with  systematic  compulsory  vaccina- 
tion, as  was  the  case  in  the  German  army. 

II.  Other  Methods  of  Prophylaxis. — Isolation  hospitals  and  sta- 
tions are  indispensable,  because  smallpox  patients  are  infectious  in  all 
stages  of  the  disease.  Isolation  is  necessary  from  the  incipiency  until 
the  disappearance  of  the  last  crust.  The  dead  body  is  dangerous  and 
the  funeral  must  not  be  public.  The  clothes  used  by  the  patient  must 
be  steamed,  and  other  articles  must  be  washed  with  bichloride  of 
mercury  and  fumigated  with  formaldehyde  vapor;  Schoch's  method 
has  the  advantages  of  not  requiring  any  special  form  of  apparatus, 
of  cheapness,  and  freedom  from  danger  of  fire.  The  following  are 
required:  good  quicklime  in  lumps,  commercial  sulphuric  acid,  and 
ordinary  40-per-cent.  formaldehyde  solution.  For  every  1,000  'lubic 
feet  of  space  one  pound  of  formaldehyde  solution,  one-half  pound 


80  THE  SPECIFIC  INFECTIONS 

of  sulphuric  acid,  and  three  pouuds  of  quicklime  are  required.  The 
acid  and  the  formaldehyde  are  first  mixed  in  an  earthenware  vessel 
by  pouring  the  acid  into  the  formaldehyde.  Then  the  lime  is  placed 
in  a  shallow  vessel  in  the  centre  of  the  room.  All  openings  to  the 
room  are  carefully  closed,  the  mixture  is  poured  on  the  quicklime, 
and  the  operator  leaves  the  room.  The  rooms  should  remain  closed 
for  from  five  to  eight  hours.  Disinfection  of  the  face,  hands,  beard, 
and  hair  of  attendants  by  bichloride  solution  is  imperative.  The 
family  should  be  isolated  for  sixteen  to  twenty  days. 

III.  Actual  Treatment. — ^As  Jaccoud  early  announced,  there  is  no 
specific  treatment  for  smallpox.  Its  hygiene  and  dietary  are  the  same 
as  in  typhoid.  For  headache,  the  ice-bag,  opium,  and  hydrotherapy 
should  be  resorted  to.     Pain  is  relieved  by  opiates. 

The  initial  vomiting  is  difficult  to  overcome,  but  its  duration  is  for- 
tunately short  Ice-pills,  lime-water,  iodine,  chloroform,  morphia,  car- 
bolic acid,  and  bismuth,  may  be  used  as  they  are  in  typhoid,  but  mustard 
plasters  should  never  be  applied  lest  they  initiate  necrosis  of  the  skin. 

Early  hydrotherapy  is  important  in  giving  relief  from  jever.  It 
lessens  the  dermatitis,  though  later,  when  the  rash  has  developed, 
baths  are  contraindicated. 

Delirium  may  be  relieved  by  hydrotherapy,  by  chloral,  bromides, 
hyoscine,  and  morphia.  The  latter,  in  half-grain  doses,  is  invaluable 
as  a  routine  treatment,  since  it  lessens  itching  and  pain  and  conserves 
metabolism.  There  is  great  danger  that  the  patient,  if  delirious,  may 
escape,  injure  himself,  or  commit  suicide.  Dr.  NcNamara,  a  class- 
mate of  the  author,  killed  himself  by  jumping  through  a  window 
which  had  been  carelessly  left  open  near  him.  Patients  should  never 
be  confined  by  straps,  for  this  may  cause  serious  skin  trouble  (necro- 
sis). It  is  better  to  dress  them,  or  even  walk  them  up  and  down  the 
room. 

The  eruption  may  be  pricked  and  cauterized  with  silver  nitrate 
(Arabian  method),  treated  with  bichloride  or  boric  compresses  (Hebra), 
covered  with  mercurial  plaster,  or  with  l-per-cent.  carbolic  acid  and 
vaseline  salve.  The  latter  is  the  best,  because  it  counteracts  the  par- 
ticularly offensive  odor.  Carbolic  salve  should  be  used  on  the  face 
only,  since  general  use  over  the  body  may  cause  carbolic-acid  poison- 
ing. These  measures  are  not  specific  nor  do  they  prevent  cicatrix 
formation,  but  they  relieve  dermatitis  and  itching.  Covering  the  face 
from  the  light  with  wet  compresses  seems  to  lessen  the  pitting.  The 
crusts  should  be  kept  soft  with  olive  oil.  The  hair  should  be  cut 
short,  and  the  eyes  should  be  closely  watched,  and  douched  frequently 
with  boric-acid  solution. 

The  mouth,  the  larynx,  the  circulation,  and  diarrhoea,  should  be 
treated  as  they  are  in  typhoid  fever.  For  bed-sores,  a  water-bag  or 
-ring  should  be  used.  Sydenham  allowed  his  patients  to  leave  bed  as 
soon  as  the  fever  declined. 

For  sepsis,  quinine  (v.  sepsis)  and  alcohol  (v.  typhoid)  are  given 
by  the  rectum,  since  dysphagia  is  always  present.     Eggnog  properly 


CHICKEN  POX  81 

prepared  will  not  injure  the  throat.  During  convalescence  the  crusts 
should  be  carefully  washed,  and  the  patient  may  be  considered  safe 
only  when  the  skin  is  clear  of  the  last  scab. 


CHICKENPOX  (VARICELLA). 

Definition. — An  acute  specific  febrile  contagious  disease,  chiefly  one 
of  infancy  and  childhood,  characterized  by  an  exanthem  of  vesicles 
which  usually  appear  in  crops. 

History. — Varicella  was  recognized  by  Heberden  in  1767,  and  by 
Trousseau,  as  a  chsease  distinct  from  smallpox.  It  is  still  classified 
by  the  Hebra  school  as  smallpox. 

Etiology. — It  is  transferable  by  direct  inoculation,  by  personal  con- 
tact, by  the  air,  or  by  a  third  person.  It  is  infective  while  crusts  re- 
main. Epidemics  of  varicella  may  coincide  with,  precede,  or  follow, 
smallpox.  Smallpox  does  not  prevent  an  attack  of  varicella  nor  is 
the  converse  true.  The  disease  occurs  chiefly  in  epidemics,  although 
sporadic  cases  are  frequently  seen.  A  second  attack  is  rare.  Season 
has  no  influence  upon  the  appearance  of  the  disease.  It  occurs  chiefly 
in  the  first  year  of  life,  or,  according  to  others,  66  per  cent,  of  the  cases 
occur  between  the  years  of  two  and  six.  It  has  never  been  observed 
congenitally,  and  some  deny  its  existence  in  the  adult,  although  such 
cases  do  occur. 

The  actual  cause  is  not  determined.  Bareggi  described  a  peculiar 
coccus;  Guttmann,  the  yellow  and  white  staphylococcus;  and  Pfeiffer 
and  Guinon,  a  protozoon.  It  may  occur  with  pertussis,  morbilli,  scar- 
latina, diphtheria,  pneumonia,  or  smallpox. 

Symptomatology. — I.  Incubation. — The  stage  of  incubation,  like 
that  of  measles,  lasts  thirteen  or  fourteen  days  (eight  to  nineteen 
days),  or  three  to  six  days  after  inoculation. 

II.  Stage  of  Prodromes. — Prodromal  symptoms  are  generally 
rare.  They  are  frequent  in  adults,  according  to  Tordeus,  and  may 
be  severe.  If  there  are  any  prodromal  symptoms,  they  last  but  twenty- 
four  hours  (Trousseau).  Severe  intoxication  is  rare,  but  the  following 
have  been  observed:  delirium,  convulsions,  violent  vomiting,  hyper- 
thermia, dyspnoea,  angina,  conjunctivitis,  pale  urine,  tenesmus,  dys- 
phagia, muscle  pains,  lassitude,  intestinal  irregularity,  bloody  vomiting 
and  stools,  and  initial  erythema  (usually  scarlatiniform,  rarely  morbil- 
liform, in  the  fifteen  cases  recorded). 

III.  Stage  of  Eruption. — The  exanthem  sometimes  appears  suddenly 
after  a  slight  chill,  usually  in  the  first  twenty-four  hours,  as  red 
macules  or  papules.  They  are  comparable  to  the  typhoid  roseolae, 
are  slightly  elevated,  disappear  on  pressure,  and  are  lenticular.  Some 
regress,  but  most  become  vesicular  in  from  six  to  twelve  hours.  The 
vesicles  mature  within  a  day.  They  are  very  superficial,  and  do  not 
occupy  the  whole  roseola,  but  leave  a  slight  areola  about  them,  which 
is  hyperaemic  and  not  inflammatory  as  it  is  in  smallpox.     In  some 

6 


82  '         THE  SPECIFIC  INFECTIONS 

cases  the  areola  may  be  absent^  the  eruption  appearing  like  drops 
of  water  sprinkled  on  the  skin.  Though  usually  discrete,  Wyss  and 
Immermann  describe  confluent  eruptions.  The  vesicles  may  be  few 
or  quite  numerous;  Thomas  counted  800  in  one  of  his  cases.  In 
shape,  the  eruption  is  mostly  elliptical  or  circular.  Rare  forms  are 
reported  with  jagged,  sinuous  edges,  when  the  vesicle  overlaps  the  skin. 
In  size,  the  vesicles  may  be  very  large,  and,  in  exceptional  cases,  re- 
semble pemphigus;  they  are  alleged  to  have  attained  a  size  of  four 
centimeters. 

The  eruption  begins  on  the  trunk,  back,  and  chest  (Osier,  Guersaut, 
Blache);  on  the  face,  temples,  forehead  (Eichhorst,  Immermann), 
and,  according  to  Thomas,  rarely  fails  to  appear  on  the  scalp.  Trous- 
seau lield  that  there  is  no  point  of  predilection  for  the  eruption.  Henoch 
finds  it  often  on  the  part  on  which  the  patient  lies  or  where  irritation 
exists.  No  part  can  be  considered  exempt,  though  most  vesicles  ap- 
pear on  the  trunk,  fewer  on  the  face,  arms  and  legs,  and  the  least 
number  upon  the  hands  and  feet.  The  eruption  is  sometimes  grouped, 
as  it  is  in  herpes  zoster. 

The  contents  of  the  vesicle  are  usually  clear  at  first,  and  become 
turbid  in  thirty-six  to  forty-eight  hours;  neutral  or  alkaline,  and  never 
acid.  Pustulation  may  occur  (Leube),  though  this  is  denied  by  some. 
Hemorrhage  rarely  occurs  into  the  vesicle.  The  vesicle  may  contain 
air  after  rupture.  Umbilication,  though  rare,  may  occur  (Wyss). 
Eichhorst  denies  the  statement  made  by  Goruall  that  the  uiniblica- 
tion  of  variola  exists  from  the  beginning  of  the  eruption,  while  that 
of  varicella  occurs  late.  Crusts  may  simulate  umbilication.  That  the 
vesicles  of  varicella  are  always  unilocular  is  also  denied. 

Occurrence  in  crops  is  frequently  observed;  the  skin  then  shows 
simultaneously  macules,  vesicles,  and  crusts.  Yellowish-brown  crusts 
form  on  the  third  and  fourth  days  and  gradually  disappear,  leaving 
a  somewhat  flattened  epidermis,  which  may  desquamate  slightly. 
Distinct  scars  are  rare,  but  may  result  from  scratching  or  infection, 
especially  on  the  body  or  on  the  face.  A  few  cicatrices  are  usual  in 
almost  every  case  of  varicella  (Guinon),  but  they  are  smooth,  white, 
and  some  of  them  disappear  with  time. 

Enanthems  are  not  frequent.  Vesicles  are  sometimes  seen  on  the 
palate  but  may  easily  be  overlooked.  Breaking  down,  they  resemble 
aphthae.  They  may  precede  the  exanthem.  On  rare  occasions  they 
are  seen  on  the  tongue,  cheek,  nose,  larynx,  external  ear,  prepuce, 
lOr  labia. 

Fever. — The  fever  is  slight,  if  indeed  there  be  any.  It  is  atypical 
and  is  not  parallel  to  the  eruption.  Fever  as  high  as  ]  06.8°  is  recorded 
by  Thomas.  It  is  very  rarely  present  in  the  prodromal  stage,  but 
may  occur  with  profuse  eruptions,  or  T\nth  successive  crops;  its  per- 
sistence suggests  complications. 

General  Symptoms. — These  are  few,  but  sometimes  include  dys- 
phagia, cervical  and  submaxillary  swellings,  tracheitis,  bronchitis, 
albuminuria,  or  acetonuria. 


SCARLET  FEVER  83 

The  entire  course  of  an  uncomplicated  case  lasts  from  one  to  two 
weeks. 

Complications  and  Sequels. — These  are  usually  dismissed  with  a  few 
words.  Nephritis,  first  described  by  Henoch  and  since  by  Vichmann, 
linger,  Janssen,  and  others,  is  generally  mild,  tubular,  and  occurs  from 
three  to  fourteen  days  after  the  rash  declines.  Though  it  is  usually 
mild,  numbers  of  fatal  cases  have  been  lately  reported  as  well  as  some 
which  have  resulted  in  chronic  nephritis,  cardiac  hypertrophy,  and 
uriemia.  Gangrene  of  the  skin,  seen  especially  in  delicate  or  tuber- 
culous children,  and  first  described  by  J.  Hutchinson,  may  occur  in 
the  extremities,  scrotum,  or  eye-lids.  Pneumonia  is  rare.  Other  com- 
plications which  are  infrequent,  are  abscess  of  the  lung,  pleurisy,  acute 
miliary  tuberculosis,  erysipelas,  sores  in  the  skin  which  may  lead  to 
tuberculosis,  glandular  swelling,  pemphigus,  infantile  hemiplegia, 
osteitis,  measles,  scarlatina,  synovitis,  simple  or  suppurative  polyarth- 
ritis, peritonitis,  otitis  media,  neuritis,  spasm  of  the  larynx,  suffoca- 
tive laryngitis,  and  the  persistence  of  an  unmanagable  mixed  papular 
and  vesicular  eruption  on  the  palms  of  the  hands  and  soles  of  the 
feet. 

Diagnosis. — The  diagnosis  is  very  easy  if  the  case  is  seen  early. 
Differentiation  from  smallpox  has  been  considered.  There  is  usually 
no  fever,  the  eruption  is  more  vesicular,  without  halo,  larger,  but  less 
in  number  than  in  smallpox.  In  peinphigus  the  vesicles  are  larger 
and  run  a  slower  course  of  weeks  or  months.  Miliaria  rubra  are  pre- 
ceded by  sweats,  occur  chiefly  on  the  covered  parts,  have  acid  con- 
tents, are  smaller  than  the  varicellous  eruption  and  disappear  more 
rapidly.  Sometimes  consideration  must  be  given  to  molluscum  con- 
tagiosum  (soft,  umbilicated  tumors  with  white  granular  contents); 
prurigo  varicelliformis  (with  crop-like  eruptions  at  longer  intervals); 
eczema  vesiculosum,  which  always  occurs  with  great  itching;  herpes, 
always  appearing  in  groups  and  often  along  nerve-trunks;  varicellae 
syphiliticae,  and  medicinal  rashes  from  cantharides,  bromide,  arsenic, 
and  iodide. 

Treatment. — Active  treatment  is  rarely  indicated. 


SCARLET  FEVER  (SCARLATINA). 

Definition. — A  specific  infective  disease  of  unknown  bacteriology, 
characterized  by  sudden  onset,  fever,  diffuse  exanthem,  and  angina. 

History. — It  was  recognized  by  Ingrasseas  and  Coyttar  in  the  six- 
teenth century,  but  was  first  fully  described  by  Sydenham  (1660); 
before  this,  it  was  known  as  measles.  Scarlatina  was  introduced  into 
America  in  1735. 

Etiology. — The  etiology  is  unknown.  Class  described  a  diplo- 
coccus,  but  this  has  not  been  confirmed.  Babes,  Babinsky,  Pearce, 
Wright,  and  others,  have  found  a  streptococcus  in  5S  per  cent,  of 
fatal  cases,  and,  while  their  results  in  no  way  prove  that  it  is  the  cause 


84  THE  SPECIFIC  INFECTIONS 

of  scarlatina,  it  is  probable  that  tthe  streptococcus  is  the  most  impor- 
tant factor  in  the  production  of  the  complications  and  in  their  mor- 
tality. Hektoen,  Weaver,  and  Ruediger,  in  100  cases,  found  it  in  the 
blood  in  12  per  cent.  Combinings  everal  statistics,  the  streptococcus  as 
found  in  about  70  per  cent,  of  the  fatalities;  i.e.,  it  is  the  cause  of  the 
malignancy  of  the  disease,  but  not  of  the  disease  itself.  The  organism 
is  also  found  in  diphtheria,  measles,  and  variola.  The  virus  of  scarlet 
fever  produces  severe  necrosis,  but  no  suppuration.  ]Mallory  describes 
a  protozoon,  the  cyclaster  scarlatinalis . 

Susceptibility  is  not  universal;  only  38  per  cent,  of  children  and 
5  per  cent,  of  adults  exposed  to  infection  acquire  the  disease.  Sus- 
ceptibility varies,  also,  from  time  to  time  in  the  same  family. 

So-called  surgical  and  puerperal  scarlatina,  noted  in  1864,  by  Paget, 
are,  in  the  vast  majority  of  cases,  sepsis,  erythema  congestivum,  ery- 
thema toxicum,  or  drug  rashes.  Alice  Hamilton  (1905)  collected  174 
cases  from  the  literature,  and  concludes  that  these  forms  are  mostly 
septic,  and  occasionally  mere  coincidents. 

The  virus  circulates  in  the  blood,  whence  the  possibility  of  foetal 
infection  even  though  the  mother  may  escape.  The  mother  may  con- 
tract the  disease  and  the  child  may  escape.  It  is  usually  held  that 
the  disease  is  probably  not  infectious  before  the  eruption,  and  that 
the  virus  is  especially  active  during  desquamation.  Aaser  holds,  and 
justly,  that  the  throat  secretions  are  most  dangerous.  The  strepto- 
cocci may  be  spread  by  coughing  (Hamilton).  Infection  is  often 
spread  even  two  months  or  more  after  desquamation  is  complete. 
In  no  other  disease  is  the  virus  so  tenacious;  it  may  persist  as  long 
as  ten  years  in  clothes,  furniture,  and  on  the  walls.  Light  forms  are 
as  contagious  as  severe  ones.  Inoculations,  from  the  living  subject 
and  from  the  cadaver,  have  occurred.  Leube  acquired  the  disease  by 
a  cut  during  an  autopsy  upon  a  scarlatina  case.  The  entrance  is 
not  known;  but  it  is  probably  through  the  throat. 

Infection  may  be  spread  by  servants,  by  physicians,  by  any  third 
person,  and  by  means  of  toys,  books,  clothes,  and  milk,  and  in  schools; 
but  the  mode  of  infection  is  often  unknown.  One  attack  usually  con- 
fers immunity,  but  second,  and  even  third,  attacks  are  known.  In 
some  individuals  there  appears  to  be  a  temporary  or  permanent  im- 
munity. Scarlet  fever  occurs  at  all  seasons,  but  probably  more  often 
in  the  autumn  and  winter.  Scarlatina  is  observed  more  in  the  cities, 
and  measles  prevails  more  diffusely  through  the  country.  Scarlatina 
is  more  permanent  than  measles.  When  it  becomes  epidemic  it  is 
likely  to  spread  widely,  and  usually  has  a  mortality  increased  three- 
or  even  thirty  fold. 

Ninety  per  cent,  of  cases  occur  under  ten  years  of  age  (Murchison), 
although  adults  are  not  exempt.  It  is  rare  in  the  first  year  of  life. 
The  sexes  are  equally  involved. 

Scarlatina  sometimes  occurs  with  other  infections,  such  as  diph- 
theria or  measles,  and  less  often  with  variola,  varicella,  herpes,  mumps, 
pertussis,  erysipelas,  or  typhoid. 


SCARLET  FEVER  85 

General  Symptomatology.— 1.  The  Stadium  Incubationis. — The 
incubation,  with  no  noticeable  symptoms  except  perhaps  anorexia  or 
slight  depression,  lasts  from  two  to  four  days,  though  sometimes  one 
to  seven  days." 

2.  The  Stadium  Invasionis.— The  invasion  lasts  one  day.  Symp- 
toms begin  suddenly,  with  perhaps  a  chill.  This  is  followed  by  {a) 
headache,  dulness,  convulsions,  and  delirium;  (6)  vomiting,  early 
and  characteristic,  which  occurs  in  scarlatina  more  often  than  in 
other  diseases  of  childhood  except  pneumonia;  (c)  sudden  elevation 
of  temperature,  even  to  105°,  with  disproportionate  pulse-rate,  120 
to  150,  with  dry,  burning  skin,  and  febrile  urine;  {d)  dryness,  red- 
ness, burning,  pain  in  the  throat,  dysphagia,  and  intumescence  of  the 
cervical  glands. 

3.  The  Stadium  Exanthematicum. — The  exanthem  lasts  four  to 
six  days.  It  appears  on  the  second  day,  first  below  the  clav- 
icles, on  the  upper  trunk,  and  on  the  neck,  then  on  the  extrem- 
ities, and  least  on  the  face  and  scalp.  The  skin  about .  the 
mouth  is  pale.  The  exanthem  pales  on  pressure.  It  consists  first 
of  small  red  spots  (swollen  hair  follicles),  the  size  of  a  pin-head, 
which  fuse  as  the  skin  swells,  and  result  in  an  intense  diffuse  lobster- 
colored  erythema.  The  tongue  swells,  becomes  covered  with  a  gray- 
ish-yellow coating,  is  red  on  the  tip  and  edges,  and  shows  swollen 
red  papillae — "cat's  tongue,"  or  "strawberry  tongue."  Later  the  whole 
tongue  becomes  red  and  dry.  On  the  tonsils  and  palate  a  grayish- 
yellow  coating  and  confluent  spots  appear.  The  nostrils  become 
slightly  swollen,  and  redness  of  the  conjunctivce  develops  with  secre- 
tion. Some  rales  over  the  larger  bronchi,  a  slight  cough,  swelling  of 
the  cervical  and  other  glands,  and  some  albuminuria,  may  be  noted. 

4.  The  Stadium  Desquamationis. — The  desquamation  lasts  several 
weeks,  though  the  rash  itself  lasts  but  three  to  six  days.  Desquama- 
tion begins  first  on  the  face,  from  the  sixth  to  ninth  day.  The 
glandular  swelling  disappears,  the  fever  falls  by  lysis,  and  convales- 
cence is  established  unless  complications  intervene. 

Special  Symptoms,  Complications  and  Sequels. — These  are  given 
in  detail  because  of  the  extreme  variability  in  the  clinical  symptoms: 

1.  The  Fever. — The  fever  is  less  typical  (Wunderlich)  than  in  most 
exanthemata;  e.  cj.,  smallpox  and  measles.  In  the  invasion  there  is 
a  rapid  rise  to  104°  or  105°.  The  fever  is  usually  somewhat  higher 
on  the  second  day,  with  slight  morning  remissions  and  gradual  sub- 
sidence when  the  rash  is  mature. 

In  the  most  severe  types  there  may  be  low  fever  or  no  fever  at  all, 
or  it  may  rise  to  107°  or  109°.  We  usually  note  a  close  parallelism 
between  the  abundance  of  the  exanthem  and  the  height  of  the  fever. 
The  temperature  should  be  taken  during  one  month  after  the  rash, 
lest  such  complications  as  sloughing  of  the  throat,  pleuritis,  endocar- 
ditis, pericarditis,  synovitis,  or  adenitis  be  overlooked.  A  long  course 
of  fever  may  exceptionally  occur  without  complications,  but  it  is 
rather  ominous. 


86  THE  SPECIFIC  INFECTIONS 

2.  The  Eruption. — The  eruption  is  often  atypical.  Typically,  it  begins 
in  the  form  of  light-red,  pin-head-like  points  which  become  darker 
as  the  skin  swells  and  the  eruption  diffuses.  It  then  appears  as  an 
even  red,  and  on  close  inspection  is  found  beset  with  small  points. 
These  are  the  first  part  of  the  exanthem  to  develop,  and  the  last  to  go. 
The  eruption,  then,  first  consists  of  red  spots,  especially  in  the  axilla 
and  groin;  second,  of  red  spots  in  a  diffuse  erythema;  and  lastly,  of 
red  spots  again.  This  minute  papulation  is  a  very  important  aid  to 
diagnosis  in  the  second  week.  There  may  be  minimal  white  lines 
in  the  eruption,  but  rarely  ever  spaces  as  there  are  in  measles.  Fiir- 
binger  compares  the  skin  in  measles  to  splashes  of  red  paint,  and  in 
scarlatina  to  an  even  red  coating.  The  skin  is  sometimes  vesiculated. 
Though  it  spreads  less  regularly  than  in  measles,  the  eruption  appears 
first  on  the  neck,  below  the  mastoid  process,  and  below  the  clavicles, 
then  upon  the  head,  trunk,  arms,  and  hands,  and  lastly  upon  the  legs 
and  feet.  It  is  most  intense  over  the  extensor  surfaces  of  the  joints 
and  on  the  trunk,  and  is  least  developed  on  the  face  and  scalp.  The 
palms  of  the  hands  and  soles  of  the  feet  are  usually  free.  The  pallor 
around  the  mouth  contrasts  vividly  with  the  scarlet  cheeks  and  mi- 
nutely papulated  forehead.  This  pale  area  is  circular  or  triangular, 
bounded  by  the  nasolabial  folds  above  and  the  chin  below.  Though 
not  pathognomonic,  it  is  always  valuable  in  differentiation,  and  is 
due  possibly  to  vascular  spasm.  The  eruption  is  occasionally  roseo- 
lous  about  the  ankles  and  wrists.  The  skin  is  always  swollen,  usually 
pales  on  pressure,  and  sometimes  itches,  or  is  wet  with  sweat  and  is 
vesiculated.  The  eruption  is  hypereemic,  and  it  therefore  pales  on 
pressure  and  disappears  after  death,  unless  there  are  punctate  hemor- 
rhages, which  are  not  uncommon  in  severe  types  of  the  disease.  After 
twenty-four  hours  of  the  eruption,  the  tension  disappears,  and  the 
bright-red  color  becomes  a  yellowish-red.  Pathological  changes  in 
the  skin,  according  to  Unna,  consist  of  hypersemia,  especially  in  the 
papillae,  but  rarely  oedema,  inflammation,  or  hemorrhage.  After  com- 
plete florition  the  skin  becomes  dry,  and  desquamation  begins.  This 
is  usually  bran-like  as  it  is  in  measles,  on  the  head,  face,  neck,  and 
trunk,  and  it  is  more  scale-like  and  lamellar  on  the  hands  and  feet, 
complete  casts  of  which  are  sometimes  shed.  The  scales  are  often 
large  in  proportion  to  the  intensity  of  the  eruption.  In  severe  cases 
even  the  hair  and  nails  are  shed,  and  the  nails  become  furrowed.  Des- 
quamation results  from  a  slight  exudation  of  serum  between  the  layers 
of  the  skin.  It  begins  on  the  cheek  with  the  "rouge-and-powder" 
appearance,  and  is  usually  first  observed  when  the  fever  and  angina 
decline,  but  it  may  be  delayed  from  two  to  seven  days  later.  The 
skin  may  present  a  "pin-hole"  or  "worm-eaten"  aspect  before  des- 
quamation begins.  Its  duration  is  most  variable,  usually  lasting  from 
one-half  to  three  weeks,  or  even  seven  or  eight  weeks  (Trousseau). 
Other  occasional  skin  complications  are:  Bed-sores,  gangrene,  oedema 
(either  with  or  without  nephritis),  and  eczema  on  the  face,  scalp,  or 
ears.     This  is  usually  impetiginous.     Anomalies  of  erv/ption:    Scar- 


SCARLET  FEVER  87 

latina  Icevigata  is  the  typical  rash  which  has  been  described  above. 
Other  forms  are  scarlatina  Icevis  (rudimentary  or  localized  eruption); 
scarlatina  sine  exanthemate  (the  rash  being  wholly  absent);  scar- 
latina 'papulosa  (marked  papulation);  scarlatina  miliaris  (promoted 
by  sweating,  but  also  the  result  of  exudation  between  the  rete  Mal- 
pighii  and  the  epidermis);  scarlatina  variegata  (like  measles,  though 
not  equally  elevated);  scarlatina  hemorrhagica  (usually  ominous,  and 
at  times  part  of  a  general  hemorrhagic  diathesis).  In  general,  ir- 
regular forms  are  dangerous. 

3.  The  Throat. — The  throat  changes  are  the  most  constant  lesions  in 
scarlet  fever,  and  constitute  the  internal  eruption  (enanthem).  The 
disease  begins  in  the  throat  with  dryness,  uniform  redness,  and  in- 
variably with  early  swelling.  The  throat  very  soon  becomes  speckled 
with  fine  red  points  like  the  skin  papulation.  Though  always  present, 
it  varies  in  intensity.  All  forms,  from  simple  angina  to  diphtheritic 
or  gangrenous  inflammation,  may  be  seen,  (a)  In  mild  cases,  a  simple 
catarrh  with  little  swelling,  a  thick  mucous  coating,  and  more  or  less 
reddening  of  the  palate  and  tonsils,  develop,  (b)  In  moderate  cases, 
there  is,  in  addition  to  the  above,  more  swelling  of  the  palate,  and 
tonsillitis,  (c)  In  severe  cases,  membrane,  small  abscesses,  gangrene, 
small  hemorrhages,  sloughing,  and,  perhaps,  sudden  hemorrhage, 
oedema,  adenitis,  periadenitis,  or  cellulitis,  develop.  Severe  inflamma- 
tion in  the  throat  occurs  in  65  per  cent,  of  the  cases  (Von  Ranke) . 

Clinical  and  anatomical  diphtheria  are  often  confused.  "Necrotic 
inflammation''  in  scarlatina  is  that  caused  by  the  virus  of  scarlatina 
alone.  Genuine  diphtheria  may  accompany  or  follow  scarlatina;  ^of 
these,  post-scarlatinal  diphtheria  is  the  more  dangerous  (Trousseau). 

Diphtheritic  Membrane. vs. Scarlatinal  Membrane. 

Firm,  adherent.  Softer,  loosened  in  fragments. 

Yellow-gray.  Brownish  tint. 

Deep  ulceration  rarer,  in  more  severe         More  frequent  and  earlier  (even  in 
cases  only,  and  later.  ■  twenty-four  hours). 

Phlegmon  rare.  Not  infrequent. 

Laryngeal  membrane  (croup)  frequent         Rare,   membrane   thinner;     lung   com- 
and  deeper.  plications  rare. 

Bacteriologically,  the  Klebs-Loeffler  Streptococcus    (Klebs-LoefHer    bacillus 

bacillus.  found  only  as  a  complication). 

Paralysis  frequent.  Rare,  except  local  paralysis  due  to  local 

swelling  of  pharynx. 

Recurrence  frequent.  Infrequent. 

Since  the  bacteriological  cause  of  scarlatina  is  undetermined,  it  is 
doubtful  whether  the  pyogenic  cocci  found  in  the  throat  are  integral 
or  complicating. 


88  THE  SPECIFIC  lAFECTIOXS 

4.  The  Respiratory  Tract. — Though  often  unaffected,  the  respiratory 
tract  may  become  secondarily  involved  by  a  descending  process.  The 
nose  is  involved  in  direct  ratio  to  the  severity  of  the  throat  develop- 
ments, such  as  necrosis,  diphtheria,  and  gangrene.  Acute  oedema  of 
the  glottis  is  infrequent.  The  bronchial  mucosa  is  more  often  in- 
volved than  is  usually  recognized.  Bronchopneumonia,  acute  lobar 
pneumonia  (usually  in  the  upper  lobes  and  coexisting  with  nephritis), 
gangrene,  infarcts,  inflammatory  oedema  and  hypostasis,  are  not  coni- 
mon.  Pleurisy,  described  especially  by  R.  P.  Howard,  occurs  in  5 
per  cent,  of  the  cases.  It  is  often  overlooked,  is  likely  to  be  severe, 
is  very  frequently  purulent,  and  often  occurs  during  convalescence. 

5.  The  Heart. — The  heart  may  be  greatly  damaged  by  the  scarlatinal 
virus,  and  is  involved  in  35  per  cent,  of  the  cases,  not  including  the 
cases  of  sepsis  and  nephritis  (Schmaltz).  Endocarditis  is  frequently 
mural,  whence  its  frequent  latency,  but  it  may  result  in  chronic 
valvular  disease,  especially  of  the  mitral  valves.  "After  rheumatism, 
scarlatina  is  the  most  frequent  cause  of  endocarditis"  (Leube). 
Tachycardia  may  often  be  observed  from  toxeemia  or  acute  infective 
myocarditis.  With  increased  arterial  tension  due  to  kidney  disease, 
the  heart  is  slowed,  and  hypertrophy  may  result,  unless  pancarditis, 
(endo-,  myo-,  and  pericarditis),  exist.  Pericarditis  is  usually  septic, 
Disquieting  cardiac  dilatation  may  be  seen  in  severe  cases,  accom- 
panied by  the  usual  evidences  of  acute  cardiac  insufficiency;  it  may 
occur  during  the  fever  (Rhomberg),  or  in  convalescence  (Schmaltz). 
Dilatation  and  hypertrophy  are  much  more  frequent  in  children  than 
in  adults,  and  often  complicate  renal  lesions.  Leukocytosis  develops 
early  and  may  become  extreme  in  fatal  cases.  It  has  been  recently 
stated  that  the  leukocytes  are  normal  in  number,  but  the  polymorpho- 
nuclears are  absolutely  and  relatively  increased  two  or  three  days 
after  the  eruption.  The  eosinophiles  are  also  increased.  The  hsemo- 
globin  and  red  cells  suffer  an  early  and  increasing  reduction.  The 
red  cells  average  4,000,000.  Hemorrhagic  diathesis  seldom  occurs 
except  as  a  result  of  sepsis. 

6.  The  Digestive  System. — The  tongue  is  swollen,  indented, 
broad,  and  thick.  Its  papillse  become  larger  and  separated  from 
each  other.  Its  coating  is  first  grayish,  and  only  the  edges  and 
tip  of  the  tongue  are  reddish,  but  later  the  coating  disappears,  leav- 
ing the  tongue  very  red,  dry,  and  glistening,  on  which  the  papillse 
appear  granular  and  warty — the  "strawberry,"  "raspberry,"  or  "cat's 
tongue."  This  appears  from  the  third  to  the  fifth  day  and  lasts  a 
week.  It  is  quite  pathognomonic,  according  to  Leube,  and  is  only 
second  in  importance  to  the  angina.  ^IcCollom,  of  Boston,  found 
it  the  only  constant  sign  in  1,000  cases  of  scarlatina.  The  breath  may 
often  be  sweet  and  of  a  very  hea\7  odor.  Diphtheritic  ulcers  and 
secondary  necrosis  in  the  stomach,  oesophagus,  and  intestines,  have 
been  found.  Vomiting  may  result  from  nephritis,  brain  toxsemia,  or 
coughing.  The  liver  and  spleen  may  be  slightly  swollen.  There  may 
be  abdominal  pain.     Constipation  is  usual.     Diarrhoea,  however,  may 


SCARLET  FEVER  89 

result  from  (a)  simple  catarrhal  enteritis,  which  is  transitory  and  not 
unfavorable  (Litten);  (6)  dysentery,  with  tenesmus  and  blood;  (c) 
the  so-called  "scarlet-typhoid"  of  Thomas,  which  is  accompanied  by 
tympany,  hemorrhage,  fluid  fseces,  very  rapid  pulse  (herein  differing 
from  typhoid),  and  lethal  outcome.  Its  resemblance  to  typhoid  is  also 
heightened  by  the  autopsy  findings  of  splenic  intumescence,  and  hy- 
perplasia with  ulceration  in  Peyer's  patches. 

7.  The  Kidneys. — The  urine  is  febrile.  It  will  respond  to  Ger- 
hardt's  reaction  and  to  the  diazo  test,  though  to  a  less  degree  than  in 
measles.  Increased  phenol  and  beta-oxybutyric  acid  may  be  found. 
Albuminuria  occurs  in  77  to  92  per  cent,  of  all  cases.  Early  renal 
changes  may  occasionally  be  observed.  The  "initial  catarrhal  ne- 
phritis," which  runs  a  short  course,  is  accompanied  anatomically  by 
hypersemia,  parenchymatous  changes,  some  fluid  in  the  glomeruli,  a 
few  cylinders  in  the  tubules,  and  little  interstitial  involvement. 

Nephritis  usually  develops  in  the  third  week  (ninth  to  fortieth  day). 
Its  frequency  varies  with  the  epidemic,  between  5  and  70,  or  even  90 
per  cent.  No  apparent  relation  exists  between  its  frequency  and  the 
severity  of  the  infection.  No  single  anatomical  form  is  invariable,  but 
the  glomerulonephritis  of  Klebs  is  most  frequent.  It  is  characterized 
anatomically  by  hypersemia,  increased  consistence,  and  such  glomerular 
changes  as  gray  color,  diffuse  fatty  granular  degeneration,  increase  of 
nuclei,  and  increase  by  50  per  cent,  in  the  size  of  the  tufts,  which  become 
sausage-like  solid  masses.  We  also  note  exudation  of  leukocytes  about 
the  afferent  vessels,  multiplication  of  capsular  epithelium  with  occlu- 
sion of  the  lumen,  hyaline  alteration  of  the  vessels,  and  small  and  early 
interstitial  changes,  and  later  connective-tissue  growth.  Friedlander 
observed  septic  interstitial  nephritis  and  the  large  variegated  kidney, 
in  cases  accompanied  by  diphtheria,  or  phlegmonous  complications. 

Hydrops  in  the  vast  majority  of  cases  is  renal  and  shows  the  char- 
acters of  renal  dropsy.  It  appears  first  under  the  skin,  and  the  cuta- 
neous blood-  and  lymph-vessels  are  altered  by  the  virus.  It  shifts  its 
location,  varies  without  cause,  and  may  produce  hydrothorax,  ascites, 
oedema  of  the  larynx,  of  the  lungs,  or  of  the  genitalia.  The  older 
writers  claimed  that  hydrops  occurred  without  nephritis,  and  that 
kidney  inflammation  might  exist  without  appropriate  urinary  altera- 
tions. Such  a  view  can  be  proved  by  autopsy  only.  The  temperature 
is  inconstant.  There  may  be  lumbar  pain,  vesical  tenesmus,  and 
ursemic  symptoms,  such  as  headache,  twitchings,  convulsions,  wide 
pupils,  amaurosis,  disturbance  in  motility,  in  sensation,  and  in  cere- 
bration, coma,  involuntary  evacuations,  vomiting,  diarrhoea,  cardial- 
gia  rapid  pulse  and  breathing,  and  pale  skin  tinged  with  cyanosis. 
The  retinae  are  usually  normal.  Many  convulsions  usually  imply  a 
lethal  termination  in  coma.  The  prognosis  is  more  favorable  if  the 
pupils  are  not  immobile.  The  urine  is  decreased  or  suppressed,  is 
heavy  with  sediment  and  albumin  (averaging  0.5  per  cent.),  is  poor 
in  urea,  turbid  (specific  gravity  1030),  and  is  full  of  casts  of  all  types— 
especially,  long,  flat,  band-like,  twisted,  and  frayed  casts.     Much  ox- 


90  THE  SPECIFIC  INFECTIONS 

alic  and  uric  acid  is  found  and,  in  many  cases,  blood.  Ursemia,  hydrops, 
and  intercurrent  inflammation,  are  always  dangerous.  Convalescence 
is  the  rule  after  four  to  six  weeks  (eight  to  eighteen  months),  and  the 
nephritis  rarely  becomes  chronic. 

8.  The  Special  Senses. — Decreased  secretion  in  the  eye  is  common. 
Cerebral  complications  promote  inflammation  in  that  the  eyes  close 
less  frequently.  Catarrhal  conjunctivitis,  diphtheritic  inflammation, 
involvement  of  the  lachrymal  sacs,  herpes  or  necrosis  of  the  cornea, 
panophthalmitis,  muscular  paralysis,  and  disturbance  in  accommoda- 
tion, are  possible  complications.  Ursemic  amaurosis,  neuroretinitis 
septica  seu  nephritica,  and  retinal  hemorrhage,  are  rare.  Middle-ear 
inflammation  (11  to  33  per  cent,  of  the  cases)  usually  begins  before 
desquamation,  but  may  be  observed  later.  It  may  easily  be  over- 
looked, and  is  accompanied  by  fever,  pain,  glandular  swelling,  difficult 
hearing,  tinnitus,  a  reddened,  glistening,  sunken  membrane,  and,  in 
children,  by  some  brain  manifestations.  It  is  quite  frequent  in  early 
life  and  rare  after  the  fifteenth  year;  10  percent.  (even42.6per  cent. !) 
of  cases  of  acquired  deafness  are  said  to  result  from  scarlatina. 

9.  The  Lymphatic  System. — The  lymphatic  system  is  generally  in- 
volved; e.  g.,  glands,  spleen,  follicles,  and  in  severe  cases,  all  the 
lymphatic  structures,  are  affected  by  the  sepsis.  The  "  collar  of  brawn  " 
results  from  cervical  adenitis  and  periadenitis.  Gangrene,  retroster- 
nal abscess,  and  jugular  phlebitis  with  sepsis,  occur  in  desperate  cases. 
After  recovery  the  neck  may  remain  swollen  for  a  long  time. 

10.  The  Bones  and  Joints. — Scarlatinal  "rheumatism"  is  found  in  6 
(2  to  12)  per  cent,  of  the  cases,  usually  in  the  second  or  third  week 
(with  desquamation  and  subsidence  of  the  fever),  and  usually  lasts 
three  or  four  days.  It  attacks  the  smaller  rather  than  the  larger  joints, 
the  wrists  rather  than  the  elbows  or  shoulders,  and  the  ankles  rather 
than  the  knees.  It  develops  with  pain,  and  is  not  so  migratory  as 
ordinary  rheumatism.  It  may  leave  no  autopsy  findings,  or  it  may 
become  purulent.  Swelling  of  the  joints  does  not  always  occur.  It 
is  claimed  that  swelling  occurs  in  those  who  have  had  rheumatism, 
and  that  it  may  respond  to  salicylates.  It  occurs  in  old  rather  than  in 
young  subjects.  Endocarditis  follows  in  less  than  3  per  cent,  of  scar- 
latinal rheumatism.  The  prognosis  is  usually  good.  Bone  involve- 
ment is  rare.  ^ 

Scarlatinal  sequels  are  anaemia,  hemorrhagic  diathesis,  retarded 
development,  and  decreased  physiological  resistance.  Tuberculosis 
rarely  follows  scarlatina,  because  the  two  diseases  are  rather  an- 
tagonistic. Latent  sepsis  with  brain  foci,  valvular  disease,  chronic 
nephritis,  chronic  adenitis,  otitis,  mastoiditis,  deafness, meningitis,  hemi- 
plegia, cerebral  venous  thrombosis,  facial  paralysis,  ascending  spinal 
paralysis,  chorea,  and  exhaustion  psychoses,  are  fortunately  the  more 
rare  complications  and  sequels. 

Diagnosis. — Typical  cases  are  easily  determined  when  an  epidemic 
prevails,  and  when  the  eruption  is  not  considered  of  chief  diagnostic 
reliance.    The  criteria  are  as  follows: 


SCARLET  FEVER  91 

1.  Sudden  onset  and  rapid  development,  with  fever  and  vomiting. 

2.  Angina,  pain,  redness,  punctate  spots  in  vault  of  the  mouthy 
swelling  and  dysphagia,  which  are  practically  always  present.  Severe 
symptoms  in 'the  throat,  especially  during  an  epidemic,  are  suspicious. 

3.  Strawberry  tongue,  which  is  practically  constant. 

4.  Exanthem.  This  appears  about  the  clavicles,  and  shows  a  char- 
acteristic progression.  The  face  is  less  involved,  and  the  mouth  is 
free;  it  is  intense  on  body;  papules  then  erythema  develop;  there 
are  no  free  spaces;   it  results  in  desquamation. 

5.  Lymphadenitis.  In  this,  the  cervical  are  less  important  than 
the  inguinal  glands. 

6.  Fever,  hydrops,  albuminuria,  and  nephritis,  in  atypical  cases. 

7.  Scaling,  tender  joints,  and  albuminuria,  are  strong  indications  of 
scarlatina  if  the  initial  symptoms  were  not  observed  or  were  not  clear; 
they  help  in  making  a  retrospective  diagnosis. 

Diagnosis  of  Atypical  Scarlatina. — 1.  Severe  scarlatina,  (a)  An- 
ginose  form.  This  resembles  septic  diphtheria,  with  marked  toxaemia, 
necrosis,  and  adenitis.  (6)  Atactic  form.  Violent  early  intoxication; 
high  fever  and  death  even  on  the  eleventh  hour  of  the  disease  (Trous- 
seau), before  the  eruption  appears;  blood  dissolution,  vomiting,  diar- 
rhoea, convulsions,  coma,  and  an  excessively  rapid,  weak  heart,  are 
the  chief  symptoms,  (c)  Hemorrhagic  scarlatina.  This  is  character- 
ized by  severe  fever  and  brain  symptoms  at  the  onset;  incomplete 
exanthem,  necrosing  angina,  marked  glandular  and  splenic  swelling; 
subcutaneous,  serous,  and  mucous  hemorrhages  with  exulceration.  It 
is  usually  lethal  after  ten  to  twenty  hours  from  hyperpyrexia,  exhaust- 
ing vomiting,  diarrhoea,  sopor,  delirium,  convulsions,  and  dyspnoea. 
It  is  encountered  especially  in  reduced  subjects  under  two  years  of  age. 

2.  Very  light  cases  may  present  (a)  all  the  usual  signs,  though 
but  mildly  developed;  or  (6)  some  symptoms  may  be  absent  {scar- 
latina fragmentaria) ,  as  in  cases  with  no  temperature  (scarlatina  sine 
febre),  no  rash  (scarlatina  sine  exanthemate) ,  or  no  angina  (scarlatina 
sine  enanthemate).  In  some  atypical  cases  a  definite  diagnosis  is 
impossible,  as  in  acute  nephritis  with  uraemia,  fever,  sore  throat,  and 
gastro-enteritis,  without  the  characteristic  rash.  Recurrent  forms  are 
not  frequent.  They  occur  in  the  middle  of  the  third  week,  and  result 
from  incomplete  elimination  of  the  virus  during  the  first  attack.  Many 
of  these  cases  are  septic  complications  rather  than  actual  recurrences. 
According  to  Koerner,  only  forty  relapses  are  on  record. 

The  differentiation  is  as  follows: 

Scarlet  Fever. vs. Sepsis. 

Bright-red   erythema,    with   small   red         A  very  deep  purple-red  rash,  sometimes 

papules.  spreading  over  entire  body. 

The  eruption  is  much  the  same  in  both  diseases,  the  same  places  being  exempt. 
Miliaria  are  rare.  Frequent. 

Rather  typical  desquamation.  Desquamation  also  observed,  but  less 

frequently. 
Criteria  {q,  v.):   angina,  tongue,  abrupt         Etiology  (lacking  in  cryptogenetic  type), 

onset,  glands,  etc.  chills,  sweats,  fever  irregularity,  clinical 

course,  polymorphous  exanthems,  etc. 


92  THE  SPECIFIC  IXFECTIOXS 

Diphtheria  is  often  differentiated  with  difficulty.  A  simple  ery- 
thema is  sometimes,  though  not  very  often,  observed  in  diphtheria. 
When  present  it  is  darker,  is  located  more  on  the  trunk,  and  is  more 
transitory  than  in  scarlatina  (see  Throat  Complicatioxs). 

Drug  rashes,  from  belladonna,  quinine,  iodide,  chloral,  or  copaiba, 
may  be  easily  differentiated,  if  the  cardinal  signs  rather  than  the  rash 
alone  are  considered. 

Measles  and  German  measles  {q.  v.).  Acute  exfoliating  dermatitis 
also  begins  with  fever,  with  a  spreading  erythema,  and  very  early 
desquamation,  but  the  other  cardinal  criteria  of  scarlatina  are  lacking. 
Erythema  is  more  transitory;  the  points  are  absent;  it  occurs  mth  less 
fever  and  without  angina  or  adenitis. 

Erysipelas  presents  a  sharp  border,  oedematous  swelling,  marked 
pain,  and  a  slow  advance. 

Prognosis. — This  should  always  be  guarded  for  at  least  one  month. 
The  outcome  often  depends  on  the  genius  epidemicu^,  since  the  mor- 
tality ranges  between  2  and  40  per  cent.  The  death-rate  averages 
about  10  per  cent.  The  prognosis  is  least  favorable  in  hospital  cases 
and  in  children.  Most  deaths  occur  under  six  years;  in  children 
under  five  years,  the  mortality  is  20  to  30  per  cent.  (Holt).  In  the 
first  year  of  life  the  disease  is  very  fatal. 

The  social  status,  severity  of  the  infection  (hemorrhagic  forms,  severe 
nervous  toxaemia),  complicating  sepsis,  necrosis  in  the  throat,  otitis, 
nephritis  (ursemia,  hydrops),  heart  complications  (high  pulse-rate 
being  always  unfavorable),  respiratory  complications,  and  laryngeal 
obstruction,  are  factors  in  the  prognosis. 

Treatment. — There  is  no  specific  therapy  and  the  disease  runs  its 
self-limited  course. 

I.  Prophylaxis. — Prophylaxis  is  equally  imperative  in  both  severe 
and  light  cases.  Indeed,  the  light  or  ambulatory  forms  are  often  the 
more  dangerous.  Isolation  is  important,  because  susceptibility,  espe- 
cially in  the  young,  is  not  universal  and  the  virus  is  less  penetrative 
than  in  measles,  and  it  is  therefore  possible  to  circumscribe  its  diffusion. 
Care  should  be  taken  to  prevent  transmission  through  schools  and 
by  means  of  fomites  and  by  third  persons.  The  infected  room  should 
be  kept  empty  for  one  month,  and  should  be  exposed  to  the  wind  and 
sun  for  several  weeks.  No  susceptible  person  should  use  the  room 
for  several  months.  The  physician  should  wear  an  operating  gown 
and  carefully  wash  his  face,  beard,  and  hands,  after  leaving  the  sick- 
room. Quarantine  should  be  maintained  from  six  to  eight  weeks.  Even 
this  is  probably  too  short  a  period.  A  sheet  saturated  with  carbolic 
acid  or  formaldehyde,  and  hung  before  the  door,  is  of  no  special  value. 
Formaldehyde  fumigation  has  been  discussed  under  smallpox.  Care  in 
surgical  and  puerperal  cases  is  important,  but  the  danger  has  been  over- 
estimated. All  discharges  should  be  disinfected.  Bichloride  wrappings 
should  be  placed  about  the  dead  body,  and  the  funeral  should  be  private. 

Schools  should  be  closed  during  epidemics.  In  hospitals  the  cases 
of  scarlatina  with  streptococcus  infection  should  be  separated  from 


SCARLET  FEVER  93 

cases  of  simple  scarlatina .  Sound  children  should  be  sent  away  from 
the  house  and  isolated  lest  they  spread  the  disease.  If  they  remain  at 
home,  about  one-quarter  of  them  will  contract  scarlatina  (Chapin). 
II.  General  Treatment.  1.  Position. — The  prone  position  in  bed 
is  imperative  in  all  cases,  both  during  the  disease  and  in  the  first  two 
weeks  of  apyrexia. 

2.  Room.— The  room  should  be  light  and  well  ventilated,  though 
somewhat  warm,  especially  in  convalescence.  A  grate  fire  is  advisable, 
and  the  windows  should  be  open  at  the  top.  The  air  should  be  kept 
dry,  since  dampness  tends  to  promote  nephritis.  During  the  fever 
the  skin  should  be  covered  with  linen,  and  in  convalescence  with  wool. 

3.  Skin. — The  eruption  should  be  brought  out,  when  necessary,  by 
pilocarpine  (Demma)  or  with  mustard  baths.  During  the  fever,  the 
patient  should  be  washed  daily  with  warm  water  and  soap,  though 
unnecessary  exposure  should  be  avoided.  The  tension  of  the  skin  is 
thus  lessened,  the  fever  decreased,  and  toxsemic  symptoms,  such  as 
insomnia  and  restlessness,  are  allayed.  During  desquamation,  oil- 
rubs  may  be  employed  to  decrease  the  risk  of  infection  by  dissemina- 
tion of  dry  scales.  They  are,  however,  now  considered  deleterious, 
as  they  decrease  the  functions  of  the  skin,  which  are  of  great  im- 
portance when  the  kidneys  are  involved.  Besides,  infection  is  more 
probably  carried  by  means  of  throat  secretions,  than  by  desquamation. 
Soap  and  warm  water  serve  equally  well.  The  author  is  opposed/to 
antiseptic  soaps  because  of  the  chance  of  absorption  which  may  re- 
sult in  renal  injury. 

4.  Fever. — The  following  is  a  harmless  fever  mixture: 

R 

Liquoris  ammonii  acetatis      Siss. 

Tincturge  aconiti njxxiv. 

Syrupi  limonis §ss. 

Aqu£e q.  s.ad  ovj. 

Misce,  fiat  mistura. 

S.— One  to  three  teaspoonfuls  every  four  or  five  hours,  according  to  age. 

This  mixture  tranquilizes,  promotes  the  rash,  and  allays  fever.  Hydro- 
therapy is  useful,  such  as  the  warm  sponge  or  full  warm  bath.  Special 
care  is  indicated  (a)  in  adynamic  cases,  because  of  danger  of  heart- 
failure;  therefore  the  full  cold  bath  should  always  be  avoided  and 
the  moderately  warm  bath  should  be  used;  (6)  in  pericarditis;  (c) 
in  stenosis  of  the  air-passages,  or  dyspnoea;  (d)  in  hemorrhagic  forms; 
(e)  in  arthritis;   and  (/)  in  nephritis. 

5.  Diet. — Water  should  be  given  very  freely.  A  fluid  diet  is  indi- 
cated by  the  fever,  the  percentage  of  renal  complications,  and  the  dys- 
phagia. This  may  consist  of  concentrated  foods,  milk,  soups,  and 
jellies.  In  defervescence,  milk-toast,  custard,  puddings,  and  bread 
andbutter,  may  be  given.  Eggs  may  cause  albuminuria,  and  should 
therefore  be  avoided.  After  defervescence,  meat,  chicken,  and  fish, 
may  be  allowed.  Meat  is  given  by  some  clinicians  because  the  urea 
is  usually  eliminated  easily.    Fruit  and  vegetables  may  be  given  freely 


94  THE  SPECIFIC  INFECTIONS 

at  all  stages,  if  this  can  be  done  without  injuring  the  throat.  In  severe 
throat  complications,  rectal  feeding  is  indicated.    (See  Gastric  Ulcer.) 

6.  Scarlet  Rheumatism. — The  A.B.C.  liniment  (aconite,  bella- 
donna, and  chloroform),  warm  wool  and  flannel  bandages,  are  helpful. 

Tr.  opii ouj. 

Acidi  carbolic! 3j. 

Tr.  belladonnse 3iij. 

01.  camphorati 3iv. 

M.  et  S. — May  be  applied  on  muslin  covered  by  cotton 

Salicylates  are  beneficial  in  some  cases,  but  unless  given  in  careful 
doses  may  injure  the  kidneys.  If  the  arthritis  is  obstinate,  aspiration 
with  all  surgical  care  and  even  drainage  may  be  indicated. 

7.  Angina. — Ice  in  the  mouth,  ice-cravats,  hot  fomentations  espe- 
cially for  the  enlarged  glands,  and  Dobell's  solution  as  a  nasal  douche 
should  be  given.  Care  should  be  exercised  in  the  use  of  antiseptics 
lest  children  swallow  them.  A  10-per-cent.  peroxide  of  hydrogen,  2- 
per-cent.  chlorate  of  potash,  or  2-per-cent.  carbolic  gargle,  may  be  used. 
Formalin  gargles  are  too  irritating.    Caustics  are  useless. 

For  the  nose  the  following  formula  is  excellent : 

^  . 

Acidi  carbolici oss. 

Acidi  borici 3ss. 

Glycerini §j. 

Tr.  myrrhae o]. 

Aquae q.s.  ad  gv. 

M.  et  S. — Locally,  in  such  dilution  that  no  irritation  is  felt. 

Huebner  injects  3-per-cent.  carbolic  solution  into  the  tonsils  (3ss 
b.i.d.  on  each  side).  A  10-per-cent.  nitrate-of-silver  solution  is  used 
with  great  advantage  in  the  early  stages  of  the  angina.  Coincident 
diphtheria  is  treated  by  means  of  local  measures  and  antitoxin  (de- 
scribed under  diphtheria),  and  the  antistreptococcus  serum  may  be 
tried  in  streptococcic  angina. 

8.  Lymph  Glands. — Secondary  infection  may  occur,  against  which 
prophylactic  care  of  the  mouth  and  throat  is  important.  Ice  should 
be  applied  in  the  beginning  only,  and  later  hot  boric-acid  dressings 
when  the  blood-  and  lymph-streams  become  stagnant.  Iodine  and 
ichthyol  salves  and  surgical  intervention  are  indicated  in  the  order 
named. 

9.  Otitis. — Otitis  is  treated  by  copious  boric  irrigation,  given  quite 
hot  and  at  a  slight  elevation,  and  followed  by  equal  parts  of  glycerine 
and  laudanum,  5-per-cent.  carbolic  acid,  or  5-per-cent.  cocaine  in  olive 
oil.  Leeches  over  the  mastoid  often  relieve  the  pain.  Examination 
of  the  drum  is  rather  impracticable  in  children  with  small  sensitive 
meatus.  There  is  said  to  be  no  harm  in  awaiting  spontaneous  rup- 
ture, but  early  puncture  under  cocaine  is  much  safer.  After  rupture, 
cotton  with  a  small  amount  of  iodoform  or  boric  powder  should  be 
applied. 


SCARLET  FEVER  95 

10.  Nephritis. — Nephritis  is  treated  (a)  according  to  the  old  prophy- 
lactic rule,  by  which  all  cases,  severe  or  light,  are  confined  to  bed  for 
at  least  four  weeks.  The  urine  must  be  watched.  An  albuminous 
diet  is  said  not  to  be  contraindicated,  since  the  urea  is  usually  well 
eliminated,  but,  according  to  Jaccoud,  the  milk  diet  is  valuable  in  the 
prevention  of  nephritis.  Irritants,  like  cantharides,  are  always  to  be 
avoided.  Tepid  baths  lasting  a  quarter  of  an  hour  should  be  given 
daily,  especially  in  convalescence.  Watch  the  temperature  and  the 
urine  in  convalescence.  Wiodowitz  in  102  cases  used  urotropin 
successfully  as  a  prophylactic.  The  number  of  his  cases  is  too  small 
for  generalization,  but  his  results  are  at  least  suggestive.  (6)  Treat- 
ment of  established  nephritis.  Hot  baths  increase  the  sweat  and  the 
flow  of  urine.  They  should  be  given  twice  daily,  and  may  last  for  even 
an  hour,  but  the  patient  must  be  kept  afterward  between  blankets. 
Alkaline  diuretics,  such  as  potas.  acet.,  pot.  bicarb.,  p.  citrat.,  and 
infus.  tritici  repentis,  may  be  given;  pilocarpine  for  a  child  two  years 
old,  4S  to  20  gr.,  will  often  relax  the  skin.  (See  Treatment  of  Ne- 
phritis.) Calomel  must  be  used  with  great  care  as  a  laxative  and 
diuretic.     Digitalis  in  moderate  doses  aids  diuresis. 

Infusi  digitalis 5v. 

Potassii  acetatis 5ss. 

Syrupi  simplicis 3  ij  • 

Aquae q.s.  ad  oij. 

M.  et  S. — One  teaspoonful  every  two  hours. 

High  arterial  tension  should  be  treated  with  nitroglycerine.  For 
convulsions,  chloroform,  chloral,  and  bromides  are  valuable.  For 
vomiting,  iodine  is  most  efficacious  (see  Vomiting  Typhoid).  Vene- 
section and  the  administration  of  digitalis  are  necessary  in  severe 
pulmonary  oedema.  For  marked  uraemia,  two  drops  of  croton  oil  in 
milk  or  placed  undiluted  on  the  tongue,  should  produce  free  catharsis 
in  two  hours.  If  not  successful  by  that  time  it  should  be  repeated. 
Powdered  jalap  (gr.  xv.  to  5j-)  will  unload  the  bowels  in  less  urgent 
cases.  Early  evacuation  is  indicated  in  pleurisy,  if  chain  cocci  are 
found  by  puncture. 

11.  Tonics. — Such  tonics  as  iron,  arsenic,  and  cod-liver  oil,  are  indi- 
cated in  convalescence.  The  heart  must  be  watched  for  weeks,  be- 
cause the  heart  is  very  often  degenerated. 

12.  Serum. — Marmoreck's  and  other  streptococcic  sera  have  given 
no  definite  general  results,  although  in  four  instances  the  author  has 
seen  good  results.  Everything  depends  on  whether  the  streptococci 
are  the  primary  cause  or  only  secondary  symbiotic  organisms.  Again, 
immunization  against  one  variety  of  streptococcus  does  not  produce 
immunity  against  other  varieties.  In  Vienna,  Moser's  serum  has  ap- 
parently been  efficacious.  In  the  St.  Anna  Children's  Hospital,  the 
mortality  was  8  per  cent.,  and  in  other  institutions  it  amounted  to  14.5 
per  cent,  without  serotherapy. 


96  THE  SPECIFIC  INFECTIONS 


MEASLES  (MORBILLI,  RUBEOLA). 

Definition. — An  acute,  highly  infectious  disease,  characterized  by 
an  initial  coryza  and  other  inflammations  of  the  air-passages,  by  a 
rapidly  spreading  eruption,  a  fever-curve  with  a  double  summit,  and 
by  toxaemia. 

History. — Its  first  clear  description  dates  from  Rhazes  (980-1037 
A.D.).  It  is  a  very  old  disease  and  was  widely  epidemic  in  the  eigh- 
teenth century. 

Etiology. — (a)  Susceptibility  is  almost  universal;  few  individuals 
escape  (14  percent,  only  [Madsen]),  and  one  attack  generally  confers 
immunity,  though  this  is  sometimes  congenital.  A  second  attack  is 
relatively  rare,  although  third  and  fourth  attacks  are  known  to  have 
occurred,  (b)  Age — It  is  rare  during  the  first  five  months  of  life, 
and  it  occurs  most  frequently  after  the  first  year.  Twenty  instances 
of  placental  transmission  to  the  child  are  reported.  It  is  more  common 
in  adults  than  is  scarlet  fever.  In  Schwalbe's  collection  of  16,981 
cases,  50.4  per  cent,  occurred  in  the  first  five  years;  42  per  cent,  between 
five  and  ten  years;  5.2  per  cent,  between  ten  and  twenty  years,  and  2.4 
per  cent,  after  twenty  years  of  age.  (c)  Season — Measles  occurs 
mostly  in  the  winter  and  in  the  cooler  spring  months,  (d)  The  actual 
virus  is  unknown.  Protozoa  are  said  to  have  been  found  by  Doehle, 
and  bacilli  by  Canon  and  Piclicke.  The  longevity  of  the  virus  without 
the  body  is  not  great.  It  exists  in  the  blood,  tears,  skin,  and  in  the 
bronchial  and  nasal  secretions.  Its  activity  is  greatest  during  the  catar- 
rhal stage,  but  it  is  also  dangerous  during  the  eruption,  and  possibly 
even  during  incubation  and  desquamation.  Hektoen  twice  succeeded 
in  inoculating  the  disease  from  the  blood  of  measles  patients. 

Propagation  usually  occurs  by  personal  contact,  and  rarely  through 
a  third  person.  Aerial  transmission  is  frequent,  whence  isolation  in 
the  home  is  not  always  prophylactic.  For  this  reason  the  disease 
usually  runs  through  the  family.  The  most  frequent  means  of  dis- 
semination is  the  school-room.  It  is  more  often  epidemic  than  is 
scarlatina,  and  epidemics  range  more  widely  through  the  country. 
They  last  from  four  to  six  months. 

General  Clinical  Course. — The  stages  are:  (I)  Incubation  of  nine 
or  ten  days;  (II)  initial,  catarrhal,  or  prodromal  stage  of  three  or 
four  days,  with  fever,  catarrhal  symptoms  in  the  eyes,  nose,  etc.,  and 
an  enanthem;  (III)  the  eruptive  stage,  lasting  four  or  five  days, 
with  renewed  fever,  intoxication,  eruption,  and  inflamed  mucosae; 
(IV)  the   desquamative   period   of  variable  duration. 

I.  Incubation. — The  incubation  lasts  nine  or  ten  (or  fourteen) 
days. 

II.  Then  the  catarrhal  (initial,  prodromal,  invasion)  symptoms 
appear.  These  are  chilly  sensations,  malaise,  frontal  headache,  red- 
ness of  the  eyes,  lachrymation,  photophobia,  coryza,  and' sneezing;  dry- 
ness, redness,  and  pain  in  the  nose,  in  the  throat,  and  in  the  bronchi, 


PLATE   IL 


FIG.  I. 


FIG.  2. 


FIG.   8. 


FIG.   4 


The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 


Fig.  1. — The  discrete  measle.s  spots  on  the  buccal  or  labial  mucous  membrane,  showing  the  isolated 
rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  normally  colored  mucous  membrane. 

Fig.  2. — Shows  the  partially  diffu.se  eruption  on  the  mucou.s  membrane  of  the  cheeks  and  lips;  patches 
of  pale  pink  intersper.sed  among  rose-red  patches,  the  latter  showing  numerous  pale  bluish-white  spots. 

Fig.  3. — The  appearance  of  <.ae  buccal  or  labial  mucous  membrane  when  the  measles  spots  completely 
coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The  exanthem  on  the  skin 
is  at  this  time  generally  fully  developed. 

Fig.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal  in  hue. 
Minute  yellow  points  are  surrounded  by  a  red  area.     Always  discrete. 


MEASLES  97 

and  cough,  which  develops  after  one  day.  Vomiting  may  occur.  The 
respiratory  symptoms  are  due  to  a  mucous-membrane  enanthem 
(Rehn)  which  is  said  to  be  seen  at  autopsy  on  other  mucosee.  Exam- 
ination of  the  throat  reveals  Koplik's  spots  (Plate  II)  in  86  to  97  per 
cent,  of  cases,  described  by  him  in  1886,  and  by  Filatow  in  1885.  They 
are  practically  constant  on  the  buccal  mucosa  near  the  molars,  and  are 
found  on  the  first  day.  They  are  round,  of  a  bluish-white  color,  and  are 
surrounded  by  a  reddish  areola.  Early  catarrhal  symptoms  are  more 
common  in  measles  than  in  any  other  acute  infection  of  childhood. 
The  initial  fever  reaches  102°  or  103°,  and  declines  gradually  during 
the  third  and  fourth  days.  Occasionally  there  is  a  prodromal  rash, 
which  is  mostly  hypersemic,  though  rarely  macular  or  papular. 

III.  The  eruption  begins  on  the  fourth  day  with  papules  on  the 
temples,  cheeks,  forehead,  and  then  on  the  back,  wrists,  forearms, 
and  on  the  anterior  surface  of  the  body  and  legs,  in  order  of  progres- 
sion as  named;  with  the  appearance  of  the  eruption,  the  fever  again 
rises.  The  eruption  disappears  on  pressure  or  on  lateral  stretching 
of  the  skin,  and  is  palpable  and  superficial.  There  are  always  islets 
of  normal  skin,  even  in  the  thickest  eruption.  The  glands  are  usually 
enlarged  and  there  is  more  or  less  marked  sweating. 

The  general  and  local  symptoms  usually  abate  on  the  sixth  day, 
and  the  fever  falls  by  crisis.  In  severe  cases,  epistaxis,  diarrhoea, 
cerebral  intoxication,  bronchiolitis,  pneumonia,  hypostasis,  cyanosis, 
and  asphyxia,  may  be  observed,  and  death  may  result  from  lung  in- 
volvement, mixed  infection,  or  decreased  physiological  resistance. 

IV.  Desquamation. — In  the  desquamative  stage  the  skin  pales,  be- 
come slightly  pigmented,  and  scales  form.  Convalescence  is  established 
in  eight  or  ten  days. 

Individual  Symptoms  in  Detail. — I.  The  Eruption. — It  is  essen- 
tially the  same  on  the  skin  and  on  the  mucosse.  In  the  mouth  the 
mucosa  is  red  on  the  first  day  of  fever,  and  Koplik's  spots  are  found; 
on  the  second  day  redness  without  swelling  is  especially  noted  on  the 
tonsils  and  palate.  The  mucous  eruption  may  reach  the  larynx,  in- 
testines, and  genitalia.  Though  the  enanthem  tends  to  spread,  the 
skin  eruption  (exanthem)  is  eircumscribed.  The  rash  is  due  to  hyper- 
semia  rather  than  to  actual  exudation.  It  fades  on  pressure;  in  some 
cases  the  roseolas  do  not  fade  on  pressure,  but  leave  a  brown-colored 
area,  especially  in  the  nodular  forms  of  measles.  The  roseolse  usually 
are  discrete,  are  slightly  elevated,  especially  in  the  centre,  from  spastic 
contraction  of  the  bloodvessels  and  oedema,  are  light  to  dark  red  in 
color,  are  round  or  crescentic  in  shape,  and  average  2  to  6  millimeters 
in  diameter.  They  always  leave  islets  of  normal  skin  between  the 
independent  spots  of  eruption,  even  in  the  most  diffuse  types.  The 
eruption  follows  a  descending  order  and  reaches  the  lower  parts  of 
the  body  last.  When  the  eruption  develops  on  the  body  first,  the 
course  is  usually  anomalous.  Itching  may  be  noted,  and  sweating 
may  be  marked.  Desquamation  follows  the  same  order  as  the  erup- 
tion, and  is  usually  fine.     Scars  never  result.     The  eruption  is  rudi- 

7  • 


98 


THE  SPECIFIC  INFECTIONS 


mentary  in  those  who  are  debiHtated  by  chronic  diseases,  and  is 
exuberant  in  the  healthy. 

The  varieties  are:  (1)  Morhilli  loeves:  the  usual  form,  with  small 
elevations.  (2)  M.  vesiculosi  sen  miliares.  (3)  M.  papulosi,  nodular 
measles:  the  eruption  may  feel  slightly  "shotty,"  but  such  induration 
is  always  superficial.  (4)  M.  confluentes  seu  conferti.  (5)  M.  hem- 
orrhagicoe,  benign  or  malignant  (black  measles;  typhoid,  septic, 
adynamic  types).  (6)  M.  sine  exanthemate ;  sine  enanthemate. 
"Recession"  of  the  eruption  (fading  or  "striking  in")  is  usually  a  sign 
of  heart-failure. 

II.  The  Fever.— The  curve  is  not  absolutely  typical.  It  begins 
suddenly  without  a  chill,  and  falls  on  the  second  day,  perhaps  even  to 
normal,  rises  again  with  the  eruption,  and  reaches  its  maximum  in 
thirty-six  hours,  thus  giving  a  curve  with  a  double  summit.  It  usually 
falls  by  crisis  before  the  eruption  disappears.  Fever,  after  the  eruption 
begins  to  fade,  indicates  complications.  In  rare  cases  fever  is  absent. 
The  temperature  is  normal,  even  subnormal  during  desquamation. 


Fig 

9. 

1  Day 

TEMP. 

2 

3 

^ 

5 

0 

104 

A 

103                A 

a/ 

\ 

10.        /\ 

/ 

\ 

loiAA/ 

A 

A 

/ 

A 

100 

V 

a/ 

\a 

99 

V 

\ 

INITIAL 
RISE 

FALL 

RISE  WITH 
RASH 

EXTENSION 
OF  RASH 

Fever  curve  in  measles. 

III.  The  Respiratory  Tract. — Nasal  catarrh  is  of  special  moment 
in  sucklings.  Epistaxis,  fibrinous  rhinitis,  and  diphtheria,  are  uncom- 
mon complications.  Catarrhal  laryngitis  may  occur,  accompanied  by 
hoarseness  and  false  croup;  50  per  cent,  of  the  cases  sufi'er  from  ero- 
sions or  ulcerations  of  the  larynx  (Rilliet  and  Barthez),  16  per  cent, 
from  pseudomembranous  laryngitis,  and  15  per  cent,  from  simple  in- 
flammation. Laryngeal  complications  are  not  necessarily  febrile. 
Bronchial  catarrh  cannot  be  excluded  by  the  absence  of  rales.  It 
may  reach  the  smaller  tubules  and  usually,  but  not  always,  occurs  late 
in  the  disease.  It  produces  a  clear,  stringy,  viscid  sputum  which 
may  later  become  purulent  and  nummular.     The  bronchial  glands 


MEASLES  99 

are  always  swollen.  Simple  atelectasis  may  occur,  and  may  occasion 
indeterminate  breathing  and  dulness,  which  decreases  with  change 
of  posture  or  deep  breathing.  Bronchopneumonia  occurs  in  6  to  12 
per  cent,  of  the  cases  and  is  the  most  frequent  fatal  complication.  It 
differs  from  other  lobular  pneumonias  in  its  rapid  development,  and 
its  greater  tendency  to  pus  formation,  which  result  from  the  fact  that 
the  measles-catarrh  promotes  the  action  of  the  pneumococcus  and 
pyogenic  cocci.  The  temperature  is  often  no  higher  than  in  bronchitis. 
There  are  often  bronchial  breathing  and  other  physical  signs.  In 
some  cases  they  may  not  be  detected  clinically.  Toxsemia  and  car- 
bon-dioxide narcosis  accentuate  the  patient's  distress.  Broncho- 
pneumonia is  rapid  in  development,  but  slow  or  sometimes  incomplete 
in  resolution.  It  may  result  in  interstitial  pneumonia,  gangrene,  or 
tuberculosis.  The  latter  is  a  dreaded  sequel  of  measles.  It  occurs 
(a)  as  a  miliary  invasion,  and  develops  in  the  brain  much  more  fre- 
quently than  in  the  lungs.  It  is  caused  by  the  bacilli  from  old  ca- 
seated  bronchial  glands  which  are  released  by  solvent  substances  which 
reach  them  from  the  lungs  by  way  of  the  lymph-vessels.  It  also  occurs 
(6")  as  a  fresh  tuberculosis  developing  upon  a  bronchopneumonia. 
This  variety  may  heal  or  apparently  recover,  to  break  out  anew  at 
a  later  time.  Croupous  pneumonia  is  as  infrequent  as  pleurisy.  Pleu- 
risy is  in  most  cases  secondary  to  lobular  pneumonic  foci  and  may 
cause  effusion. 

IV.  Cardiac  Symptoms. — These  are  rare.  Accidental  bruits  may  be 
heard.  Toxsemia  may,  in  exceptional  cases,  cause  myocardial  degen- 
eration. 

V.  The  Digestive  Tract. — The  tongue  is  coated.  There  is  thirst 
and  aphthae,  and  stomatitis  may  be  observed.  As  a  result  of  an  intes- 
tinal enanthem,  diarrhoea  (which  is  important  prognostically) ,  mucus 
in  the  stools,  and  (anatomically)  swelling  of  Beyer's  patches,  have  been 
described.     The  liver  is  seldom  swollen. 

VI.  The  Nervous  System. — Nervous  symtoms,  such  as  delirium, 
sopor,  coma,  or  convulsions,  may,  in  rare  cases,  result  from  severe  tox- 
semia, even  though  the  delicate  nervous  system  of  children  is  seldom 
involved  in  measles.  Nervous  symptoms  may  occur  in  protracted 
pneumonia,  and  doubt  may  exist  as  to  whether  they  are  caused  by 
the  measles,  miliary  tuberculosis,  tuberculous  meningitis,  or  carbon- 
dioxide  narcosis.  Paralyses,  myelitis,  muscular  atrophy,  polyneuritis, 
and  polymyositis,  are  most  infrequent. 

VII.  Genito-Urinary  Tract. — Acetonuria  and  albuminuria  are  fre- 
quent. Ehrlich's  diazo  reaction  occurs  in  nearly  100  percent,  of  the 
cases.  Nephritis  is  very  uncommon.  It  may  occur  during  desquama- 
tion, but  is  more  often  due  to  complicating  diphtheria,  or  tubercu- 
losis.    Gangrene  of  the  genitalia  has  been  observed. 

VIII.  Other  Symptoms. — The  spleen  and  lymph-nodes  are  but 
slightly  swollen;  bone  and  joint  complications  are  rare;  keratitis  is 
infrequent;  otitis  media  occurs  in  a  small  percentage  of  cases,  although 
some  observers  have  found  it  in  as  high  as  50  to  60  per  cent.     It  is 


100 


THE  SPECIFIC  INFECTIONS 


said  that  streptococci  in  the  conjunctivae  are  much  more  frequent  in 
severe  than  in  mild  cases.  The  red  cells  are  little  altered,  while  the 
leukocytes  show  a  relative  lymphocytosis,  with  ana  bsolute  leukopenia. 

Differentiation  feo^i  German  Measles  and  Scarlatina. 


German  Measles 


Scarlatina 


Incubation:    14  to  21  days.|2  (1  to  7)  days. 

Prodromes:   absent,    short, 
or  light. 

Invasion:     very  mild. 


Exanthem:  the  rash  is  the 
first  symptom,  usually 
appearing  on  the  first  or 
second  day  on  the  face;  as 
small  red  dots,  rosy  and 
brighter  than  in  measles; 
small,  little  elevated,  andj 
thick  about  the  mouth.! 
They  do  not  fuse.  Less 
crescentic  than  in  mea- 
sles. 

Enanthem,  etc.:  may  be 
diffuse  redness  of  throat 
and  conjunctivae. 


Brief,  a  few  hours  to  1  or 
IJ  days. 

Sudden,  stormy,  vomiting, 
convulsions,  angina,  and 
adenitis. 

Appears  on  first  or  second 
day,  reaching  a  maximum 
on  second  to  fourth  day, 
first  below  clavicles,  in- 
volving face  later,  dusky- 
red,  diffuse,  burning,  leav- 
ing mouth  and  eyes  free 


Measles 


Angina  proportionate  to 
skin  eruptions;  dusky- 
red;  tonsillar  plugs;  con- 
junctivaB,  bronchi,  intes- 
tines  usually  intact. 


Glands :     usually  enlarged,  Proportionate    to    angina 


hard,  tender,  especially 
posterior  cervical,  also 
axillary  and  inguinal. 
Spleen  somewhat  j  en- 
larged. 


hence     largely    cervical. 
Enlarged  spleen. 


Constitutional     symptoms :  Much  depression  with  rash, 
few;    no  depression;    noi     coated  tongue  with  peel 


leukocytosis;    little  pulse 
increase  and  fever. 


Complications :    practically 
none. 


ing  on  the  fourth  day 
(Strawberry  tongue);  fe 
yer  105°  to  106°;  pulse 
increased  more  than  fe- 
ver ;  lysis  on  seventh  day; 
leukocytosis. 

Nephritis,  arthritis,  endo- 
carditis, sepsis,  periaden- 
itis. 


9  to  10  days. 

3     to     4     days,     generally 
markedly  catarrhal. 

Catarrhal  symptoms. 


Occurs  on  fourth  day, 
greatest  on  fifth  or  sixth 
day,  on  the  face,  forehead, 
and  about  the  mouth; 
brick-red  elevated  pap- 
pules  or  crescentic  islets 
of  eruption,  always  with. 
areas  of  healthy  skin  be- 
tween. 


Koplik's  spots;  patchy  red- 
ness of  throat;  photo- 
phobia; conjunctivitis, 
marked  bronchitis,  very 
often  bronchopneumon- 
ia; .  diarrhoea  in  some 
cases. 

Mostly  at  angle  of  jaw; 
rarely  systematic  en- 
largement. No  enlarge- 
ment of  spleen. 


Depression,  coated  tongue, 
anorexia;  fever-curve 
with  two  elevations;  cri- 
sis on  seventh  day;  no 
leukocytosis. 


Catarrhal  pneumonia,  pleu- 
risy, tuberculosis. 


Convalescence:  rapid;  des-i Prolonged,  tardy;  desqua-  Often  prolonged;  desqua- 
quamation  rarely  copious,  I  mation  copious  and  usu-|  mation  rarely  copious 
and  always  fine.  I     ally  in  shreds  (hands  andj     and  always  fine, 

feet).  ' 


MEASLES  101 

Diagnosis. — The  diagnosis  depends  upon  the  existence  of  an  epi- 
demic, and  upon  consideration  of  all  the  symptoms  rather  than  of 
the  eruption^alone.  Differentiation  from  typhus,  where  there  is  also 
catarrh,  is  made  by  the  greater  general  disturbance  in  typhus,  its 
more  sudden  onset,  higher  fever,  greater  swelling  of  the  spleen,  and 
by  the  fact  that  the  roseolous  eruption  becomes  petechial  and  is  least 
marked  on  the  face. 

Sepsis  with  a  morbilliform  exanthem,  the  early  stage  of  influenza, 
syphilis  (in  which  other  secondary  symptoms  appear  with  the  erup- 
tion), and  variola  (q.v.),  may  sometimes  delay  the  early  diagnosis. 
In  drug-eruptions  (those  of  turpentine,  iodides,  copaiba,  and  anti- 
pyrin),  the  diagnosis  may  be  most  difficult.  The  fever,  Koplik's  spots, 
catarrh,  and  central  elevations  in  the  eruption,  are  indications  of  measles. 

Prognosis. — The  mortality  is  very  great  among  aboriginal  races. 
In  the  Fiji  Islands  the  death-rate  was  very  high.  In  the  Samoan 
Islands  4,000  deaths  followed  the  introduction  of  measles,  in  1893. 
The  usual  important  factors  are:  (a)  The  genius  epidemicus:  Henoch 
records  30  per  cent,  and  Heubner  37  per  cent,  in  some  epidemics.  The 
mortality  in  a  German  epidemic  of  2,881  cases  was  only  1  per  cent. 
(Heissler).  (b)  Individual  resistance:  in  private  practice  3  per  cent, 
is  the  average  death-rate.  It  is  higher  in  institutional  practice  and  in 
the  army.  It  is  16  per  cent,  in  the  children's  hospitals  in  Paris. 
Measles  ranks  third  among  the  exanthemata  in  mortality,  (c)  Age: 
The  death-rate  is  highest  at  the  second  year;  55  per  cent,  of  fatal  cases 
occur  in  the  first  two  years  of  life  (Henoch),  (d)  Complications  are 
more  important  than  the  disease  itself;  e.g.,  tuberculosis  and  broncho- 
pneumonia, which  is  the  worst  complication,  with  a  mortality  of  33 
per  cent. 

Treatment. — 1.  Prophylaxis. — Prevention  is  important,  especially 
in  children  under  two  years,  in  severe  epidemics  with  pneumonia, 
in  the  weakly,  and  in  cases  of  pertussis.  Though  the  mortality  and 
complications  are  greater  in  adults,  it  is  of  no  advantage  to  contract 
measles,  and  the  too  prevalent  practice  of  allowing  the  disease  to  run 
through  the  family  must  be  condemned.  In  all  cases,  the  secretions 
from  the  nose,  throat,  and  bronchi,  must  be  disinfected,  and  general 
sanitary  care  should  be  exercised  as  in  smallpox  and  scarlatina. 

2.  Hygiene. — The  patient  should  have  fresh  air,  a  warm  room, 
rest  in  bed  until  after  desquamation,  and  a  liquid  diet.  A  mustard 
bath  may  be  employed  in  order  to  bring  out  the  rash. 

3.  Catarrhal  Symptoms. — Photophobia  does  not  necessitate  a  dark 
room.  Some  sunlight  should  be  admitted.  A  boric-acid  solution 
should  be  dropped  frequently  into  the  eyes  and  vaseline  applied  to  the 
lids.  Prophylactic  care  of  the  mouth  is  necessary.  To  relieve  pain 
in  the  ears,  belladonna,  opium,  and  a  1-per-cent.  cocaine  solution 
may  be  used;  paracentesis  is  indicated  for  gathering.  The  nose  should 
be  douched  with  Dobell's  solution.  Tr.  belladonnse,  ttji  i.-iii.  may 
be  given  every  two  hours  for  coryza  until  flushing  of  the  face,  increase 
of  pulse-rate,  or  a  dry,  red  throat,  develops. 


102  THE  SPECIFIC  INFECTIONS 

4.  Antipyresis. — Antipyretics  are  indicated  (a)  in  sudden  high 
elevation  with  severe  cerebral  toxaemia;  and  (6)  in  high  fever  with 
diffuse  bronchitis  or  pneumonia.  They  are  given  most  efficaciously 
in  the  form  of  baths,  with  cold  affusions  to  the  head  and  neck.  Wine, 
leeches  to  the  mastoids,  mustard  plasters,  and  laxatives,  may  also 
be  indicated  in  toxaemia. 

5.  The  Circulation. — The  heart  rarely  requires  treatment,  except 
in  septic  types  or  in  pulmonary  complications,  when  camphor,  am- 
monia (aromatic  spirits),  strychnia,  wine,  or  coffee,  are  indicated. 

6.  Respiratory  Symptoms. — Care  of  the  mouth,  a  soft  or  liquid 
diet,  inhalations  of  steam,  hot  fomentations  over  the  larynx,  warm 
baths,  emetics  (such  as  apomorphine  or  ipecac),  and  possibly  intubation 
or  tracheotomy,  are  indicated  for  laryngeal  complications.  Bronchitis 
should  be  treated  with  ipecac,  codeine  (morphine),  emetics,  inhala- 
tions of  steam,  massive  hot  packs  to  the  chest,  and  cold  affusions  over 
the  nape  of  the  neck  (see  Acute  Beonchitis);  stimulation  for  pneu- 
monia iq.'V.)  may  be  indicated. 

7.  Alimentary  Tract. — Enemata  relieve  constipation.  When  diar- 
rhoea is  excessive,  opium,  hot  wine,  or  cognac,  demulcents,  hot  appli- 
cations, and  physiological  salt-solution  by  rectum,  are  indicated. 

8.  The  Skin. — The  skin  should  be  rubbed  with  olive  oil;  a  2-per- 
cent, menthol  salve,  or  1-per-cent.  carbolic  solution,  relieves  itching. 

9.  Complications. — The  treatment  of  complications,  such  as  tuber- 
culosis, pertussis,  etc.,  will  be  described  under  these  topics. 


RUBELLA. 

S3nion5niis.- — Rubeola  notha,  German  measles,  Rotheln. 

History. — Rubella  was  first  described  by  Bergen  (1752)  in  Ger- 
many, and  its  separate  existence  was  established  by  Maton  (1815)  in 
England,  though  it  is  still  called  by  some  writers  a  'hybrid  form  of 
measles  and  scarlatina.  It  is  more  often  confused  with  atypical  scar- 
latina than  with  atypical  measles.  By  the  Germans  it  is  called  rubeola, 
though  we  employ  rubeola  as  synonymous  with  measles. 

Definition. — An  independent  infection,  which  occurs  often  in  those 
who  have  had  measles  and  scarlatina.    One  attack  confers  immunity. 

Etiology. — Its  etiology  is  not  known.  Most  cases  occur  during  the 
first  half  of  the  year.    The  disease  most  frequently  attacks  children. 

Symptoms. — I.  The  Incubation. — The  incubation  lasts  from  ten 
to  twelve  (or  perhaps  fourteen  to  twenty-one)  days. 

II.  Prodromes. — Prodromes  may  be  lacking,  or  for  a  period  of 
from  two  hours  to  a  day,  there  may  be  cough,  slight  photophobia,  or 
sneezing.  Slight  temperature  and  a  few  general  symptoms,  such  as 
chilliness  or  headache,  usually  develop. 

III.  The  Eruption. — The  eruption  occurs  on  the  first  day,  usually 
in  the  palate  and  throat.  It  resembles  measles,  and  consists  of  hyper- 
aemic  punctate  red  spots  (Forscheimer's  spots).    The  skin  is  red,  and 


RUBELLA  103 

the  eruption  disappears  at  first  under  pressure;  then  the  macules  be- 
come darker  and  more  circumscribed;  later,  the  eruption  does  not 
entirely  disappear  under  pressure.  There  are  two  forms,  the  cir- 
cumscribed ^nd  the  diffuse.  The  eruption  becomes  slightly  elevated, 
does  not  fuse  as  it  does  in  measles,  and  erythema  is  not  present  about 
the  points  of  eruption  as  it  is  in  scarlatina.  Anatomically,  it  is  a  capil- 
lary hypersemia  of  the  papillary  and  upper  layers  of  the  corium, 
accompanied  by  slight  infiammation  and  exudation  between  the  corium 
and  epidermis.  It  advances  in  "jumps,"  and  fades  in  one  place  while 
it  blossoms  in  another.  It  appears  first  on  the  scalp  and  face,  and 
progresses  downward  to  the  neck,  body,  arms,  and  lastly  to  the 
legs  and  feet.  Unlike  scarlatina,  spots  may  be  observed  about  the 
lips.  The  eruption  is  greatest  on  the  upper  parts  of  the  body,  and  is 
increased  by  constriction  or  by  pressure  of  the  clothing.  Its  average 
duration  is  from  two  to  four  days.  The  papillae  of  the  tongue  show 
slightly  through  the  fur.  Desquamation  is  minimal  and  fine.  Trach- 
eitis, or,  rarely,  bronchitis,  may  be  observed.  Almost  characteristic 
is  the  swelling  of  the  posterior  cervical  and  post-auricular  glands. 
There  may  be  some  angina,  dysphagia,  or  anorexia. 

IV.  The  Constitutional  Symptoms. — The  constitutional  symptoms 
are  few.  The  fever  is  usually  slight.  Its  duration  averages  three  days, 
and  it  falls  by  crisis  or  lysis  when  the  eruption  has  matured.  Except 
in  a  few  American  epidemics,  urgent  nervous  and  other  complica- 
tions, such  as  icterus,  albuminuria,  nephritis,  or  colitis,  have  rarely 
been  observed. 

Diagnosis. — The  diagnosis  is  often  very  difficult  and  the  unity  of 
the  disease  is  sometimes  questioned  (see  Measles).  The  "fourtli 
disease,"  described  by  Dukes,  is  said  to  present  a  longer  incubation 
and  more  diffuse  rash.  Erythema  infectiosum,  emphasized  particu- 
larly by  Escherich,  is  a  weakly,  contagious,  maculo-papular  erythema, 
prevalent  particularly  in  the  spring  and  fall,  and  occurring  chiefly 
on  the  extensor  surface  of  the  extremities,  and  rarely  on  the  trunk. 

Prognosis. — The  prognosis  is  good,  and  therapy  is  symptomatic. 
Isolation  is  theoretically  advisable. 


ERYSIPELAS. 

Synonym. — *S^.  AntJwtiy's  Fire. 

Definition. — An  acute,  febrile,  contagious  disease  caused  by  Fehleis- 
sen's  Streptococcus  erysipelatos.  It  is  characterized  by  a  peculiar 
circumscribed  inflammation  of  the  skin  and  adjacent  mucosae,  which 
tends  to  rapid  and  broad  extension.  It  usually  runs  a  self-limited 
course,  with  slight,  if  any,  visceral  involvement. 

History. — Erysipelas  was  known  to  Hippocrates  and  Galen.  Trous- 
seau (1848),  in  France,  maintained  that  it  was  always  a  wound 
infection.  Werner,  in  England,  maintained  that  it  was  an  infec- 
tious disease,    and  Koch  (1880)  found  the  streptococcus,  which  was 


104  THE  SPECIFIC  INFECTIONS 

more  fully  described  by  Fehleissen  (1881)  and  which  bears  his 
name. 

Etiology. — It  is  wide-spread,  and  sporadic  cases  are  seen  in  almost 
every  centre  of  population.  It  occasionally  breaks  out  epidemically. 
It  prevails  largely  in  the  early  spring  months;  60  per  cent,  of  cases 
occur  between  January  and  May  (Anders).  In  the  preantiseptic 
era  it  was  the  dread  of  hospital  physicians,  and  even  at  this  day  it 
occasionally  visits  the  most  sanitary  institutions.  It  is  conveyed  by 
a  third  person  and  by  fomites;  and,  infrequently,  by  unclean  instru- 
ments, and  vaccine.  Cases  of  placental  transmission  to  the  foetus  are 
known.  The  virus  is  not  particularly  penetrating  but  uiay  adhere  to 
clothing  and  furniture  with  great  tenacity.  Individual  predisposition 
varies,  but  many  persons  have,  apparently,  a  natural,  or  perhaps  a 
hereditary,  susceptibility  to  the  disease.  It  is  like  rheumatism  or  acute 
angina,  in  that  it  often  recurs  repeatedly.  It  occurs  mostly  in  the  female 
sex  (73  per  cent,  of  the  cases).  Alcoholism,  debility,  and  chronic  ne- 
phritis, are  predisposing  factors.  Any  distinction  between  "idiopathic" 
and  "wound"  erysipelas  is  artificial,  for  in  practically  every  instance, 
some  abrasion,  though  perhaps  too  small  for  the  eye  to  detect,  occurs 
in  the  skin  or  mucosae. 

Bacteriology. — The  Streptococcus  erysipelatos  (seu  pyogenes  longus) 
was  found  in  the  lymph-vessels  by  Fehleissen,  who  first  drew  the  dis- 
tinction between  erysipelas  and  phlegmon.  Though  it  strictly  coincides 
with  Koch's  criteria,  its  absolute  differentiation  from  the  Streptococcus 
pyogenes  is  impracticable.  Inoculations  from  cases  of  erysipelas 
sometimes  produce  suppuration.  Pus  from  abscesses  has  caused 
erysipelas,  and,  in  certain  cases,  erysipelas  and  suppuration  have  de- 
veloped simultaneously.  This  has  given  some  weight  to  the  theory 
of  the  bacteriological  unity  of  erysipelas,  suppuration,  and  septi- 
caemia. 

Symptoms. — I.  Incubation. — Incubation  lasts  from  three  to  seven 
days  (fifteen  to  seventy-two  hours  in  direct  inoculations). 

II.  The  Eruptive  Stage. — (a)  This  stage  usually  begins  with  vomit- 
ing, fever,  chill,  and  the  eruption,  and  is  sometimes  preceded  by  gen- 
eral symptoms,  such  as  fatigue,  anorexia,  or  pains  in  the  joints.  The 
fever  rises  rapidly  to  103°.  The  chill,  occurring  in  75  per  cent,  of  the 
cases,  is  usually  preceded  by  a  few  hours  of  general  discomfort.  It 
is  absent  chiefly  in  erysipelas  which  is  secondary  to  other  diseases. 
(6)  The  eruption,  in  typical  cases,  first  appears  on  the  face  (95  per 
cent,  of  the  cases),  near  the  inner  canthus  of  the  eye,  near  the  nose, 
or  on  the  cheek.  It  consists  of  a  hard,  bright-red,  slightly  elevated, 
burning,  and  painful  area  of  inflammation,  which  pits  but  little  on 
pressure,  though  its  color  may  disappear,"  Pathologically,  erysipelas 
is  simple  inflammation;  in  and  under  the  skin  are  found  oedema, 
hypersemia,  white-  and  red-cell  extravasation,  and  streptococci  which 
advance  in  the  lymph-clefts,  and  are  most  abundant  in  the  spreading 
edge,  but  are  also  found  in  the  lymph-vessels  beyond  it.  Its  elevated 
red  edge  is  sharply  marked,  or  "wall-like."     As  the  area  spreads, 


ERYSIPELAS  105 

the  skin  becomes  much  swollen,  oedematous,  smooth,  tense,  red,  and  hot, 
causing  a  shapeless  swelling  of  the  eyes,  nose,  lips,  and  ears,  and  ob- 
literating the  facial  lines  and  expression.  The  extent  of  this  area  is 
indicated  by^  tenderness,  and  is  therefore  more  accurately  measured 
with  the  finger  than  with  the  eye.  Under  the  lens,  small  vesicles  are 
always  found.  The  prong-like  advance  of  the  eruption  is  similar  to 
that  of  spilt  alcohol,  or,  as  Volkmann  puts  it,  like  burning  paper;  i.  e. 
it  disappears  behind  as  it  advances  forward.  Its  extension  is  irregular, 
because  the  streptococci  follow  the  line  of  least  resistance.  If  obstructed 
by  dense  tissue,  deep  attachments,  or  the  so-called  ligamenta  cutis, 
its  course  becomes  circuitous,  asymmetrical,  and  tardy  in  one  area 
though  rapid  in  another.  It  is  limited  at  the  base  of  the  skull,  and 
rarely  affects  the  chin,  or  passes  over  it  to  the  opposite  side.  The  neck 
resists  its  advance,  often  successfully,  but  erysipelas  may  course  over 
the  entire  body.  The  sternum,  condyles,  ilium,  and  Poupart's  liga- 
ment, check  or  divert  its  progress.  When  apparently  obstructed,  new 
islets  of  eruption  appear  near  by,  which  are  nearly  always  consecutive, 
as  may  be  seen  by  the  faint  lymphatic  involvement  between  the  foci. 
The  scalp  is  often  unaffected,  but  if  invaded  it  becomes  swollen,  tense, 
and  pale  or  blue  rather  than  red,  and  the  hair  falls  out.  The  genitalia 
may  swell  enormously.  Necrosis  of  these  tissues,  and  also  of  the 
elbow  and  knee,  may  result  from  excessive  tension.  The  first  area 
pales,  and  a  coarse  desquamation  results,  while  the  eruption  at  more 
remote  points  advances.  The  lymph-glands  are  almost  constantly 
swollen,  tender,  and  are  palpable,  unless  hidden  by  oedema.  They 
b9come  enlarged  proportionately  to  the  dermatitis.  The  eruption 
presents  few  variations :  erysi'pelas  miliare  (vesiculosum) ;  less  frequently 
erysipelas  hullosum;  erysipelas  squamosum,  or,  in  old  and  cachectic 
subjects,  erysipelas  hemorrhagicum.  (c)  The  fever  rises  suddenly,  and 
is  highest  on  the  third  or  fourth  day  (103°  to  104°  or  higher).  It  is 
continuous,  then  becomes  remittent  or  irregular,  and  finally,  after 
seven  to  nine  days,  resolves  by  crisis,  or  less  often  by  lysis.  Fever  is 
almost  always  present;  in  very  rare  cases  is  it  wholly  absent.  In  at- 
tenuated erysipelas  there  is  little  fever  and  there  are  few  general  symp- 
toms, though  the  rash  may  be  well  developed.  In  general  the  intensity 
and  the  progress  of  the  infection  are  marked  by  the  degree  of  fever. 

Other  General  Sjnnptoms. — The  pulse  is  soft,  and  ranges  between 
100  and  120;  albuminuria  occurs  in  38  to  67  per  cent,  of  the  cases; 
moderate  leukocytosis  is  the  rule,  and  there  may  be  some  pain  and 
swelling  of  the  liver  and  spleen.  Nervous  toxaemia,  with  the  exception 
of  headache,  is  uncommon. 

Course. — When  limited  to  the  face  and  head,  eight  to  ten  days 
is  the  usual  duration,  and  a  course  longer  than  two  weeks  is  uncom- 
mon. Erysipelas  migrans  may  last  weeks  or  months,  travel  from  limb 
to  limb,  and  recur  again  and  again.  In  one  of  the  author's  cases  it 
lasted  six  months. 

Complications  and  Sequels. — 1.  Nervous. — Toxeemic  symptoms 
are    infrequent    except    in    aged,   debilitated,  or    alcoholic   subjects. 


106  THE  SPECIFIC  INFECTIONS 

Delirium  is  toxemic,  but  was  considered  reflex,  resulting  from  trigem- 
inous  involvement,  by  Traube  and  Jaccoud.  It  is  an  unfavorable 
development  and  occurs  especially  when  the  scalp  is  invaded.  A  pro- 
found typhoid  condition  may  occur  in  debilitated,  or  alcoholic  cases. 
Meningitis,  formerly  confused  with  toxaemia,  infrequently  follows  or- 
bital cellulitis  or  extension  along  the  fifth  nerve.  Post-febrile  psy- 
choses, multiple  neuritis,  and  degeneration  of  the  cord,  are  exceptional. 
Eye  inflammation,  ulceration,  and  blindness,  are  very  infrequent. 

2.  Circulatory. — Endocarditis  is  infrequent  though  simple  and  ul- 
cerative types  may  develop.  Pericarditis,  myocarditis,  acute  dilata- 
tion, and  arterial  or  venous  thrombosis,  are  infrequent.  Leukocytosis 
is  usually  moderate,  and  is  generally  parallel  with  the  fever.  High 
counts  usually  indicate  concomitant  suppuration.  Streptococci  in  the 
blood  are  usually,  but  not  necessarily,  ominous. 

3.  Respiratory. — Erysipelas  may  invade  the  nose,  throat,  ear, 
larynx,  and  bronchi,  and  begins  with  local  symptoms  or  with  chill 
and  fever.  Erysipelatous  coryza,  otitis,  and  stomatitis,  are  infrequent 
and  are  difficult  of  recognition.  Erysipelatous  angina  is  characterized 
by  much  pain,  sharply  marked  redness  or  lividity,  a  glazed  varnished 
surface,  marked  oedema  of  the  uvula  and  epiglottis,  and  the  forma- 
tion of  vesicles  or  bullae.  Sometimes  a  wall-like  margin  is  seen.  Gan- 
grene may  develop  in  severe  instances.  The  neck  glands  may  be 
swollen.  For  the  recognition  of  erysipelatous  angina,  coincident  facial 
erysipelas  is  necessary. 

Laryngeal  erysipelas  is  more  often  secondary  (to  pharyngeal  erysipe- 
las) than  it  is  primary.  It  is  rare,  severe,  is  easily  or  necessarily  con- 
fused with  glottis  oedema,  and  is  marked  by  great  turgescence,  rapid 
spreading  and  swelling,  and  high,  early  fever.  Without  trache- 
otomy, fatal  stenosis  and  extension  to  the  lower  air-passages  may 
occur.  The  rare  so-called  "erysipela  spneumonia"  is  especially  de- 
scribed by  French  writers.  Though  the  existence  of  this  type  cannot 
be  denied,  because  any  infection  may  travel  downward  from  the  throat, 
it  is  more  probably  a  septic  localization  than  "internal"  erysipelas. 
In  streptococcus  pneumonia,  the  spleen  is  enlarged  (sepsis)  more  fre- 
quently than  it  is  in  ordinary  pneumonia.  The  advance  is  rapid,  the 
extension  is  wide,  the  gray  hepatization  is  great,  and  fibrin  formation 
is  scant  or  lacking.  Nevertheless,  in  pneumococcus  infection  the  same 
"wandering  pneumonia"  may  be  seen.  Pleurisy  is  usually  metastatic 
(septic). 

4.  Alimentary. — Vomiting  is  often  cerebral.  Exceptional  com- 
plications are  parotitis,  oesophagitis,  gastritis,  enteritis,  intestinal 
ulceration,  hemorrhage,  pain,  icterus,  and  pylethrombosis. 

5.  Genito-TJrinary. — Albuminuria  (67  per  cent,  of  the  cases)  is  the 
most  constant  visceral  finding.  Nephritis  (4  per  cent.)  is  often  of  the 
acute  glomerular  type,  and  rarely  becomes  chronic.  Streptococci  have 
been  seen  in  the  urine  and  kidneys,  especially  in  septic  types.  Typical 
erysipelas  may  begin  in  the  external  genitalia,  especially  in  puerperse, 
or  may  first  infect  the  internal  mucosa  which  has  been  abraded  dur- 


ERYSIPELAS  107 

ing  labor.  There  may  be  great  pain,  local  necrosis,  and  imminent 
risk  of  higher  or  peritoneal  invasion.  Accurate  diagnosis  of  the  inter- 
nal form  of  erysipelas  (E.  puerperale  grave  internwrn,  Virchow)  can 
seldom  be  made. 

6.  Septic — Subcutaneous  abscesses,  which  are  usually  small,  and 
which  resemble  cold  abscesses  (Tillmann,  Alcalme),  appear  on  the 
head  or  body,  occur  in  6  per  cent,  of  the  cases,  especially  in  alco- 
holic, nephritic,  diabetic,  or  debilitated  patients.  Phlegmons  may  de- 
velop, usually  on  the  legs,  and  are  known  to  occur  even  without  mixed 
infection.  Gangrene  is  fortunately  rare  (  |  of  1  per  cent.) .  It  may  de- 
velop early,  in  the  eye-lids,  in  the  genitalia,  over  the  lean  tissue  cover- 
ing the  joints,  or  it  may  develop  later  in  the  extremities.  Herpes  is 
not  infrequent.  Baldness  may  also  result.  The  joints  may  be  painful 
or  swollen.  Suppuration  is  metastatic.  Suppurative  adenitis  may 
occur  with  or  without  mixed  infection.  General  fatal  sepsis,  aside 
from  the  puerperal  form,  is  infrequent.  It  bears  the  same  relation 
to  local  erysipelas  as  does  miliary  tuberculosis  to  a  local  tuberculous 
focus  (Ponfick). 

Diagnosis. — Diagnosis  is  easy,  when  the  area  is  the  size  of  a  dollar, 
(a)  because  of  its  very  location;  (6)  because  of  the  early  involvement 
of  the  lymphatics  and  of  the  lachrymal  sac;  (c)  because  in  most  cases 
the  point  of  entrance  can  be  found;  it  may  have  healed;  it  may  be 
concealed  by  the  swelling,  or  lie  an  inch  or  more  away  from  the  first 
eruption;  {d)  because  of  the  redness,  smoothness,  swelling,  and  oedema; 
(e)  because  of  the  elevated,  wall-like  margin;  and  (/)  because  of  the 
prong-like,  irregular  progression. 

In  weeping  eczema,  the  edges  are  not  raised,  the  skin  is  not  smooth, 
there  is  less  fever,  and  the  development  is  slower  than  in  the  ordinary 
type,  and  itching  is  present.  Malignant  pustule  may  cause  redness  and 
swelling,  but  anthrax  bacilli  are  found  under  the  primary  papule  and 
crust.  Dermatitis  venemata,  or  medicamentosa,  and  pemphigus,  are 
unlike  erysipelas.  Erythema  nodosum  is  discrete,  though  diffuse,  and 
does  not  spread.  Diffuse  simple  erythema  is  a  febrile  affection,  and  of 
short  duration.  Dermatitis  exfoliativa  (Ritter)  in  the  new-born  is 
afebrile,  develops  first  about  the  mouth  and  chin,  and  reaches  the  body 
and  limbs  later.  Its  diffuseness  and  redness  are  characteristic.  In 
lymphangitis  the  swelling  of  the  lymphatics  advances  toward  the  centre 
and  presents  cord-like  or  net-like  areas,  which  are  neither  confluent, 
vesiculated,  uniformly  red,  nor  evenly  edged.  In  phlegmon  and  deep 
cellulitis,  the  process  is  deeper  and  harder,  and  the  blisters  and  margin 
of  erysipelas  are  lacking. 

Erysipelatous  angina  may  not  be  diagnosed  without  coincident 
facial  erysipelas.  The  local  findings,  such  as  great  swelling,  dysphagia 
and  lymphatic  enlargement,  are  not  pathognomonic;  neither  are  the 
general  findings,  such  as  high  fever,  albuminuria,  nephritis  and  splenic 
tumor. 

Erysipeloid,  a  zoonotic  affection  described  first  by  Rosenbach, 
occurs  especially  in  persons  whose  occupation  leads  them  to  handle 


108  THE  SPECIFIC  INFECTIONS 

meat.  It  is  recognized  by  the  "butterfly"  eruption  which  develops 
on  both  cheeks  or  on  the  finger-ends,  and  is  unaccompanied  by  fever 
or  general  symptoms.  The  edge  of  the  eruption  is  clear-cut,  its  ad- 
vancement slow,  its  color  a  dark  livid-red,  and  its  course  lasts  one  to 
three  weeks  with  spontaneous  recovery.  Gilchrist  (1904)  reported 
329  cases,  of  which  323  were  caused  by  crab-bites. 

Prognosis. — (a)  In  uncomplicated  facial  erysipelas  the  outlook 
is  good.  In  general  the  mortality  is  3  to  4  per  cent,  in  private  practice, 
and  double  that  figure  in  hospitals,  (b)  In  erysipelas  migrans  the 
outlook  is  less  favorable,  (c)  In  erysipelas  neonatorum  (Trousseau, 
Lorain)  the  outlook  is  almost  invariably  fatal  on  the  fifth  to  seventh 
day.  It  begins  on  the  navel,  and  less  often  on  the  vulva,  and  on  cir- 
cumcision-wounds. Vomiting,  diarrhoea  from  toxaemia,  peritonitis, 
icterus,  pneumonia,  necrosis,  gangrene,  suppuration,  and  sepsis,  are 
much  more  common  than  in  adult  forms.  Fortunately,  like  puer- 
peral fever,  this  form  is  now  infrequent,  (d)  Erysipelas  secondary  to 
other  infections  is  serious,  especially  in  chronic  maladies,  such  as 
alcoholism,  diabetes,  nephritis,  and  tuberculosis,  and  also  in  bed-ridden, 
or  senile  subjects,  in  whom  the  asthenic,  hemorrhagic,  or  gangrenous, 
types  are  chiefly  observed.  In  acute  diseases  such  as  typhoid,  diph- 
theria, and  pneumonia,  this  complication  is  dreaded,  (e)  Puerperal 
forms  or  involvement  of  the  mucosa,  especially  that  of  the  larynx,  are 
unfavorable  (Hippocrates).  (/)  Recurrence  is  more  frequent  than 
in  any  other  infection,  which  shows  that  no  permanent  immunity  is 
conferred.  Relapses  (10  to  15  per  cent,  of  the  cases)  are  attacks  recur- 
ring within  a  few  days.  Recurrences  (20  to  50  per  cent.),  properly 
speaking,  return  after  months  or  years;  indeed,  in  some  individuals, 
erysipelas  may  be  called  habitual.  It  is  observed  most  frequently 
in  the  young  and  in  women  (75  per  cent.),  and  mostly  on  the  face. 
It  may  result  in  elephantiasis.  Five  to  fifteen  attacks  are  not  uncom- 
mon, and  Roger  has  seen  forty  in  one  person. 

Treatment. — 1.  Prophylaxis. — In  this  bacteriological  era,  the  dis- 
ease has  been  decreased  by  means  of  asepsis  and  isolation,  though  in 
regard  to  the  latter,  many  physicians  are  still  remiss.  Chronic  rhinitis, 
rhagades,  decayed  teeth,  and  neglected  ulcers,  must  be  considered  in 
cases  of  habitual  erysipelas. 

2.  Mechanical  Means. — Mechanical  efforts  to  limit  the  extension 
of  the  disease  are  still  used,  but  unsuccessfully.  These  consist  of 
binding  with  elastic  strips,  elastic  constriction,  or  heavy  applications 
of  collodion. 

3.  Local  Applications. — Iodine,  creolin,  bichloride  of  mercury,  car- 
bolic acid,  alcohol,  iodoform,  boric  acid,  and  numerous  other  topical 
applications,  may  be  recommended,  but  the  water  they  contain  is  the 
best  ingredient,  and  was  recommended  by  Hippocrates  himself. 
Mechanical  and  local  applications  cannot  reach  the  deeply-situated 
cocci.  Cold  compresses  afford  a  sure  relief  for  pain  and  tension. 
Ichthyol  ointment,  10  to  20  per  cent.,  is  soothing  but  in  no  sense 
curative. 


MALARIA  109 

Creolin 1  part. 

Iodoform 4  parts. 

Lanolin 10  parts. 

M.  f.  ung.  ^  (Koch.) 

4.  Drugs. — Erysipelas  is  a  self-limited  disease,  therapeutically  un- 
approachable. Tincture  of  the  chloride  of  iron  (Hamilton  Bell,  1861) 
is  well  tolerated  in  large  doses  (np-x-xxx)  but  neither  shortens  nor  miti- 
gates the  disease. 

Tincturse  ferri  perchloridi 3iiss._ 

Quininae  sulphatis gr.xxiv. 

Spiritus  chloroformi 3ij. 

Aquse q.  s.  ad   ovj. 

M.  f.  mist. 

S. — Two  tablespoonfuls  every  three  or  four  hours.     (J.  Burney  Yeo.) 

5.  General  Treatment.— The  symptoms  are  managed  expectantly,— 
I.  e.,  as  they  arise.  Headache,  delirium,  pain,  vomiting,  and  cardiac 
weakness,  are  treated  as  in  typhoid.  Rest  in  bed  and  as  generous 
nourishment  as  the  stomach  will  tolerate,  are  indicated. 

6.  Marmorek's  Serum. — Chantemesse  reduced  the  death-rate  of  his 
cases  to  2^  per  cent,  by  serum  treatment,  a  figure  often  reached  by 
more  simple  measures  (Roger  and  Botognesi). 

Erysipelas  as  a  curative  agent  {erysipelas  salutare) :  Permanent 
cure  of  lupus  has  followed  a  complicating  erysipelas.  Syphilis  quickly 
subsides  after  this  infection,  and  its  beneficial  effects  have  been  ob- 
served in  leukgemia,  Hodgkin's  disease,  carcinoma,  sarcoma,  chronic 
arthritis,  rheumatism,  iritis,  tuberculous  adenitis,  neuralgia,  diph- 
theria, and  tuberculosis. 


MALARIA. 

Definition. — An  acute  infection  caused  by  the  Plasmodium  malariee, 
inoculated  in  man  by  the  mosquito  and  characterized  clinically  by 
(1)  paroxysms  of  intermittent,  quartan,  tertian,  or  quotidian  fever,  or 
by  (2)  remittent  or  subcontinuous  fever,  and  sometimes  by  (3)  perni- 
cious, or  (4)  chronic  cachectic  forms. 

History. — Malaria,  known  to  Hippocrates  and  Celsus,  is  the  dis- 
ease most  completely  investigated,  in  that  (a)  its  cause  is  exactly  known; 
(b)  its  prophylaxis  has  become  known  since  the  discovery  of  infection 
by  the  mosquito;  (c)  the  disease  can  be  watched  in  different  stages 
in  the  blood;   and  {d)  there  is  a  specific  treatment. 

Etiology. — All  ages  and  both  sexes  are  aifected  equally.  Men  are 
more  exposed  to  infection,  and  children  are  readily  infected  on  ac- 
count of  their  thin  skin.  Such  occupations  as  sewer  and  railroad 
building,  ditching,  and  night  work,  especially,  are  predisposing  factors; 
32  per  cent,  of  the  French  soldiers  in  Madagascar  in  1895  acquired 
malaria;  reduced  physical  resistance,  exposure,  excesses,  and  alcohol- 


110  THE  SPECIFIC  INFECTIONS 

ism,  also  predispose  to  the  disease.  Negroes  have  a  relative  immunity. 
Instances  of  familial  or  individual  immunity  have  been  noted.  Epi- 
demics may  occur,  as  happened  during  the  building  of  the  Paris 
boulevards.  Indirect  causes,  such  as  warmth  of  climate,  the  warm 
season,  moisture,  rain,  swampy  localities,  telluric  influences,  bad  air 
(mal-aria),  and  impure  drinking-water,  are  now  proved  to  be  causes 
only  in  so  far  as  they  relate  to  the  breeding  of  the  mosquito.  In  Africa, 
severe  forms  of  malaria  are  found  everywhere  except  in  the  lower  part 
and  in  the  Sahara.  In  the  far  East  its  chief  seats  are  India,  Burmah, 
Assam,  Faral,  and  the  East  Asiatic  coast;  Asia  Minor,  Japan,  and  the 
East  Indies.  In  Europe,  lower  Russia,  Italy,  Hungary,  the  Balkans, 
and  Greece,  are  most  affected.  Malaria  also  abounds  in  South  America, 
in  the  northern  three-fourths  of  the  continent.  In  the  West  Indies, 
severe  types  prevail.  In  the  United  States,  malaria  is  slowly  moving 
southward,  and  cases  seldom  develop  on  the  Pacific  coast,  in  the 
Northwest,  in  the  dry  West  and,  in  the  Lake  region.  Even  in  the 
South  it  is  becoming  less  frequent. 

Direct  Cause. — The  direct  cause  is  the  malarial  parasite,  described 
by  Laveran,  in  1880,  and  also  by  Marchiafava  and  Celli,  in  1885.  In 
this  country  Councilman,  Abbott,  Osier,  James,  Dock,  Koplik, 
Thayer,  Hewetson,  and  others,  have  studied  the  disease.  It  is  a  red- 
cell  parasite,  a  hsemocytozoon.  The  biology  of  the  Plasmodium  ma- 
larise  concerns  (A)  its  life  in  the  human  blood,  and  (B)  its  life  in  the 
mosquito.  The  unity  of  all  species  was  maintained  by  Laveran,  but 
various  species  must  be  recognized  because  (1)  their  morphology 
varies;  (2)  their  geography,  seasonal  prevalence,  and  malignancy 
also  vary;  (3)  on  inoculation,  the  species  and  fever  type  are  main- 
tained; (4)  the  type  remains  the  same  in  the  same  individual. 
(A).  The  Plasmodium  in  Man.— Special  forms  of  the  parasite: 
1.  The  quartan  parasite  has  a  life-cycle  of  three  days.  In  the  first 
twelve  hours  the  young  form  is  without  pigment.  A  small  amor- 
phous hyaline  bright  spot  lies  in  the  red  cell,  whose  form  flattens  the 
parasite.  There  is  some  amoeboid  movement  upon  warming  the  slide. 
It  gains  little  in  size  for  one  day,  when  some  pigment  or  melanin  ap- 
pears in  the  form  of  coarse  dark  rods  and  granules  with  little  move- 
ment. Melanin  is  the  haemoglobin  digested  by  the  parasite.  It  is 
usually  dark  or  black  and  resembles  the  melanin  of  malignant  growths. 
It  is  dissolved  by  alkalies  and  ammonium  sulphide,  but  not  by  acids. 
Movement  of  the  parasite  ceases  as  pigment  increases.  The  para- 
site occupies  one-half  to  two-thirds  of  the  red  cell  after  forty-eight 
hours,  and  almost  the  entire  cell  after  sixty  hours.  There  is  rarely 
more  than  one  parasite  in  each  cell.  Flagella  (v.i.)  are  not  frequent. 
During  growth  the  red  cell  on  which  the  plasmodium  feeds  either 
undergoes  no  change  in  size  or  becomes  smaller  and  darker  periph- 
erally. As  sporulation  occurs,  the  pigment  gathers  centrally  and 
the  spores,  usually  not  numbering  more  than  ten,  develop  into  the 
"daisy"  form.  Vacuoles  are  seen  in  some  cases.  After  sixty-nine 
hours,  mature  segments  finally  separate,  each  with  a  bright  spot  or 


PLATE  III. 


'~i!5i2^' 


A 


K/ 


9 


(& 

q^' 


B 


^0 


C 


Malarial  Parasites. 


A.  Tertian  parasite,  i ,  young  form;  2-4,  stages  of  gro^wth  and  pigmentation; 
S-7,  segmentation;  8,  rupture  of  spores  from  corpuscle;  9,  extracellular  form; 
lO,  flagellate  fgrm. 

B.  Quartan  parasite.  1-6,  development  and.  pigmentation;  7,  8,  central  group- 
ing of  pigment  and  spore  formation;  9,  rosette  of  spores  -with  nuclei;  lO,  extra- 
cellular form;  11,   flagellate  form. 

C.  ^^siivo-autumnal  parasite.  1,  ring-like  body;  2,  8,  amoeboid  forms;  4, 
parasite  in  brassy  degenerated  red  cell;  5,  pignnentation;  6,  segmentation;  7,  8, 
half-moon  bodies;  9,  flagellate  forms. 


MALARIA  111 

nucleolus;  i.  e.,  segmentation  occurs  in  the  peripheral  blood  three 
hours  before  the  paroxysm,  which  corresponds  with  their  rupture 
from  the  red  corpuscle  into  the  plasma.  Sporulation  means  death 
of  the  adult  parasite,  or  its  "death  in  childbed,"  as  Mannaberg  well 
describes  it.  The  spores  rupture  through  the  mother  cell  and  the  red 
cell,  and  escape  into  the  plasma,  whence  they  attack  and  enter  other 
red  cells,  to  repeat  their  life-cycle.  The  pigment  and  fragments  of 
red  cells  are  picked  up  by  the  leukocytes  and  are  carried  to  the  liver 
and  spleen.  Some  forms  (gametocytes)  do  not  mature  nor  sporulate. 
They  are  taken  up  by  the  mosquito,  to  complete  in  it  another  cycle. 
(Plate  III.) 

2.  The  tertian  organism  has  a  forty-eight-hour  cycle.  In  its  first 
day  it  is  small  (1/^  to  2/j.),  and  appears  as  a  bright,  unpigmented,  disk- 
like or  annular  spot  in  the  red  cell,  thrusting  out  pseudopodia,  with 
most  active  amoeboid  movement,  and  possessing  a  relatively  large 
nucleus, — partly  clear  chromatin,  and  partly  chromatin  which  may  be 
deeply  stained  by  the  Romanowsky  method.  It  fills  about  one-third 
of  the  cell.  In  its  second  day,  pigment  rapidly  accumulates  in  the 
form  of  fine  granules  or  rods,  which  are  usually  peripherally  located, 
and  which  have  an  actively  swarming  movement,  compared  by  Lav- 
eran  to  that  of  boiling  water.  This  is  due  to  currents  in  the  proto- 
plasm of  the  parasite.  The  amoeboid  movement  of  the  parasite 
decreases  in  twenty-four  to  thirty-six  hours,  as  it  grows  and  as  the  pig- 
ment increases,  but  some  movement  remains  for  a  long  time.  Vacuoles 
are  frequent.  The  parasite  occupies  two-thirds  to  three-fourths  of 
the  red  cell,  which  becomes  distended  and  chlorotic.  The  most  com- 
mon form  of  the  sporulation  is  the  concentric  accumulation  of  pig- 
ment and  the  development  of  fifteen  to  twenty  rough,  refractile  spores, 
which  form  in  two  concentric  circles  ("sunflower"  arrangement),  or 
are  more  frequently  irregular,  like  a  bunch  of  grapes.  The  spores 
are  small  and  round.  Sporulation  occurs  three  hours  before  the  chill 
and  the  rise  of  temperature,  and  is  completed  in  forty-eight  hours, 
when  the  toxins  secreted  produce  the  rigor  and  fever.  Most  spores  are 
seen  at  the  time  of  the  chills,  and  even  then  few  can  be  seen,  because 
sporulation  occurs  to  a  greater  extent  in  the  internal  organs  than  in 
the  peripheral  blood-stream.  When  spores  are  seen  between  paroxysms 
they  represent  the  sporulation  of  another  generation  of  parasites,  too 
weak  or  too  few  to  induce  a  paroxysm.  The  generations  are  never 
absolute  as  they  are  in  the  quartan  type,  and  the  parasites  of  the 
same  generation  vary  six  or  eight  hours  in  their  cycle.  This  explains 
the  clinical  variations  in  periodicity.  Flagellated  forms  may  be  seen 
a  few  minutes  after  withdrawal  of  the  blood.  The  nodulated  and 
clubbed  flagella  lash  about  and  indent  the  red  cells.  They  may  break 
off  and  swim  about.  They  occur  in  numerous  parasites  which  never 
sporulate  in  human  blood,  and  remain  as  large  bodies  with  vibrating 
pigment.  They  were  formerly  regarded  as  degenerated  parasites, 
but  really  represent  gametocytes  or  the  "sexual  forms,"  which  de- 
velop later  in  the  mosquito. 


112  THE  SPECIFIC  INFECTIONS 

3.  The  (Bstivo-autumnal  parasite  has  a  life-cycle  of  from  twenty- 
four  to  forty-eight  hours.  It  has  a  very  small,  unpigmented  body,  and 
possesses  most  active  amoeboid  movement.  It  thus  attracts  early 
attention  but  is  easily  overlooked,  as  it  possesses  almost  the  same 
refraction  as  the  red  cell.  It  becomes  quiet  after  drawing  the  blood 
from  the  body,  when  it  appears  characteristically  ring-like,  often  with 
a  central  vacuole.  The  shape  may  be  successively  amoeboid,  diskoid, 
annular,  cruciform,  or  often  may  have  a  slight  protuberance  at  one 
side — the  seal-ring  form.  Mature  forms  contain  particles  of  haemo- 
globin. The  pigment  is  extremely  fine,  powder-like,  dark,  sometimes 
reddish,  peripherally  located,  and  has  some  movement.  When  the 
parasite  reaches  one-third  the  size  of  the  corpuscle,  it  is  usually  motion- 
less, and  the  pigment  becomes  concentrated  centrally  or  sometimes 
peripherally.  Motion  in  the  parasite  has  been  seen  in  the  cadaver  by 
Ziemann.  The  spores  number  six  to  fourteen  (or  sixteen),  are  very 
small,  round,  and  without  movement  or  vacuoles.  Sporulation  occurs 
as  in  the  other  forms.  Fever,  pigment  concentration,  and  sporulation, 
coincide  (Golgi).  If  large  parasites  vnih.  much  pigment  are  seen  in 
the  peripheral  blood,  they  denote  the  onset  of  a  paroxysm,  and  after 
the  paroxysm,  ring-forms  without  pigment  may  be  observed.  The 
young  forms  circulate  in  the  general  blood-stream,  though  sporula- 
tion usually  occurs  in  the  deep  viscera.  The  half-moon  bodies,  or  cres- 
cents, are  delicate,  slender,  highly  refractile  bodies,  measuring  eight  to 
ten  microns  by  two  to  three  microns,  are  developed  in  the  bone-marrow 
or  spleen,  and  possess  considerable  pigment,  which  is  usually  mesially 
located  and  has  little,  if  any,  motion.  They  have  no  amoeboid  move- 
ment but  may  slowly  change  form.  In  shape  they  are  spindle,  oval, 
or  spherical.  They  occur  singly  in  the  red  cell.  They  do  not  mul- 
tiply in  the  human  blood.  The  young  crescents  develop  in  the  ^as- 
cera  or  bone,  and  their  adult  forms  are  seen  in  the  peripheral  blood, 
for  the  periphery  offers  the  best  opportunity  for  leaving  the  body — 
through  the  bites  of  mosquitos.  The  male  form  of  the  crescent  has 
flagella  (microgametes)  which  penetrate  the  sexual  elements  of  the 
female  crescents  (macrogametes).  This  occurs  outside  of  the  body, 
either  on  the  slide  or  in  the  body  of  the  mosquito.  After  several  days 
crescents,  spherules,  or  spindles,  appear.  Crescents  indicate  that  the 
fever  has  just  begun.  Fever  rarely  occurs  when  crescents  alone  are 
found  in  the  blood.  If  fever  develops  with  the  presence  of  crescents, 
amoeboid  bodies,  also,  are  nearly  always  found.  The  red  blood-cell  be- 
comes copper-colored  or  brassy. 

This  knowledge  of  the  parasite  explains  experimental  inoculation 
from  individual  to  individual  as  well  as  accidental  infection  during 
operations.  Transmission  to  the  foetus  is  unknown.  The  parasite 
may  be  stained  with  methylene  blue  or  hpematoxylin,  and  may  be 
counterstained  with  eosin.  For  the  beginner,  at  least,  study  of  the 
fresh  blood  under  an  oil-immersion  is  the  best  method. 

The  Nocht-Romanowsky  staining  fluid,  according  to  Ewing,  is  made 
as  follows:     (1)    Polychrome  methylene  blue    solution:    To  1  ounce 


MALARIA 


113 


of  polychrome  methylene  blue  (Griibler)  add  5  drops  of  3-per-cent. 
solution  of  acetic  acid  (U.  S.  P.  33  per  cent),  to  neutralize  the  undue 
alkalinity.  (2)  Ordinary  methylene  blue  solution:  Make  a  1-per-cent. 
(saturated)  watery  solution  of  methylene  blue,  preferably  Ehrlich's 
rectified,  or  Koch's,  by  aid  of  gentle  heat.  This  solution  improves 
with  age  and  should  be  at  least  a  week  old.  (3)  Eosin  solution:  A 
1-per-cent.  solution  in  water  of  Griibler's  aqueous  eosin.  Then  to  10 
cc.  of  water  add  4  drops  of  (3),  6  drops  of  (1)  and  2  drops  of  (2),  mix- 
ing well.  To  use,  the  specimens,  fixed  by  alcohol  or  heat,  should  be 
immersed  for  two  hours,  specimen-side  downward;  they  will  not  over- 
stain  by  twenty-four  hours'  immersion.  They  should  then  be  washed 
in  distilled  water,  dried  slowly  over  the  flame,  and  mounted  in  Canada 
balsam.  The  density  of  the  blue  may  be  varied  to  suit  individual 
fancy,  nor  need  the  proportions  be  rigidly  followed,  but  the  accurate 
neutralization  of  the  polychrome  solution  is  most  important. 


Mannaberg's  Table:   Characteristics  of  the  Varieties  op  the  Parasite. 

(Note. — Forms  3,  4,  and  5,  are  usually  grouped  as  one,  sestivo-autumnal.) 


Maxi- 

Form  of 

Number 

Half- 

Changes  in  the  in- 

Life- 
oycle. 

Motility. 

Pigment. 

rQum 

sporula- 

of 

moon 

fected     red     cor- 

size. 

tion. 

spores. 

bodies. 

puscle. 

1. 

72 

Little   move- 

Coarse, 

Size  of 

Daisy 

6  to  12. 

None. 

Red     cells*  "httle 

hours. 

ment   in   the 

with     lit- 

red 

form; 

changed  in'size  or 

Quartan 

young  forms. 

tle  move- 

blood 

single 

color. 

parasite. 

ment. 

cor- 

spores 

puscle. 

elongated  1 

and  nu- 

cleated. 

2. 

48 

Active  move- 

Fine 

Size    of 

Sunflow- 

15 to  20 

None. 

Often      hypertro- 

hours 

ment    in    the  granules; 

red  cell,. 

er  or 

(or    less). 

phic.     Chlorotic. 

Ordinary 

(or  less) 

youngest  and 

very 

some- 

grape 

tertian 

middle-aged 

active, 

times 

form; 

parasite. 

forms. 

"swarm- 
ing" 
move- 

larger. 

single 
spores, 
small, 
round. 

ment. 

and  sel- 

dom vis- 
ible 

when  un- 
stained. 

Irregular 

3. 

24 

In  the  young 

Very  fine, 

i  to  i 

fi    to   8 

Present 

Brassy,  shrunken. 

hours 

unpigmented 

no 

of  red 

particles. 

(or  more). 

or      sometimes 

Pigmented 

(or  less) 

forms    very 

swarming 

cell. 

wholly  decolor- 

quotidian. 

active    amoe- 
boid     move- 
ment,   grow- 
ing less. 

move- 
ment, 
forming 
in 
clumps. 

ized. 

4 

24 

Very     active 

None. 

ttoi 

Stellate 

6  to  8. 

Present 

Shrunken   and 

hours. 

amcEboid 

of  red 

or  irregu- 

brassy. 

Unpig- 

movement. 

cell. 

lar. 

mented 

quotidian. 

5. 

48 

Active,     per- 

M o  d  e  r- 

i  to  tj 

I  r  r  e  g  u- 

10   to    12 

Present 

Shrunken   and 

hours . 

sisting  also  in 

ately  fine, 

of  red 

lar  forms. 

(rarer 

brassy. 

Malignant 

pigmented 

often 

cell. 

15  to  16). 

tertian. 

bodies. 

shows  os- 
cillating 
move- 
ment. 

114  THE  SPECIFIC  INFECTIONS 

(B).  The  Life  of  the  Organism  Without  the  Human  Body.  ^— King 
(1883)  first  suggested  that  the  mosquito  was  the  intermediate  host 
and  sole  source  of  infection.  It  takes  the  plasmodium  from  man  and 
reinoculates  him  mth  it  after  the  life-cycle  within  its  body.  Other 
analogous  infections  are  known,  such  as  the  hsemosporidia  of  birds, 
frogs,  bats,  dogs,  sheep,  monkeys;  e.g.,  Texas  cattle-fever  inoculated 
by  the  tick,  and  the  African  tsetse  disease  (trypanosoma)  in  animals 
and  man,  which  is  inoculated  by  the  tsetse-fly.  INIanson,  especially, 
then  Ross,  Grassi,  Bastianelli,  Bignami,  Daniels,  Stephens,  Christo- 
pher, and  others,  have  developed  this  most  interesting  subject.  The 
Plasmodium  malarise  has  not  been  found  except  in  man  and  in  the 
mosquito.  The  mosquito  is  the  primary  and  higher  host,  since  the 
sexual  process  of  reproduction  in  its  stomach  is  biologically  higher 
than  the  simple  sporulation  in  man.  The  culex  and  the  anopheles 
are  the  two  chief  genera.  The  culex  does  not  contain  nor  convey  the 
parasite.  Its  palpi  are  very  short  and  its  wings  generally  have  no 
mottling.  When  sitting,  its  hind  legs  are  carried  above  the  body 
and  its  body  lies  parallel  with  the  wall,  or  may  sag,  from  the  blood 
it  has  sucked.  Its  eggs  are  laid  in  tanks  or  puddles.  It  is  the  ordi- 
nary house  mosquito  and  is  found  chiefly  in  cities.  The  anopheles 
conveys  malaria.  Its  palpi  are  almost  as  long  as  the  proboscis;  the 
wings  are  mottled;  the  rear  legs  usually  depend,  or  touch  the  wall, 
but  sometimes  are  carried  over  the  body.  Its  body  makes  an  angle 
of  45°  with  the  wall.  The  eggs  are  laid  in  pools  or  sluggish  streams 
with  algse  growth,  and  the  open  country  is  its  preferred  habitat.  In 
America,  four  species  exist:  (1)  The  most  important  is  the  Anopheles 
maculopennis  (the  Anopheles  claviger  of  Europe);  (2)  Anopheles  cru- 
cians; (3)  Anopheles  punctipennis;  (4)  Anopheles  argyritarsis.  When 
the  anopheles  bites  persons  whose  blood  contains  sexually  mature 
forms  of  the  plasmodium  (gametocytes),  flagellation  in  the  male  form 
occurs  and  .the  flagella  enter  the  female  cells.  After  fecundation  in 
the  insect's  stomach,  the  impregnated  cell  enters  the  muscular  walls 
of  the  middle  intestine,  and,  after  two  days,  small,  round,  refractile, 
pigmented  bodies  appear,  which,  after  a  week,  grow  to  60  or  70,u  in 
diameter.  They  develop  into  myriads  of  sporoblasts  which  reach 
the  salivary  glands  of  the  insect,  whence  they  are  again  inoculated 
into  man  by  biting.  These  sporozoids  thus  resulting  from  sexual 
-conjugation  in  the  mosquito,  are  equivalent  to  spores  formed  by  asex- 
ual sporulation  in  the  human  blood.  Entering  the  red  cells  in  man, 
they  follow  the  cycle  of  their  type  as  above  described,  and  produce 
either  sporulating  forms  or  sterile  forms.  The  sterile  forms  in  the 
human  blood — i.  e.,  the  forms  which  do  not  sporulate — linger  in  the 
peripheral  blood  with  the  teleologic  purpose  of  preserving  and  con- 
tinuing their  life  in  the  mosquito,  and,  on  reaching  its  body,  develop 
again  the  agents  of  reinfection.  This  knowledge  concerning  the  mos- 
quito explains  many  interesting  and  formerly  incomprehensible  de- 
tails. We  now  know  why  those  living  in  the  first  story  of  houses  are 
more  likely  to  be  infected  than  those  living  in  the  upper  floors,  and 


MALARIA  115 

why  those  who  slept  in  houses  facing  inland  were  infected  while  those 
in  houses  exposed  to  the  sea  air  escaped,  etc.  In  Rome,  the  fever  pre- 
vailed just  outside  the  Porta  del  Populo,  while  the  Corso,  three  hun- 
dred feet  distant  in  the  city,  escaped. 

Symptomatology. — (A).  Fever. — Fever  is,  next  to  the  finding  of 
the  melanin  and  the  plasmodium,  the  most  constant  symptom,  though, 
strictly  speaking,  malaria  should  not  be  divided  into  types  by  the 
fever  alone.  It  comes  on  after  an  incubation  varying  irregularly  from 
one  and  a  half  to  fifteen  days.  Fever  bears  a  close  relation  to  sporu- 
lation,  as  was  demonstrated  by  Golgi,  in  1885.  The  fever-curve  is 
most  variable,  being  very  irregular  in  some  types  or  almost  mathe- 
matically regular  in  others.  It  is  usually  irregular  at  first  even  in 
regular  types.  It  may  be  remittent  (subcontinuous),  intermittent 
(tertian,  quartan,  quotidian),  or  continuous  for  a  few  days,  when  it 
ends  by  crisis  or  becomes  remittent  or  intermittent  before  recovery. 
The  paroxysm  may  be  delayed  beyond  the  time  when  it  is  due  (post- 
ponens),  or  may  anticipate  this  time  (anteponens) .  There  may  be 
hyperpyrexia,  or  normal  or  subnormal  temperature.  This  occurs 
in  the  algid  variety. 

The  classical  divisions  of  the  paroxysm  are  (1)  chill,  (2)  fever,  and 
(3)  sweating,  whose  respective  duration,  according  to  Lorain,  is  in 
the  proportion  of  3-2-7.  Any  element  of  the  paroxysm  may  be  ab- 
sent. Thus  the  fever  or  the  rigor  is  absent  in  some  virulent  varieties 
and  in  persons  partly  immunized,  and  the  sweating  may  be  slight  or 
absent.  The  paroxysm  lasts  ten  (four  to  forty-eight)  hours,  and  in  91 
per  cent,  of  the  cases  occurs  between  10  a.  m.  and  3  p.  m.  Prodromal 
symptoms  are  fatigue,  and  anorexia.  (1)  The  chill  then  occurs. 
It  is  rather  sudden  in  its  onset,  often  very  severe,  with  headache, 
nausea,  emesis,  coldness,  contraction  and  lividity  of  the  skin  (cutis 
anserina);  the  temperature  by  rectum  is  elevated,  the  pulse  rapid, 
small,  and  hard;  the  respiration  is  rapid  or  even  dyspnoeic,  and  the 
urine  is  increased.  The  parasites  are  in  the  peripheral  blood  in  the 
tertian  and  quartan  types,  but  largely  in  the  internal  organs  in  the 
sestivo-autumnal  type.  (2)  The  fever  is  high,  perhaps  not  higher  by 
rectum  than  during  the  chill,  but  is  more  evidenced  by  the  red,  burn- 
ing skin,  thirst,  delirium,  and  headache,  soft,  full,  or  dicrotic  pulse, 
and  other  fever  symptoms.  In  this  stage  the  young  parasites  are 
free  in  the  blood  and  begin  to  attack  new  red  cells.  After  their 
entrance  into  these  cells  the  fever  ceases.  (3)  In  the  siveating  stage 
the  young  parasites  are  found  in  the  red  cells,  and  phagocytes 
take  up  the  detritus  and  pigment.  The  sweat  is  usually  profuse 
and  somewhat  characteristic,  giving  off  an  odor  like  that  of  semen; 
The  patient  may  be  exhausted,  but  post-febrile  euphoria  is  usual. 

Special  Febrile  Types  of  Malaria. — The  quartan  and  tertian 
forms  are  regular  and  intermittent,  and  the  sestivo-autumnal  forms 
are  more  irregular  and  remittent. 

1.  The  quartan  fever  is  the  rarest  of  all  types  (f^  of  1  percent.), 
is  found  in  the  temperate  zones,  and  occupies  a  position  geographically 


116 


THE  SPECIFIC  INFECTIONS 


intermediate  between  those  occupied  by  the  tertian  and  sestivo-au- 
tumnal  varieties.  It  is  caused  by  the  quartan  parasite,  is  the  most 
regular  of  all  types,  and  is  called  quartan  because  the  simple  form 
causes  paroxysms  every  fourth  day.  The  parasitic  cycles  are  readily 
followed  in  the  circulating  blood,  and  the  organisms  do  not  accumu- 
late in  the  internal  organs.  Sometimes  fission  bodies  may  be  found 
without  fever.     The  fever  is  rather  obstinate  and  recurrence  is  fre- 


Day 

] 

2 

Fig.  10. 
3 

4 

5 

TEMP. 
104 

\ 

i 

102 

\ 

100 

/ 

\ 

J^ 

L      A/l 

r^ 

J 

\ 

I 

/ 

V 

Quartan  malaria  (Silvestrini). 


quent,  but  quinine  exerts  its  specific  action  in  a  relatively  short  time. 
The  type  may  be  single,  from  one  generation  of  parasites;  double, 
from  two  generations;  or  triple,  from  three  generations,  thus  produc- 
ing, respectively,  temperature  every  fourth,  every  first  and  second,  or, 
finally,  every  day  of  the  cycle. 


Fig.  11. 


Das 

1 

2 

3 

4 

5 

6 

7 

TEMP. 

104 

i 

103 

A 

A 

103 

/ 1 

A 

A 

101 

/ 

44 

A 

103  ^       / 

/ 

/   l! 

/\ 

99 

/ 

/ 

\ 

/  \ 

/ 

J 

\    ys. 

^ 

^         /"^'            \ 

'J-! 

^\ J  \                 \\ 

Tertian  malaria. 


2.  Tertian  fever  is  most  frequent  in  the  temperate  zones  and  is  the 
most  widely  distributed  variety.  It  is  found  in  all  malarial  countries 
and  constitutes  50  to  65  per  cent,  of  all  malaria.    The  organisms  tend 


MALARIA 


117 


to  accumulate  in  the  internal  organs.  Fission  bodies  are  rarely  found 
without  fever.  It  is  rarely  pernicious.  The  type  may  be  single,  or, 
more  frequently,  double  from  two  generations  of  parasites.  Fever 
which  is  almost  continuous  may  sometimes  be  observed  (Thayer  and 
Hewetson).  It  responds  very  readily  to  quinine  or,  indeed,  to  simple 
rest  in  bed  (spontaneous  recovery). 

3.  Mstwo-autumnal  fever,  caused  by  the  sestivo-autumnal  parasite, 
is  often  irregular,  remittent,  intermittent,  or  continuous  (subcontin- 
uous).  It  is  characterized  clinically  by  severe  and  recurrent  fever, 
marked  anaemia,  frequently  by  absence  of  paroxysms  (chills  occurring 
in  only  71  per  cent,  of  the  cases),  and  sometimes  by  pernicious  symp- 
toms. It  was  first  called  sestivo-autumnal  by  Marchiafava  and  Big- 
nami,  in  contradistinction  to  the  vernal  or  milder  spring  forms.  Suh- 
types:  (a)  Regular  intermittent  sestivo-autumnal  fever.  Its  two 
varieties  are:  (i)  The  sestivo-autumnal  tertian,  in  which  the  parasite 
is  dijOFerent  from  that  of  the  ordinary  tertian.  The  temperature  is  apt 
to  be  high,  and  the  paroxysm  doubly  long.     The  typical  curve  may 


Day 

1 

2 

}i 

Fig.  12. 

4 

5 

G 

7 

8 

TEMP. 

106 

105 

104 

103 

A 

\. 

A 

103 

/ 

\ 

A 

101 

/ 

\, 

\  A 

/^ 

I 

100 

V 

r 

V 

yy 

\ 

99 

■ 

V 

v\ 

^ 

\ 

9S 

jEstivo-autumnal  malaria. 


be  modified  by  the  absence  of  a  distinct  initial  elevation,  by  an  ex- 
aggerated pseudo-crisis,  by  a  briefer  or  longer  duration  of  the  attack, 
by  anticipation  or  procrastination,  by  double  attacks,  and  by  marked 
oscillations,  (ii)  The  sestivo-autumnal  quotidian,  in  which  the  attacks 
are  usually  short,  but  have  an  abrupt  elevation  of  temperature.  They 
often  become  irregular,  frequently  fuse,  and  have  fewer  symptoms  than 
in  the  other  variety.  This  form  is  often  mild  and  the  patient  may  re- 
cover spontaneously.  It  may,  however,  become  pernicious.  This  form 
is  readily  confused  with  typhoid.  (6)  The  irregular  intermittent  sestivo- 
autumnal  fever,  which  has  marked  irregular  intermittency  or  remit- 
tency,  or  subcontinuous  fever,  because  the  attacks  are  duplicated, 
anticipated,  or  prolonged.  The  paroxysm  may  last  twenty  hours.  The 
life-cycle  of  the  parasite  is  often  difficult  to  follow.  The  symptoms 
may  be  mild  or  very  severe. 


118  THE  SPECIFIC  INFECTIONS 

(B).  Blood-Findings. — The  blood-findings  are  pathognomonic;  viz.y 
parasites,  anaemia,  absence  of  leukocytosis,  and  melansemia  are  found. 

(a)  Red  Cells. — Anaemia  is  always  present  during  the  attack,  from 
direct  deglobulization  by  the  parasite,  and  possibly  also  from  liberated 
toxins.  Acute  anaemia  is  naturally  more  marked  and  rapid  than  in 
any  other  acute  infection.  The  loss  is  greatest  in  the  first  attack, 
especially  in  pernicious  cases,  and  sometimes  reaches  half  a  million 
cells.  Reduction  to  500,000  red  cells  (Kelsch),  thus  giving  the  pic- 
ture of  pernicious  anaemia,  has  been  observed  especially  in  cases  of 
pregnancy,  and  in  children   (Frayer  and  Ewart). 

(6)  White  Cells. — In  the  first  attack  absolute  and  relative  leuko- 
penia is  observed,  which  is  due  to  the  collection  of  the  white  cells  in 
the  liver  and  spleen,  to  the  destruction  of  the  phagocytes,  and,  in 
cachexia,  to  lesions  of  the  blood-making  organs.  As  in  other  anaemias 
caused  by  diseases  of  the  bone-marrow  and  spleen,  an  increase  of 
lymphocytes  or  large,  mononuclear  cells,  with  decrease  of  the  poly- 
morphonuclear cells,  may  be  observed,  especially  in  the  apyretic  inter- 
vals. Genuine  leukocytosis  in  malaria  denotes  a  complication  such  as 
pneumonia  or  sepsis.  An  absolute  increase  is  sometimes  observed  in 
pernicious  malaria,  such  as  the  "black-water  fever,"  but  even  here 
the  increase  is  in  the  lymphocytes.  Cell  division  and  degeneration  in 
the  leukocytes  may  be  observed. 

(c)  Melan^mia. — Melanaemia  (first  observed  by  Virchow  and 
Heschl,  1847-50)  is,  next  to  the  presence  of  the  plasmodium,  the  most 
constant  change  in  malaria.  It  probably  occurs  in  every  instance, 
though  an  unpigmented  aestivo-autumnal  form  is  believed  by  some 
to  exist.  Melanaemia  is  present  at  all  times  during  fresh  infection 
and  may  occur  shortly  after  the  fever  has  disappeared,  as  in  the  half- 
moon  forms.  After  infection  it  usually  disappears  within  forty-eight 
hours.  It  is  practically  pathognomonic  of  malaria,  though  it  is  said 
to  occur  in  recurrent  fever,  in  melanotic  new  growths,  and  in  Addi- 
son's disease.  It  is  found  in  the  polymorphonuclears  and  sometimes 
in  the  lymphocytes.  It  is  seen  in  the  smaller  capillary  walls  where 
their  diameter  suddenly  decreases  (lung  alveoli,  intestinal  villi,  appen- 
dices epiploicae,  renal  glomeruli,  dura  mater,  cerebral  convolutions, 
spleen,  liver,  and  bone-marrow);  the  capillaries  may  be  occluded  by 
pigment.  The  lymph-glands  are  usually  free  of  pigment,  with  the 
possible  exception  of  the  portal  glands.  Besides  this  pigment  there 
is  also  the  copper-colored  haemosiderin.  This  may  be  found  not  only 
in  the  vessels  but  in  the  parenchyma  of  the  liver. 

(C).  Spleen. — Enlargement  of  the  spleen  (first  described  by  Andou- 
ard,  1803),  is  the  third  important  finding.  It  is  palpable  in  88  per 
cent,  of  the  cases  and  is  rarely  anatomically  absent  (Laveran,  Plehn, 
Kiener,  and  Kelsch)  in  tropical  forms.  Its  size,  hardness,  and  plump- 
ness, are  proportionate  to  the  length  of  the  fever.  They  increase  with  its 
rise,  and  remit  between  attacks.  In  acute  infections  the  spleen  is  increased 
three  to  five  times  its  normal  weight  (five  ounces) ;  it  is  soft  and  friable; 
the  veins  are  dilated,  and  the  parenchyma  is  flooded  with  infected  cells 


MALARIA  119 

and  macrophagic  cells ;  and  there  are  sometimes  areas  of  focal  necrosis. 
The  Malpighian  bodies  contrast  strongly  with  the  pulp.  There  is 
often  a  sticking  pain  over  the  organ,  which  is  increased  by  moving 
the  diaphragm.  Pain  is  due  to  capsular  tension,  or  perisplenitis,  and 
is  often  associated  with  pain  and  tenderness  in  the  bones.  As  the 
disease  subsides  the  splenic  intumescence  disappears  but  may  occa- 
sionally remain  (fever-cake).  In  chronic  infections  the  spleen  is  per- 
manently enlarged,  reaching  even  into  the  pelvis.  It  may  weigh  two 
to  ten  pounds.  The  capsule  is  thickened,  even  calcified.  Perisplenic 
adhesions  occur  and  friction  is  frequent.  Sometimes  also  a  systolic 
murmur  is  heard  (Griesinger).  The  organ  is  plump,  the  veins  are 
patent,  and  the  acute  hypersemia  and  focal  necrosis  lead  to  increase  of 
the  connective  tissue.  The  pigment,  enormous  at  first,  gradually  de- 
creases. Ultimately  little  remains  of  the  pulp,  follicles,  and  splenic 
function. 

Rare  complications  are  pressure  on  the  intestines,  nerves,  and  ure- 
ters, torsion  of  the  pedicle  of  a  wandering  spleen,  rupture  (of  which 
Choux  has  collated  147  cases),  abscess,  or  perisplenic  abscess. 

(D).  Skin. — The  skin  is  congested  during  the  chill,  and  the  vaso- 
motor constriction  gives  way,  during  the  febrile  rise,  to  hyperalgesia 
and  vaso-dilatation.  Miliaria  appear  in  the  sweating  stage.  Herpes 
is  very  frequent,  mostly  nasal  or  labial;  erythema  is  not  common 
except  when  it  results  from  quinine  or  antipyrin.  Erythema  nodosum 
has  been  observed  in  children.  Roseolse  are  most  rare.  (Edema 
occurs  chiefly  in  chronic,  and  ambulant  cases,  and  an  earth-colored 
cachectic  hue  appears  in  chronic  cases.  The  mucosae  are  gray  but 
not  pigmented.  Slight  icterus  is  not  infrequent  (urobilin  icterus), 
and  sometimes  it  is  intense.  Infrequent  complications  are  urticaria, 
pemphigus,  petechise,  pigmentation,  a  measles-like  eruption,  fur- 
uncles, phlegmon,  noma,  gangrene,  or  erysipelas. 

(E).  Circulatory  Symptoms. — The  heart  is  little  involved,  though 
sometimes  myocardial  degeneration  and  dilatation  may  occur  dur- 
ing the  paroxysm.  The  pulse  rises  parallel  with  the  fever,  small  at 
first  from  vaso-constriction,  later  dicrotic  and  full  from  vaso-dilatation. 
Endocarditis  is  a  rare  development,  as  are  angina  pectoris,  aortitis, 
or  phlebitis.  The  author  observed  one  case  complicated  with  ulcera- 
tive endocarditis  and  aortitis. 

(F).  Respiratory  Symptoms. — Dyspnoea  and  pulmonary  congestion 
may  occur  during  the  paroxysm.  These  are  due  to  parasites  and 
phagocytes  accumulating  in  or  even  occluding  the  capillaries  of  the 
lung.  Chronic  bronchitis,  emphysema,  and  chronic  interstitial  pneu- 
monia, occur  as  complications.  Bronchopneumonia  is  frequent  in 
malarial  cachexia.  Genuine  lobar  pneumonia  occurs  only  as  a  mixed 
infection,  since  the  malarial  parasite  possesses  no  phlogogenic  proper- 
ties. Plasmodia  have  been  seen  in  the  sputum.  Pneumonia  is  atypical, 
is  often  present  without  rusty  sputum  and  without  chill,  and  is  espec- 
ially dangerous  in  malarial  cachexia,  the  mortality  ranging  from  60 
to  78  per  cent.    Pulmonary  tuberculosis  and  pleurisy  are  rare. 


120  THE  SPECIFIC  INFECTIONS 

(G).  Digestive  Symptoms. — The  oral  mucous  membrane  is  dry  and 
is  sometimes  the  seat  of  hemorrhage,  or  gangrene;  the  tongue  is  heavily 
coated  and  the  breath  is  foul.  The  parotid  gland  is  sometimes  swollen.  , 
The  stomach  may  be  the  seat  of  erosions,  catarrh,  hypersemia,  or  of 
infarction  with  plasmodia.  Anorexia,  pyrosis,  vomiting,  and  cardialgia, 
are  common  symptoms.  Ulceration  from  amyloid  degeneration  is 
observed  in  only  a  few  chronic  cases.  Heematemesis  from  chronic 
splenic  tumor  has  proved  fatal. 

The  Intestines. — Swelling  of  the  lymphatic  structures,  erosions, 
catarrh,  hypersemia,  thrombosis  from  parasite  aggregation,  meteor- 
ism,  constipation,  and  rarely  diarrhoea,  are  observed.  Acute  abdom- 
inal pain  is  not  uncommon,  but  occurs  without  obvious  cause.  Pain 
may  simulate  peritonitis.  Hemorrhage  is  rare.  The  disease  may  re- 
semble dysentery,  with  ulcers  in  the  large  and  small  gut.  Acute 
ascites  may  result  from  pylethrombosis,  from  plugging  of  the  capil- 
laries by  melaniferous  cells,  or  from  congestion  of  the  peritoneum. 

The  Liver. — In  acute  infections  the  liver  is  swollen,  hypersemic, 
or  is  the  seat  of  focal  necrosis.  Its  endothelial  cells  are  swollen,  it 
becomes  macrophagic,  and  its  veins  are  full  of  pigment,  though  as 
a  rule  few  parasites  are  present.  Icterus  may  develop  from  sepsis 
or  red-cell  destruction;  it  is  usually  polycholic.  Pigmentation  from 
degenerated  red  cells  is  more  common  than  actual  melanosis.  In 
chronic  infections  the  liver  may  weigh  eight  or  ten  pounds,  is  hard 
and  smooth,  and  has  a  thick  capsule.  The  changes,  seriatim,  are  focal 
necrosis,  atrophy  or  partial  regeneration,  and  pigmentation  with  hyper- 
semia. As  a  result  of  atrophy  and  regeneration,  angioma,  lymph-cysts, 
or  abnormal  lobules  develop;  hyperplasia  of  the  perilobular  connec- 
tive tissue  occurs  with  ultimate  cirrhosis.  Atrophic  and  also  hyper- 
trophic cirrhosis  may  follow  chronic  malaria  (Frerichs,  Bamberger), 
but  Marchiafava,  Bignami,  and  Osier,  rather  question  its  malarial 
origin,  because  other  causes  are  also  present.  Amyloid  degeneration 
(Rokitansky),  and  simple  atrophy  from  pylethrombosis  and  marasmus, 
are  rather  uncommon  sequels. 

(H).  Genito-Urinary  Symptoms. — Polyuria  is  often  observed  dur- 
ing the  paroxysm,  which  sometimes  reaches  two  to  four  quarts, 
despite  the  severe  sweating.  The  urine  is  usually  decreased  in  the 
sestivo-autumnal  type.  The  post-malarial  polyuria  of  convalescence 
is  more  frequent.  In  one  instance  the  author  observed  a  veritable 
diabetes  insipidus  as  described  by  Sydenham  and  IMosse. 

The  urea,  iron,  chlorides,  and  specific  gravity,  of  the  urine  are  in- 
creased. Phosphates  are  decreased  during  the  paroxysm,  and  increased 
afterwards.  Albuminuria  is  present  in  25  to  40  per  cent,  of  cases, 
and  usually  disappears  with  the  paroxysm,  but  sometimes  lasts  two 
to  three  weeks,  or  longer.  Nucleoalbumin  has  been  found  in  the 
urine,  besides  peptone,  acetone,  and  indican.  Ehrlich's  diazo  reaction 
may  often  be  obtained,  in  5  per  cent.  (Thayer  and  Hewitson)  to  40  per 
cent,  (in  the  author's  experience).  Glycosuria  is  occasional.  The 
toxic  coefficient  is  increased.    Nephritis  occurs  in  4.5  per  cent,  of  the 


MALARIA  121 

cases  but  is  not  often  fatal.  The  parasites  are  rarely  found  in  the 
glomeruli  or  veins  but  frequently  abound  in  the  intertubular  capil- 
laries. Glomerular  desquamation  and  epithelial  exfoliation,  endo- 
capsular  exudation,  necrosis,  and  cast  formation,  develop  in  the 
convoluted  tubules.  Chronic  parenchymatous  and  interstitial  neph- 
ritis may  result  from  previous  malarial  infection.  The  large  white 
kidney,  followed  by  secondary  contraction,  is  considered  by  some  to  be 
a  frequent  sequel.  Hsemoglobinuria,  anuria,  and  uraemia,  occur  in 
blackwater  fever  (See  Pernicious  Forms).  Gangrene  of  the  genitalia 
is  an  uncommon  sequel.  Orchitis  is  usually  due  to  other  diseases. 
Metrorrhagia,  and  abortions  occur  frequently. 

(7).  Nervous  Symptoms. — The  parasite  and  its  presumed  toxin 
affect  especially  the  nervous  system,  and  for  this  reason  von  Swieten 
has  called  malaria  a  neurosis.  There  is  scarcely  a  nervous  symptom 
which  is  not  occasionally  observed  in  malaria.  The  sensorium,  which 
is  involved  slightly  in  mild  cases,  may  be  more  seriously  affected  in 
the  more  severe  types,  the  symptoms  ranging  from  simple  exaltation 
to  coma  and  paralysis.  Headache  is  usual,  and  neuralgias  are  fre- 
quent, especially  in  the  first  and  second  branches  of  the  fifth  nerve. 
Cerebral  confusion  was  noted  by  the  writer  in  two  ordinary  tertian 
cases.  In  pernicious  types  especially,  it  is  not  always  easy  to  determine 
whether  nervous  symptoms  are  due  to  simple  toxaemia  or  to  cerebral 
thrombosis.  The  central  nervous  tissues  are  usually  distinctly  hyper- 
semic,  and  are  ansemic  only  in  the  algid  or  choleraic  types.  The  endothe- 
lial cells  of  the  vessels  are  fatty,  swollen,  and  pigmented.  Thrombosis 
in  grave  cases  may  result  from  swelling  of  the  endothelium,  though 
it  is  usually  caused  by  the  rough  infected  red  cells.  Thrombosis 
may  lead  to  multiple  small  extravasations  of  blood.  The  infected 
erythrocytes  never  leave  the  vessels. 

Symptoms  of  paralysis  (aphasia,  hemiplegia,  paraplegia,  and  mono- 
plegia), or  of  motor  irritation  (tremor,  chorea,  tetany,  athetosis, 
contractures,  epileptic  attacks,  or  reflex  spasms,  such  as  sneezing  or 
vomiting),  may  possibly  occur  in  urgent  types.  Neuritis,  neuroses, 
psychoses,  spinal  paraplegia  with  atrophy  and  bladder  disturbance, 
ascending  spinal  paralysis,  bulbar  symptoms,  symptoms  resembling 
multiple  sclerosis  (Spiller),  tabes,  acute  ataxia  (Kahler  and  Pick), 
and  paralysis  agitans,  are  rare  sequences. 

Special  Senses. — The  eyes  are  reddened.  Herpes  may,  in  rare 
cases,  affect  the  cornea.  Retinal  hyperaemia,  hemorrhage  or  atrophy, 
neuroretinitis,  or  choroiditis,  may  occur  (especially  in  pernicious  cases). 
Otalgia,  otitis  media,  labyrinthine  vertigo,  and  deafness,  are  very 
exceptional. 

(J).  Muscles  and  Bones. — The  muscles  are  rarely  infiltrated  or 
degenerated,  but  are  often  painful.  Rheumatism  is  infrequent  except 
in  India.  The  bone-marrow  is  at  first  fatty  and  pigmented;  the  fat 
and  pigment  then  disappear  with  marked  vascularization,  and,  finally, 
with  proliferation  of  the  marrow-cells  and  connective-tissue  thicken- 
ing.    Bone  tenderness  is  often  noted. 


122  THE  SPECIFIC  INFECTIONS 

Relapses. — Relapses  caused  by  the  awakening  of  an  old  infection 
almost  invariably  occur  in  all  forms,  and  are  most  obstinate  in  the 
sestivo-autumnal  type;  the  blood-findings  are  almost  always  positive. 
Reinfection  is  also  frequent. 

Chronic  Malaria. — Untreated  infection,  or  reinfection,  persists  for 
months,  especially  in  the  sestivo-autumnal  variety.  It  is  accompanied 
by  irregular  fever,  marked  ansemia,  the  parasite  in  the  blood,  and 
splenic  and  hepatic  swelling;  repeated  attacks  always  occur.  In 
severe  chronic  cases,  the  malarial  cachexia  develops,  usually  after 
years  of  infection.  It  is  most  marked  in  intensely  malarial  regions, 
in  the  sestivo-autumnal  form  of  the  infection,  and  in  reduced  subjects. 
The  fever  is  either  slight,  or  entirely  absent;  sometimes  it  is  irregular 
and  reaches  102°  to  103°.  The  essential  features  of  malarial  cachexia 
are  (1)  anaemia  from  defective  blood  regeneration,  with  its  general 
symptoms,  such  as  oedema,  rapid  pulse,  venous  thrombosis,  and 
hemorrhages  in  the  skin,  retinae,  and  stomach;  (2)  vascular  changes, 
possibly  due  to  pigment  deposit,  and  (3)  enlarged  spleen  and  liver. 
Gangrene,  chronic  nervous  symptoms,  alimentary  and  respiratory 
catarrh,  amyloid  disease,  liver  hypertrophy,  and  extreme  malnutrition, 
may  occur. 

Relation  to  the  Other  Diseases. — Malaria  and  typhoid  do  not 
positively  exclude  each  other;  however,  they  rarely  co-exist  in  this 
country.  The  detection  of  the  plasmodia  on  the  one  hand,  and 
typhoid  bacillaemia  or  the  response  of  the  blood  to  the  Widal  test, 
on  the  other  hand,  are  necessary  for  diagnosis.  Surgical  operations 
may  arouse  a  latent  malaria.  Sunstroke  may  initiate  a  pernicious 
attack.  Erysipelas,  septicaemia,  suppuration,  dysentery,  cholera,  small- 
pox, scarlatina,  recurrent  fever,  scurvy,  and  tuberculosis,  may  very 
infrequently  co-exist  with  malaria. 

Pernicious  Malaria. — Pernicious  malaria,  in  the  widest  sense,  is 
malaria  which  threatens  life.  It  is  characterized  by  severe,  obstinately 
recurring  fever,  pronounced  intractable  anaemia,  pernicious  visceral 
symptoms,  frequently  by  abortive  paroxysms  without  chills,  by  con- 
siderable depression,  tendency  to  recurrence,  and  the  presence  in  the 
blood  of  the  aestivo-autumnal  plasmodium.  Pernicious  malaria  con- 
stitutes but  a  small  proportion  of  cases  of  aestivo-autumnal  malaria. 
Very  few  pernicious  cases  have  occurred  from  infection  with  the 
ordinary  benign  tertian  parasite  (Ziemann,  French,  and  one  case  ob- 
served by  the  author).  The  pathogenesis  of  the  pernicious  type  lies 
in  the  inelastic,  irregular,  infected  red  cells  which  cannot  pass  the 
visceral  capillaries,  and  therefore  slow  the  blood  current.  In  cases  of 
capillary  hemorrhages,  only  the  normal  red  cells  escape  from  the 
vessels,  and  the  parasite-laden  red  corpuscles  always  remain  in  the 
vessels.  Regressional  organic  changes  may  occur  in  the  cerebrum, 
gastrointestinal  mucosa,  spleen,  liver,  and  kidney.  The  melanosis, 
phagocyte  aggregations,  and  endothelial  swelling  are  of  wholly  secon- 
dary importance.  Accessory  factors  are  (a)  arteriosclerosis,  renal 
disease,  cardiac  dilatation  (from  toxaemia),  alcoholism,  sunstroke,  over- 


MALARIA  123 

work,  malnutrition,  and  lack  of  acclimatization;  (6)  the  number  of 
parasites  and  their  abundance  in  internal  organs.  Parasites  of  the 
sestivo-autumjial  group,  with  large  blocks  of  central  pigment,  usually 
indicate  many  plasmodia  in  the  viscera.  The  parasites  are  often  few  in 
the  peripheral  blood  or,  indeed,  in  the  blood  of  a  splenic  puncture,  though 
they  may  be  found  in  very  great  numbers  in  the  brain  at  autopsy 
(Bastianelli,  Marchiafava,  and  Bignami);  (c)  great  activity  in  mul- 
tiplication may  be  observed  even  in  the  peripheral  blood  where  they 
are  usually  less  abundant  during  the  sporulating  stage.  Several  plas- 
modia are  sometimes  found  in  a  single  corpuscle;  the  spores  may 
number  ten,  twenty,  or  even  thirty;  (d)  increased  toxicity  of  the 
malarial  parasites  is  purely  hypothetical,  as  their  toxin  has  not  yet 
been  isolated;  but  the  necroses  in  the  spleen,  liver,  and  kidney,  and 
the  great  morphologic  alteration  in  the  "brassy"  red  cells,  are  at  least 
suggestive. 

1.  The  pernicious  typhoid  form  {'perniciosa  typhosa),  is  inapprop- 
riately called  typhomalaria.  Its  clinical  picture  is  variable;  chills 
are  often  absent ;  the  sensorium  is  involved  to  a  variable  extent,  and 
depression,  delirium,  insomnia,  headache,  and  backache,  occur.  The 
fever  is  atypical,  intermittent,  or  remittent  (subcontinuous),  resolves  by 
crisis  or  by  lysis,  and  is  sometimes  hyperpyretic  or  subnormal  in  register. 
Quinine  disturbs  or  breaks  the  type.  The  pulse  and  respiration  are 
increased.  Gastro-intestinal  symptoms  may  be  marked;  vomiting 
sometimes  of  bile  or  blood,  epigastric  pain  and  tenderness,  frequently 
tympany,  and  thin,  dark  movements  of  the  bowels,  occur.  The  spleen 
and  liver  are  usually  tender  and  swollen.  An  irregular  bronchitis 
(sometimes  dyspnoea),  hsemoglobinuria,  albuminuria,  or  urobilinuria, 
are  frequent.  The  course  is  usually  benign,  and  responds  to  quinine; 
the  mortality  is  10  per  cent.,  and,  in  adynamic  forms,  25  per  cent.  Fatal 
cases  usually  terminate  with  nervous  symptoms,  and  especially  with 
coma.  The  differential  diagnosis  was  impossible  before  the  blood- 
findings  were  known,  but  was  often  made  ex  juvantihus  by  adminis- 
tration of  quinine.  Without  blood  examination  malaria  and  typhoid 
may  be  confused;  they  very  rarely  co-exist;  benign  or  malign  malaria 
may  resemble  typhoid  closely,  with  slow,  dicrotic  pulse,  splenic  tumor, 
headache,  fever-curve,  cerebral  and  abdominal  symptoms,  and  even 
roseolse  and  intestinal  hemorrhage;  and,  on  the  other  hand,  erratic 
typhoid  with  remittent  temperature,  chills,  and  sweats,  or  typhoid  in 
the  latter  part  of  its  normal  course,  may  simulate  malaria. 

Baccelli  gives  the  following  differentiation: 

Malaria  (Subcontinua  typhosa) vs. ^Typhoid. 

Begins  intermittently.  Progressively  remittent. 

Remissions  very  irregular.  Very  regular,  and  in  the  morning;  step- 

like. 

Temperature  may  be  high  at  first.  Considerable  fever,  reached  only  on  the 

third  or  fourth  day,  or  later. 
(Concluded  on  next  page  ) 


124 


THE  SPECIFIC  INFECTIONS 


Malaria  (Subcontinua  typhosia)- 

Headache  in  beginning  is  rare,  variable 
in  site  and  intensity,  pulsating  and 
neuralgic. 

Eyes  dull,  subicteric  from  beginning. 


Stuporose    facies,    dry   tongue,     and 
sordes,  less. 

Breath  nauseating. 

Delirium  present  from  beginning,  recurs 
with  temperature  and  other  symp- 
toms. 

If  lung  congestion  occurs,  it  begins  sud- 
denly; foci  change  from  lobe  to  lobe, 
recurrently;  dyspnoea  from  deranged 
circulation. 

Nervous  restlessness,  jactitation. 

Meteorism  can  occur,  but  is  not  char- 
acteristic as  in  typhoid ;  stools  darker. 


Liver  congestion  frequent;   subicterus, 
even  icterus. 

Herpes  is  frequent. 

Cycle,  none. 

Blood :  Plasmodia  and  melansemia. 

Recurrence. 

Convalescence  more  rapid  and  easier. 

In  adynamic:  icterus,   hsemoglobimu-ia, 
leukocytosis,  great  ansemia. 


-Typhoid. 

Early,  permanent,  frontal,  oppressive, 
characteristic. 


In   early   stages,    glistening    eyes;     no 
icterus. 

Marked. 


Mouse-like. 

Occurs  first  with  advanced  stage,  is 
constant  and  varies  only  in  intensity. 

Slow  development,  hj'postatic;  dys- 
pnoea may  rarely  result  from  tym- 
pany, etc. 


Stupor,  sopor,  prostration. 

Meteorism  and  diarrhoea  begin  gradu- 
ally, and  develop  to  a  high  degree; 
ochre  stools. 

Less  congestion,   rarely  icterus. 


Rare;  roseolae. 

Very  typical. 

Widal  reaction  and  tj^hoid  bacil- 
Isemia. 

Relapses  less  frequent. 

Tardy. 

Does  not  respond  to  quinine,  which 
practically  always  reduces  fever  and 
other  malarial  sjTnptoms. 

2.  Of  cerebral  forms,  the^'comatose  {perniciosa  comatosa)  is  the 
most  frequent.  Physical  depression,  sopor,  melancholia,  and  impaired 
memory,  may  exist  in  the  preliminary  stage;  later,  contracted  pupils, 
involuntary  evacuations,  lessened  reflexes,  or  paralysis,  may  develop. 
The  coma  may  be  intermittent.  Its  second  appearance  is  longer  and  more 
dangerous  than  the  first.  If  the  patient  recovers,  bradylalia,  scanning 
speech,  and  insufficient  motility  of  the  lips  or  tongue,  may  be  ob- 
served. The  pulse  at  first  is  generally  slow  and  regular,  but  as  death 
approaches  it  becomes  soft,  thready  and  rapid.  Death  is  usually 
cardiac.  The  respirations  vary,  being  quiet  or  noisy,  hurried,  or  of 
the  Cheyne-Stokes  type.  If  fever  is  present  it  is  irregular.  The 
author  has  seen  four  such  cases  in  Chicago.  Apoplexy,  uraemia,  and 
sunstroke,  must  be  considered.  The  splenic  tumor  per  se  suggests  a 
blood  examination.    The  "meningeal  type"  occurs  especially  in  chil- 


MALARIA  125 

dren,  and  in  these  cases  the  slow  pulse,  headache,  rigid  and  tender 
neck,  sopor,  convulsions,  involuntaries,  hypersesthesia,  and  ultimate 
coma,  can  be  correctly  interpreted  only  after  a  blood  examination. 
Delirium  ma"y  be  the  main  symptom,  and  may  appear  as  a  mania, 
as  fixed  ideas,  hallucinations,  or  as  melancholia.  The  rare  convulsive 
type  may  be  (a)  generalized,  and  may  simulate  tetanus,  hysteria, 
uraemia,  or  epilepsy  especially  in  children,  or  (b)  localized,  with  such 
symptoms  as  contractions,  trismus,  eye  deviations,  or  opisthotonos. 
The  paralytic  form  is  the  least  frequent  type.  Hemiplegia  with  aphasia 
is  more  common  than  monoplegia,  focal  paralysis,  or  the  bulbar 
form. 

3.  The  algid  'pernicious  type  occurs  with  cyanosis,  collapse,  Hippo- 
cratic  expression,  and  marked  alimentary  symptoms,  early  death  being 
the  rule. 

4.  The  pernicious  g astro-intestinal  variety  is  most  frequent  next  to 
the  cerebral  type,  and  occurs  with  vomiting,  pain,  epigastric  distress, 
cardialgia,  icterus,  and  dysenteric  manifestations.  In  a  soldier  from 
Cuba,  the  author  observed  profuse  hemorrhages  from  the  bowel.  A 
prompt  response  to  quinine  followed  the  detection  of  the  sestivo- 
autumnal  plasmodium. 

5.  The  pernicious  biliary  fever  ("jungle  fever")  occurs  with  vomit- 
ing, polycholia,  icterus,  nervous  symptoms,  hemorrhages,  adynamia, 
oedema,  and  dark  albuminous  urine.  The  course  is  usually  ten  to 
twelve  days,  but  even  after  the  administration  of  quinine  this  type 
may  be  lethal.  The  blood  examination  differentiates  it  from  yellow 
fever. 

6.  The  hemorrhagic  types  resemble  Werlhoff's  disease,  and  scurvy. 

7.  The  febris  biliaris  hoemoglobinurica  ("black- water  fever")  occurs 
in  South  America,  in  Africa,  and  in  our  Southern  States.  The  factors 
in  its  production  are  syphilis,  alcoholism,  repeated  malarial  attacks, 
exposure  to  changes  in  climate,  undue  exertion,  and  cold,  as  well  as 
local  influences,  and  in  some  instances  the  use  of  quinine.  Stephens 
(1903)  in  95  cases  found  the  parasite  in  96  per  cent,  before,  and  in  62 
per  cent,  at  the  onset  of  the  attack.  The  etiological  role  of  quinine  is 
questioned,  but  some  other  factor  is  apparently  more  potent.  The 
cardinal  symptoms  of  this  type  are  (a)  hsemoglobinuria;  the  urine  is 
always  albuminous,  neutral,  or  alkaline,  in  reaction;  hsemoglobin  is 
detected  only  after  the  destruction  of  at  least  one-sixth  of  the  circu- 
lating red  blood  corpuscles;  (b)  icterus,  invariable  except  in  the  mildest 
cases;  (c)  irregular  fever;  (d)  the  detection  of  the  plasmodia.  The 
mortality  (40  to  50  per  cent,  of  the  cases)  is  due  to  syncope,  hemorrhages, 
anuria,  and  coma. 

Diagnosis. — 1.  From  Symptoms. — A  probable  diagnosis  can  often 
be  made,  as,  for  instance,  from  typical  intermittent  fever  which  occurs 
early  in  the  day  and  is  distinct  from  the  vesperal  hectic  or  septic  fever. 
The  three  elements  of  the  paroxysm  are  most  marked  in  the  benign 
malaria.  In  the  sestivo-autumnal  form  the  chills  may  often  be  absent. 
Splenic    enlargement,  pain,  and  herpes,  are  always    suggestive,  but 


126  THE  SPECIFIC  IXFECTIOXS 

they  also  occur  frequently  in  ephemeral  fevers,  acute  gastritis,  pneu- 
monia, meningitis,  rheumatism,  and  influenza,  and  more  rarely  in 
typhoid,  tuberculosis,  and  tuberculous  meningitis.  Much  emphasis 
was  once  placed  on  various  intermittent  manifestations,  such  as  neu- 
ralgia, vertigo,  herpes  zoster,  and  alimentary  and  respiratory  catarrh. 
To-day  equal  skepticism  is  properly  entertained  in  regard  to  their 
malarial  origin. 

2.  The  Diagnosis  ex  Juvantibus. — Laveran  excluded  malaria, 
when  the  fever  persisted  for  more  than  four  days,  with  the  daily  ad- 
ministration of  20  to  .30  grains  of  quinine.  In  tropical  forms  more 
quinine  may  be  necessary  for  this  purpose.  It  must  be  remembered, 
however,  that  other  diseases  than  malaria  may  subside  under  the  ad- 
ministration of  quinine. 

3.  The  Plasmodium. — Mistakes  in  interpretation  are  possible. 
The  Plasmodium  may  be  mistaken  for  vacuoles  resulting  from  mechan- 
ical injury-  to  the  red  cells;  it  may  be  mistaken  for  particles  of  im- 
mersion oil  which  may  reach  the  specimen;  or  for  retraction  of  the 
heemoglobin,  which  may  show  the  stroma  of  the  corpuscle,  and  for  poi- 
kilocytosis.  Possibly  less  mistakes  are  made  when  the  inerperienced 
observer  examines  the  fresh  blood.  The  plasmodium  may  also  be  con- 
fused with  swarming  particles  from  the  red  blood-cells,  or  \\*ith  blood 
plates  which  are  sometimes  mistaken  for  spores.  The  differentiation 
from  these  is  easily  made  in  the  stained  specimen.  Leukocytes  con- 
taining pigment  are  distinguished  by  their  large  nucleus  and  by  their 
amceboid  movement,  the  latter  of  which  is  lacking  in  plasmodia  suflB- 
ciently  large  to  cause  confusion. 

Positive  Findings. — The  malarial  parasite  is  found  in  the  blood 
of  malarial  patients  only.  Osier  found  them  in  every  instance,  in 
.531  cases.  It  is  usually  stated  that  they  occur  in  largest  numbers 
before  or  at  the  time  of  the  parox^'sm,  though  it  must  be  admitted 
that  the  first  examinations  in  early  fever  are  often  negative.  Pre\"ious 
administration  of  quinine  may  render  the  findings  obscure.  INIelan- 
eemia  is  practically  pathognomonic.  Pigment  lying  free  in  the  plasma 
is  of  no  importance,  for  even  the  greatest  care  will  not  eliminate  the 
possibility  of  contamination. 

Negative  Fixdixgs. — These  are  of  relative  value  only,  and  depend 
upon  the  skill  of  the  observer,  and  the  time  of  the  examination.  In 
Baccelli's  series  there  were  negative  findings  in  only  2  percent,  of  the 
cases.  If  Plasmodia  are  not  foimd  in  the  circulating  blood,  the  spleen 
may  be  punctured— a  proceeding,  which  is  not  without  danger.  Ste- 
vens regards  an  increase  of  the  large  mononuclears  to  20  per  cent, 
as  a  safe  sign. 

Differential  Diagnosis. — 1.  From  typhoid  fever  (see  Perxicious 
Malaria  axd  Typhoid). 

2.  In  sepsis  (see  table  under  typhoid),  pytemia,  ulcerative  endo- 
carditis, liver  abscess,  septicopyaemia,  hectic  pulmonary  phthisis,  sup- 
puration in  the  intestinal  and  urinary  tracts,  and  irregular  fever,  may 
be  confounded  with  malaria.     However,  we  find  in  malaria  the  plas- 


MALARIA  127 

modium,  melansemia,  response  to  quinine,  and  absence  of  leukocytosis; 
whereas  in  sepsis,  leukocytosis,  positive  blood  cultures,  and  septic 
localizations,  are  very  frequent. 

3.  Pneumonia  with  remittent  curve,  irregular  grippal  temperature, 
and  hysterical  fever;  gastro-intestinal  catarrh;  Malta  fever;  recurrent 
fever;  miliary  tuberculosis;  fever  in  malignant  new  growths  and 
especially  in  sarcomatosis ;  filarial  infection;  pernicious  anaemia; 
splenic  anaemia;  leukaemia;  pseudoleukaemia;  Weil's  disease;  and 
acute  febrile  jaundice,  may  be  confused  with  malaria,  if  careful  and 
repeated  blood  examinations  are  not  made.  In  Weil's  disease,  mus- 
cular pains,  especially  in  the  calves,  and  decolorization  of  the  stools, 
which  are  usually  polycholic  in  malaria,  are  suggestive.  Pernicious 
malaria  {v.  s.)  may  superficially  simulate  apoplexy,  sunstroke,  menin- 
gitis, cholera,  dysentery,  or  purpura. 

Prognosis. — The  degree  of  infection,  type  of  parasite,  reinfection, 
health  and  habits  of  the  individual,  and  antecedent  renal  or  cardiac 
disease,  are  the  most  important  considerations.  The  prognosis  must 
be  conservative  in  pernicious  and  cachectic  forms.  In  Italy  the  yearly 
death-rate  is  54  per  1,000,  and  the  French  lost  6,000  soldiers  in  Mada- 
gascar in  three  months.  On  the  other  hand,  fully  20  per  cent,  recover 
when  given  rest  in  bed  and  a  full  diet,  as  is  often  shown  in  cases 
which  are  treated  with  placebos,  and  saved  for  clinical  demonstrations. 
Spontaneous  recovery  is  not  yet  fully  understood.  The  factors  are 
the  phagocytes  in  the  spleen,  in  the  bone-marrow,  and,  to  a  less  de- 
gree, in  the  endothelium  of  the  splenic,  hepatic,  and  cerebral  vessels, 
Kupfer's  cells  in  the  liver,  and  possibly  the  leukocytes  which  are 
usually  decreased  in  other  than  pernicious  types. 

Treatment. — 1.  Prophylaxis. — Prophylaxis  now  embraces  more 
than  personal  prevention.  In  Italy  and  other  countries  it  is  a  national 
economic  problem.  Drainage,  the  filling  in  of  stagnant  pools  and 
swamps,  and  the  planting  of  pines,  eucalyptus  trees  and  sugar-cane, 
have  proved  most  successful,  though  sometimes  accomplished  at  great 
sacrifice  of  life.  The  drainage  of  the  great  Bordeaux  swamp  in  1805 
cost  3,000  lives.  In  digging  canals  or  building  roads,  immunes  should 
be  employed,  but  whites  may  work  successfully  if  they  avoid  exces- 
sive labor  in  the  hot  sun,  alcohol,  and  exposure  to  the  night  air.  Noc- 
turnal infection  by  mosquitoes  may  be  minimized  by  using  nettings 
on  the  doors  and  windows.  The  pools  where  the  insects  breed  should 
be  filled  in,  or  covered  with  crude  petroleum  to  kill  the  larvae.  The 
stocking  of  semistagnant  streams  with  fish  is  also  of  value.  The 
prophylactic  use  of  quinine  in  daily  doses  of  5  to  10  grains  is  effective. 

2.  Specific  Treatment. — Quinine  is  one  of  our  few  specifics.  It 
has  been  used  for  ages  in  Peru.  The  plant  was  known  as  the  "tree 
of  health"  to  Pizarro  in  the  conquest  of  Peru.  Quinine  was  intro- 
duced over  one  hundred  years  later  into  Europe  by  del  Vego  (1640). 
It  acts  on  the  malarial  organism  while  it  is  developing  (Marchiafava 
andBignami);  when  the  parasite  has  transformed  all  the  haemoglobin  into 
melanin,  and  segmentation  begins,  quinine  is  inefi^ectual.     All  such 


128  THE  SPECIFIC  INFECTIONS 

malarial  manifestations  as  fever,  acute  splenic  tumor,  and  ansemia, 
are  cured  by  quinine  except  in  pernicious  forms.  It  acts  as  a 
direct  protozoan  poison.  Binz  thought  it  entered  into  such  close 
union  with  the  haemoglobin  that  the  parasite  was  suffocated.  Just  as 
syphilitics  tolerate  much  mercury  and  iodide,  so  malarial  subjects 
escape  many  or  all  of  the  symptoms  of  cinchonism,  such  as  tinnitus 
aurium,  cephalic  distention,  and  slight  deafness  resulting  from  thera- 
peutic doses  (gr.  x.);  deafness,  disordered  vision,  flushed  face,  and 
cerebral  congestion  (sometimes  relieved  by  epistaxis),  vomiting,  stag- 
gering, giddiness,  tremor,  and  twitchings,  resulting  from  larger  doses, 
and  stupor,  delirium,  cardiac  oppression,  complete  deafness,  and  amau- 
rosis, dilated  pupils,  convulsions,  paralysis,  heemoglobinuria,  dyspnoea, 
coma,  weak  heart,  or  hemorrhages  resulting  from  ordinarily  toxic 
doses. 

Administration. — If  idiosyncrasy  exists,  cinchonism  is  lessened  by 
ext.  ergotae  fl.  5ss,  or,  better,  by  sodium  bromide  3ss.  Its  antiperiodic 
action  is  enhanced  by  combining  it  with  opium  gr.  ss.  Such  laxatives 
as  cream  of  tartar  and  calomel  are  unnecessary.  Pills  are  often  in- 
soluble, and  the  dose  is  therefore  given  in  capsules,  in  'powders  in- 
volved in  starch  wafers,  or  with  one  drop  of  sulphuric  acid  to  each 
grain  of  the  sulphate.  Chloroform,  coffee,  cognac,  and  extract  of  gly- 
cyrrhiza,  but  poorly  disguise  its  bitterness.  If  the  stomach  rebels,  a 
warm-water  injection  with  equal  parts  of  quinine  and  tinct.  opii  de- 
odorat.  may  be  used.  In  severe  cases  double  the  ordinary  dose  of  the 
bimuriate  of  quinine  and  urea  (Quininse  carbamas  bichlorida)  should 
be  used  hypodermatically,  but,  though  every  care  be  taken,  abscesses 
develop  too  often.  In  comatose  and  other  pernicious  types,  Baccelli 
injects  quinine  intravenously  (sterilized  solution  of  sodium  chloride, 
quinine  muriate,  and  water,  in  the  proportion  of  1,  10,  and  100,  parts 
respectively) . 

Time  of  Exhibition. — If  the  fever  recurs  regularly,  grs.  x.  to  xx. 
should  be  given  in  the  interval  to  act  on  the  growing  young  forms  in 
the  red  cells,  and  this  should  be  repeated  in  three  to  five  hours  before 
the  paroxysm,  in  order  to  have  the  drug  in  the  circulation  when  the 
spores  are  scattered  (Torti  and  Golgi).  If  the  fever  is  continuous  or 
sub-continuous,  or  if  the  type  is  severe,  doses  of  the  same  amount 
should  be  given  daily.  Large  doses  are  recommended  because  they  are 
more  effectual,  the  symptoms  are  frequently  severe,  and  small  doses 
are  quite  useless  and  sometimes  only  serve  to  aggravate  existing  malaria 
and  develop  quiescent  forms  (Steudel-Kuchel).  Opinions  vary  as  to 
the  treatment  of  black-water  fever;  one  view  maintains  that  it  is 
caused  by  the  parasite,  and  another  that  quinine  is  its  cause.  Quinine, 
however,  should  be  given  only  when  plasmodia  are  found,  and  should 
be  withheld  after  they  disappear. 

3.  Symptomatic  Treatment  of  the  Paroxysm. — During  the  vaso- 
constriction of  the  chill,  morphia  gr.  \  and  nitroglycerine  gr.  bo, 
hypodermatically,  and  spirits  of  chloroform  5  j  •  j  in  hot  whiskey  and  water 
afford  great  relief.     The  fever  is  short-lived  and  requires  little  inter- 


SEPTIC  AFFECTIONS  129 

ference  other  than  the  ice-bag  or  cap,  and  cool  sponging.  The  sweat- 
ing requires  no  treatment.  A  weak  heart  should  be  supported  by 
morphine,  strychnine  and  camphor  by  the  hypodermic  needle,  heat 
and  saline  eriemata  or  infusions. 

In  chronic  malaria,  iron  and  full  increasing  doses  of  arsenic  should 
be  combined  with  quinine.  Arsenic  is  said  by  Durham  to  act  on  the 
gametocytes. 

The  contraindications  to  the  use  of  quinine  usually  listed,  (gastro- 
intestinal inflammation  or  irritation,  middle-ear,  genito-urinary,^  and 
cerebral  inflammation,)  are  negligible  in  the  treatment  of  malaria. 


SEPTIC  AFFECTIONS. 

Synonyms. — Saprsemia,  septicaemia  (sepsis),  pyaemia,  septicopyae- 
mia. 

Definition. — Intoxications  are  the  result  of  the  absorption  of  sub- 
stances which  are  elaborated  for  the  most  part  by  microorganisms, 
but  possibly  also  to  a  less  degree  by  living  cells.  Infections  are  always 
due  to  microorganisms.  Saprcemia  is  the  absorption  of  putrescent 
substances  but  not  of  the  germs  which  develop  them.  SepticoBmia 
(sepsis)  is  the  presence  in  the  blood  of  microorganisms  (bacterisemia), 
which  are  usually  pyogenic,  without  haematogenous  suppuration  or 
metastasis.  Pyoemia  is  infection,  caused  by  microorganisms,  which 
leads  to  haematogenous  metastasis  or  suppuration.  Septicopyaemia  is 
coexistent  septicaemia  (bacteriaemia)  and  pyaemia  (metastatic  suppu- 
ration). 

General  Groups. — 1.  Some  infections — such  as  carbuncles,  puer- 
peral parametritis,  diphtheria,  and  tetanus — are  wholly  local  so  far 
as  the  causal  microbe  is  concerned,  and  their  symptoms  are  due  to 
absorbed  toxins,  toxinaemia  (toxaemia). 

2.  Other  infections  —  such  as  typhoid,  pneumonia,  carbuncles, 
puerperal  sepsis,  anthrax,  and  gonorrhoea,  which  cause  bactericemia 
or  septicaemia — at  first  local,  may  become  general  when  their  germs 
enter  the  blood.  Some  of  these  infections,  especially  typhoid  and 
pneumonia,  which  were  previously  considered  local,  are  always  general. 

3.  Still  other  infections,  often  resulting  from  the  same  germs, 
cause  metastatic  suppuration  (pycemia).  Among  these  are  multiple 
abscesses  from  carbuncle,  puerperal  fever,  typhoid  osteomyelitis, 
pneumococcic  arthritis,  and  gonorrhoeal  endocarditis.  It  is  frequently 
difficult  or  impossible  to  preserve  clinically  these  types  which  so  often 
blend;  (a)  what  is  seemingly  toxaemia  may  prove  bacteriaemia  on 
examination  of  the  blood;  (b)  apparently  pure  bacteriaemia  may 
prove  pyaemia  at  necropsy;  (c)  all  three  grades  may  occur  successively; 
(d)  the  primary  infection — e.  g.,  with  scarlatina,  tuberculosis,  and 
diphtheria — whether  local  or  general,  may  be  complicated  by  second- 
ary, or  mixed  infection,  especially  by  the  streptococcus;  (e)  again 
the  symptoms  vary,  first  with  the  variety  of  microbe  and  its  virulence; 


130  THE  SPECIFIC  INFECTIONS 

second,  with  its  localization  (in  the  throat,  lung,  pelvis,  etc.) ;  and  third, 
with  the  physiological  resistance.  Subjects  of  malignancy,  cardiac, 
vascular,  nephritic,  cirrhotic,  and  other  disease,  readily  succumb  to 
an  ultimate  sepsis  to  which  the  name  of  terminal  infection  is  applied. 
For  these  reasons  we  will  discuss  septic  infections  as  a  whole,  and  indi- 
cate such  special  etiological  and  clinical  variations  as  seem  necessary. 

Etiology  of  Septicopyaemia. — The  causal  organisms  of  septic  in- 
fections are  numerous.  The  most  common  are  the  pyogenic  cocci, 
the  pneumococcus  and  the  colon  bacillus;  less  frequent  are  the  gono- 
coccus,  anthrax  bacillus,  typhoid  bacillus,  Friedlander's  pneumo- 
bacillus,  meningococcus,  bacillus  pyocyaneus,  influenza  bacillus,  gas 
bacilli  (Fraenkel's  bacillus  phlegmonesemphysematosse;  bacillus  aerog- 
enes  encapsulatus),  and  possibly  the  micrococcus  tetragenus,  the 
spirilli  and  bacilli  of  Vincent,  and  the  proteus  group.  Although  puer- 
peral fever,  primary  wound  fever  and  severe  late  pysemic  infection 
were  known  to  Hippocrates,  and  also  to  Willis  (1682),  Semmelweiss 
(1847),  and  others,  it  was  reserved  for  the  bacteriological  era,  build- 
ing on  Virchow's  work,  to  clarify  this  group  of  affections.  Though 
Wunderlich  (1847)  spoke  of  spontaneous  pyaemia,  and  Leube  (1878) 
coined  the  term  cryptogenetic  (occult)  septicopysemia,  careful  clinical 
and  necropsy  investigations  have  gradually  revealed  the  atrium  of 
infection.  Although  some  cases  are  still  obscure,  the  source  of  infec- 
tion is  now  found  in  90  to  94  per  cent,  of  cases;  (1)  skin  lesions,  such 
as  acne,  furuncles,  felons,  and  bites,  (staphylococcus  most  frequent; 
less  often  streptococcus);  (2)  throat  (streptococcus);  (3)  nose  (not 
frequent  in  sepsis,  though  probably  the  atrium  in  meningitis  for  the 
meningococcus  and  pneumococcus);  (4)  ear  (pneumococcus  and 
streptococcus);  (5)  lungs  (pneumococcus);  (6)  intestines  and  hile 
tracts  (colon  bacillus;  typhoid  bacillus,  gall-stones  with  infection,  ap- 
pendicitis, dysenteric  ulcers);  (7)  urinary  tract  (pyelitis  from  colon 
bacillus;  vesical  and  urethral  infections  chiefly  by  the  staphylococcus, 
far  less  by  the  streptococcus  and  gonococcus) ;  (8)  vagina  and  uterus 
(chiefly  streptococcus) . 

General  Pathology  and  Symptomatology. — {A.)  General  Toxsemic 
Symptoms. — 1.  Fever. — Fever  is  usually  the  first  clinical  symptom 
and  occurs  more  often  abruptly  than  gradually.  The  virulence  of 
the  germ  and  its  toxin  (rather  than  its  variety)  governs  the  intensity 
of  the  toxsemic  symptoms.  In  general  the  fever  tends  to  be  remittent 
or  intermittent.  Lenhartz,  in  his  work  on  septic  infections,  concludes 
that  (a)  the  streptococcus  infections  usually  produce  irregular  inter- 
mittent fever  with  moderate  variations  (sometimes  remittent  or  in 
severe  cases  continuous  fever);  (b)  the  staphylococcus  usually  causes 
weakly  remittent  or  continuous  fever;  (c)  the  pneumococcus  produces 
remittent  or  continuous  fever;  {d)  the  colon  bacillus  and  gonococcus 
cause  intermittent  fever  with  great  variations.  Fever  may  be  absent 
in  very  severe  forms,  especially  before  death. 

2.  Chills. — Chills  occur  both  in  septiciemic  and  in  pya?mic  forms, 
are  usually  irregular,  but  may  occur  daily  or  two  or  more  times  a  day. 


SEPTIC  AFFECTIONS  131 

3.  Nervous  Toxaemia. — Nervous  toxaemia  may  be  pronounced.  It 
may  appear  as  unrest,  delirium,  sopor,  convulsions,  dry  tongue,  and 
the  status  typhosus,  or  it  may  resemble  meningitis.  The  brain  may 
be  clear,  as  it' is  in  many  puerperal  infections. 

4.  Vasomotor  and  cardiac  weakness,  with  increased,  often  irregular, 
pulse,  may  be  present. 

5.  Increased  respiration  and  bronchitis  may  be  noted. 

6.  Albuminuria  and  acute  nephritis  are  common. 

7.  Septic  diarrhoea,  in  which  the  dark  movements  number  six  to 
ten  daily,  may  be  observed. 

8.  Acute  splenic  tumor  is  present. 

9.  Anatomically  we  find  cloudy  swelling  of  the  heart,  liver,  and 
kidneys;  a  vascular,  soft,  moderately  swollen  spleen;  often  acute 
nephritis;  hemorrhages  into  the  skin,  retina,  and  mucous  and  serous 
membranes,  with  or  without  bacteria;  lung  oedema,  and,  where  there 
is  marked  anaemia,  fatty  heart,  hemorrhage  into  the  bone-marrow, 
and  increased  iron  deposit  in  the  liver. 

(B.)  Blood- Findings. — 1.  Bacterioemia  is  found  in  50  per  cent,  of 
the  cases  clinically,  and  in  95  per  cent,  at  autopsy  (Lenhartz).  Some 
circulating  bacteria  are  apparently  killed  by  the  blood.  In  most 
streptococcic  and  staphylococcic  infections,  these  organisms  are  found 
in  the  blood. 

2.  Polymorphonuclear  leukocytosis  is  frequent,  though  not  invariable. 

3.  Ancemia — Marked  anaemia  is  usual,  and  sometimes  even  re- 
sembles the  pernicious  form. 

(C.)  Metastases. — They  are  apparent  clinically,  or  first  found  at 
necropsy.  Metastases  occur  through  the  veins  or  lymph-vessels. 
Thrombo-phlebitis  develops  at  the  seat  of  primary  infection,  and  dis- 
integrated thrombi,  containing  bacteria,  escape  into  the  venous  cir- 
culation. They  lodge  in  the  lungs  or,  passing  them,  reach  the  left 
heart  and  arterial  system.  Purulent  lymphangitis  may,  in  the  same 
way,  cause  metastatic  suppuration.  If  "end  arteries"  are  plugged, 
infarcts  result;  if  the  arteries  are  not  terminal,  small  foci  develop. 
Not  all  the  infarcts  suppurate.  This  difference  is  explained  by  the 
fact  that  the  germs  found  in  them  are  less  virulent,  or  that  the  embolic 
material  is  bland  or  free  of  microbes.  Foci  occur  in  organs  in  which 
there  are  end  arteries  and  in  which  the  circulation  is  slow,  especially, 
therefore,  in  the  liver,  kidney,  and  spleen.  (1)  Cerebral  metastasis  may 
cause  meningitis,  brain  abscess,  or  extensive  softening  (encephalo- 
malacia  with  aphasia  and  hemiplegia).  (2)  Cardiac  metastasis  de- 
velops in  21  (even  63)  per  cent,  of  the  metastatic  group;  endocarditis 
is  localized  chiefly  on  the  mitral  (62  per  cent.)  and  aortic  (22  per  cent.) 
valves;  it  is  attended  by  a  heart  murmur  in  60  per  cent.,  and  often  by 
pericarditis;  the  heart  muscle  is  sometimes  the  seat  of  abscesses.  (3) 
Lung  localization  may  cause  multiple  or  single  abscesses,  and  often 
sero-fibrinous  or  purulent  pleurisy.  4)  Renal  localization  may  result 
in  nephritis  or  suppurating  infarcts,  with  albuminuria,  cylindruria, 
pyuria  and  bacteriuria.     (5)  Splenic  localization  usually  results  in  en- 


132  THE  SPECIFIC  INFECTIONS 

largement,  frequently  in  pain,  and  rarely  in  perisplenic  friction.  (6) 
Localization  in  the  bones,  may  cause  early  fugitive  bone  pain,  or 
later,  fixed  osteomyelitic  tenderness  over  one  or  more  bones,  with  in- 
flammatory signs;  in  the  joints  (as  in  the  post-febrile  arthritides),  it 
may  cause  simple  pain,  or  serous  or  purulent  synovitis;  in  the  muscles 
it  may  produce  abscesses,  purulent  oedema,  or  Wagner's  polymyositis. 
(7)  Localization  in  the  skin  may  cause  scarlatiniform,  morbilliform, 
roseolous  or  urticarial  eruptions,  resembling  the  antitoxin  rashes. 
Ecchymoses  occur  in  50  per  cent,  of  fatal  cases;  they  are  usually  late, 
often  symmetrical,  and  sometimes  occur  on  the  tip  of  the  nose,  fin- 
gers, toes,  or  ears.  Pustules  and  vesicles  are  less  frequent;  herpes 
occasionally  develops.  (8)  Localization  in  the  eyes  may  produce 
retinal  ecchymoses  (in  at  least  33  per  cent.),  which  were  first  described 
by  Litten.  They  are  round,  or  irregular,  or  appear  in  streaks;  they 
often  have  white  centers  (which  are  usually  small),  range  in  number 
from  three  to  six,  and  appear  late  or  just  before  death;  the  white 
spots  of  Roth  (8  percent.)  were  once  considered  inflammatory,  and  are 
still  unexplained.  Least  frequently  eye  localization  results  in  pan- 
ophthalmitis, of  which  33  per  cent,  is  due  to  ulcerative  endocarditis. 
(9)  The  peritoneum  is  chiefly  involved  in  puerperal  forms.  (10)  The 
slightly  enlarged  liver  is  more  often  due  to  toxic  parenchymatous 
degeneration  and  cardiac  weakness  than  to  abscess,  which  occurs 
(Baerensprung)  in  only  15  per  cent,  of  cases  of  surgical  septicopysemia. 
Intestinal  infarction  is  rare. 

Special  Symptomatology. — This  may  be  considered  etiologically  or 
topographically.  To  avoid  repetition,  only  the  leading  characteristics 
are  presented. 

(A).  Etiological. — 1.  Streptococcic  infection  is  the  most  frequent 
primary  and  secondary  septic  infection.  It  constitutes  66  per  cent, 
of  all  forms  (Mau),  and  is  said  to  enter  the  blood  before  death  in  33 
per  cent,  of  all  fatal  diseases.  Its  atrium  is  most  often  the  throat 
and  (in  the  female)  the  genitalia;  it  enters  the  veins  (in  puerperal 
infection)  more  often  than  the  lymphatics  (erysipelas  and  puerperal 
sepsis);  it  more  often  produces  septicsemia  (65  per  cent.)  than  pyaemia 
(35  per  cent.);  the  lungs  are  usually  unaffected;  endocarditis  occurs 
in  7  per  cent. ;  its  course  is  chiefly  acute,  though  sometimes  subacute 
(ulcerative  endocarditis). 

2.  Staphylococcic  infection  usually  enters  by  the  skin  and  the  fu- 
runcle is  the  typical  primary  local  lesion.  On  the  eye-lids,  nose,  or  lips, 
this  lesion  is  dangerous  because  infection  may  reach  the  facial  vein, 
then  the  ophthalmic  vein  and  the  cavernous  sinus.  Furuncle  of  the  neck 
may  reach  the  transverse  sinus.  Infections  of  the  skin  are  the  most 
frequent  cause  of  osteomyelitis.  Meningitis  is  known  to  have  followed 
a  felon.  The  infection  enters  through  the  throat,  first  with  difficulty 
but  then  with  increased  malignancy  (Kocher  and  Tavel).  It  travels 
by  the  veins  or  lymphatics;  it  produces  metastasis  in  95  per  cent, 
and  endocarditis  in  6  per  cent,  of  the  cases.  Abscesses  of  the  lung 
and  kidneys  are  very  frequent;    the  coccus  is  found  very  often  in  the 


SEPTIC  AFFECTIONS  133 

blood  and  urine.     Pustular  skin  eruptions  are  frequent.     Staphylo- 
coccic infection  is  usually  acute. 

3.  Pneumococcic  Infections. — In  all  cases  of  pneumonia  (q.  v.) 
the  pneumococcus  appears  in  the  blood  (pneumohaemia).  In  sepsis 
following  pneumonia,  it  is  assumed  to  enter  the  blood  through  the 
pulmonary  veins.  Infection  through  the  ear  or  bile-tracts  is  less  fre- 
quent; metastases  occur  in  25  per  cent,  and  endocarditis  in  6  per 
cent.  Twenty-nine  cases  of  meningitis  were  first  reported  by  Nau- 
werk  (1881),  but  it  is  yet  unknown  why  lung  infections  so  frequently 
cause  brain  metastases.  The  pneumococcus  alone  may  produce  pus 
in  the  joints,  skin,  thyroid,  and  serous  membranes.  Netter's  state- 
ment that  pneumococcic  sepsis  is  less  severe  than  other  types  may 
be  true  in  some  cases,  but  it  is  often  malignant.  It  may  be  associated 
with  the  pyogenic  cocci,  or  saprophytes. 

4.  Colon  sepsis,  which  is  less  frequent,  may  follow  wounds,  suppu- 
ration in  cholelithiasis,  cystitis,  pyelitis,  or  intestinal  obstruction. 
Endocarditis  is  exceptional,  and  sepsis  (78  per  cent.)  is  more  common 
than  metastasis  (22  per  cent.).  As  the  intestine  is  its  normal  host,  it 
is  sometimes  regarded  as  an  autoinfection. 

5.  Gonococcic  injection  is  rather  more  benign  than  the  other  types. 
There  may  be  gonorrhoeal  endocarditis  (Bordoni,  Uffreduzzi)  (of  which 
Loeb  has  collected  62  cases),  pericarditis,  and  pleuritis,  or  the  more 
common  gonorrhoeal  "rheumatism."  Thayer  found  the  gonococcus 
in  the  blood  {v.  Gonorrhoeal  Infection). 

Other  forms  are  less  frequent.  These  are  the  typhoid  sepsis  (typhoid 
suppuration  in  the  pleura,  thyroid,  bones,  meninges,  muscles,  ear,  and 
parotids),  sepsis  from  Friedlander's  pneumobacillus,and  the  meningo- 
coccus. Pyocyaneus  sepsis  is  attended  by  irregular  or  continuous 
fever,  rapid  pulse,  vomiting,  diarrhoea,  and  a  hemorrhagic  diathesis. 

{B).  Topographical. — (1)  Ulcerative  endocarditis;  (2)  cholangitic 
sepsis;  (3)  otogenous  sepsis  (v.  Sinus  Thrombosis,  Meningitis,  Brain 
Abscess)  will  be  considered  elsewhere.  The  two  following  surgical 
or  obstetrical  localizations  are  of  importance  to  the  general  prac- 
titioner and  internalist. 

(4.)  Osteomyelitis  is  either  a  solitary  metastasis  or  part  of  a  general- 
ized sepsis.  Even  when  a  solitary  bone  is  involved,  the  blood  often 
contains  the  causal  microorganism.  It  is  due  to  the  staphylococcus 
chiefly,  then  to  mixed  infection  with  the  streptococcus,  which  is  found 
in  all  fatal  cases,  or  with  the  pneumococcus,  and  but  rarely  to  the 
typhoid  organism.  Fraenkel  has  recently  found  that  in  most  autopsies 
on  typhoid  and  pneumonia  cases,  their  causal  bacteria  are  present 
in  the  bone  marrow.  Acute  forms  of  osteomyelitis  are  most  frequent 
in  the  growing  bones  of  children.  Trauma  is  a  promoting  element, 
and  the  onset  occurs  with  chill,  fever,  vomiting,  diarrhoea,  head- 
ache, and  bone  pain.  It  is  usually  first  seen  (and  often  mistaken) 
by  the  general  practitioner.  Chronic  forms  are  quite  infrequent, 
but  Kocher,  Jordan,  and  others,  have  described  cases,  which,  lasting- 
one  year  or  more  (even  thirty),  may  simulate  sarcoma,  or  syphilis. 


134  THE  SPECIFIC  AFFECTIONS 

(5.)  Puerperal  fever  is  caused  by  the  streptococcus  (95  per  cent.)  or 
by  the  bacterium  coli,  staphylococcus,  gonococcus,  proteus,  or  anae- 
robic organisms.  It  is  still  disputed  whether  streptococci  normally 
reside  in  the  healthy  vagina  and  whether  autoinfection  may  occur 
from  this  source,  but  some  cases  seem  clearly  proved.  It  is  sporadic 
or  epidemic;  it  is  promoted  by  anaemia;  some  women,  however, 
seem  immune,  especially  those  in  the  lower  classes  (De  Lee).  Its 
varieties  are  (a)  toxcemia,  or  saprsemia.  The  symptoms  are  caused 
by  toxins  or  putrid  decomposition  products  respectively.  Even  in 
cases  apparently  of  this  group,  bacterisemia  may  be  found  (colon  bacil- 
lus, saprophytes,  or  streptococcus).  The  rare  puerperal  tetanus  is 
wholly  toxsemic.  (6)  Lymphangitic  form — Lymphangitis,  from  in- 
fected vaginal  or  cervical  wounds,  may  cause  moderate  parametritis, 
which  is  usually  a  benign  local  infection.  The  usual  forms  are:  1. 
General  septicaemia,  from  vaginal  or  cervical  wounds,  which  follows 
the  lymph-vessels  through  the  cellular  pelvic  tissue  to  the  general 
circulation.  The  symptoms  usually  appear  within  a  day  or  so  after 
delivery.  Death  may  result  (in  two  to  fourteen  days),  or  encapsulation 
(the  important  prognostic  element)  may  last  over  a  month  with  mas- 
sive cellulitis.  2.  Lymphangitic  peritonitis  is  more  frequent  (about  20 
per  cent,  of  fatal  cases).  It  begins  three  or  four  days  after  delivery  and 
is  usually  generalized  and  suppurative.  Infection  may  travel  directly 
to  the  peritoneum  or,  more  often,  by  retrograde  lymphatic  routes.  This 
form  includes  Virchow's  "  erysipelas  grave  internum  puerperale."  It  is 
more  common  in  labor  at  term  than  in  abortion.  The  symptoms  are 
chill,  fever,  tense  pulse,  vomiting,  peritoneal  pain,  distention,  and  often 
effusion,  and  diarrhoea.  In  many  apparently  purely  peritonitic  cases 
bacterisemia  is  found.  Early  death  is  the  rule,  commonly  in  five  to 
six  days,  but  encapsulation  is  possible.  3.  The  thrombophlebitic 
(pygemic)  type  occurs  in  50  per  cent,  of  fatal  cases.  It  usually  begins 
in  endometritic  ulceration,  diphtheria,  or  ichorous  inflammation,  in 
contradistinction  to  the  lymphangitic  form  of  vaginocervical  origin. 
Infective  thrombophlebitis  travels  (a)  from  the  upper  veins  by  way 
of  the  spermatic  veins,  of  which  the  right  empties  into  the  inferior 
cava  and  the  left  into  the  renal  vein;  the  phlebitis  may  actually  ex- 
tend into  the  vena  cava;  (b)  from  the  lower  plexus,  by  way  of  the 
uterine  veins  into  the  hypogastric  (less  often  the  obturator)  veins,  and 
thence  to  the  inferior  cava.  Bilateral  venous  thrombosis  is  common 
(25  to  66  per  cent.)  Metastases  are  common;  58  per  cent,  occurs 
ir  the  lungs,  25  per  cent,  in  the  kidneys,  20  per  cent,  in  the  joints  and 
muscles,  and  16  per  cent,  in  the  spleen.  Ulcerative  endocarditis, 
panophthalmitis,  and  suppurative  peritonitis,  may  be  present.  It  is 
unknown  why  the  brain  is  so  often  unaffected  in  this  form.  The 
course  may  be  stormy  from  predominating  toxaemia,  or  slower  with 
metastasis.  The  fever  is  irregular,  the  pulse  rapid,  the  chills 
severe,  the  ana?mia  marked,  and  bacteriaemia  is  present  (strepto- 
coccaemia  in  over  90  per  cent.). 


SEPTIC  AFFECTIONS  135 

Diagnosis. — The  differentiation  from  typhoid,  malaria,  and  miliary 
tuberculosis,  is  fully  considered  under  typhoid  fever.  In  typhoid,  the 
bacillsemia  (85  to  95  per  cent.)  and  the  Widal  test  (95  per  cent.)  are 
decisive.  In  septicaemia,  bacterisemia  is  present  in  50  per  cent,  of  the 
cases.  In  malaria,  the  plasmodium  is  absent  in  less  than  1  per  cent., 
and  quinine  is  successful  at  once.  In  miliary  tuberculosis,  the  choroidal 
tubercles  (possibly  confused  with  Roth's  white  spots),  and  tubercle 
bacilli  in  the  blood  are  the  only  positive  criteria,  though  unfortunately 
they  are  infrequent.  Retinal  hemorrhages  argue  for  septicopysemia. 
Septic  pseudorheumatism  rarely  needs  to  be  confused  with  true  multiple 
articular  rheumatism.  Bacterisemia,  or  organisms  in  the  fluid  of  the 
joints,  is  never  genuine  rheumatism.  Uraemia;  secondary  (terminal) 
infections  in  cardiac,  arterial,  renal,  and  hepatic  disease;  mixed  infec- 
tion in  tuberculosis;  fever  in  Hodgkin's  disease;  carcinosis;  or  sar- 
comatosis,  may  sometimes  cause  confusion. 

Prognosis.^ — The  prognosis  depends  upon  the  organism,  its  virulence 
and  dissemination,  the  patient's  physiological  resistance  (whence  the 
obviously  poor  outlook  in  terminal  infections),  and  finally  on  the  sur- 
gical accessibility  of  the  primary  lesion  or  metastatic  foci.  Only  17 
per  cent,  of  Lenhartz's  cases  with  bacteriaemia  recovered.  A  stormy 
onset  and  chills  are  ominous.  A  case  of  Lenhartz  with  empyema, 
lung  abscess,  panophthalmitis,  diffuse  venous  thrombosis,  and  multiple 
osteomyelitis,  recovered.  Puerperal  infections,  with  the  large  wound- 
surface  and  frequent  hemorrhages,  are  severe,  the  mortality  of  all 
forms  being  55  per  cent.,  and  of  severe  forms  65  per  cent.  (Cursch- 
mann).  The  streptococcus  has  been  regarded  with  particular  dread; 
however,  Bertelsmann  (1904)  states  that  the  prognosis  is  twice  as 
favorable  as  in  staphylococcic  invasion. 

Treatment. — Surgical  prophylaxis,  even  in  apparently  insignificant 
wounds,  and  obstetrical  asepsis,  are  important,  especially  in  subjects 
reduced  by  general  diseases.  Treatment  of  existing  sepsis  consists 
in  giving  the  largest  possible  amount  of  food  which  can  be  digested; 
in  free  administration  of  water~and-salt  solution  by  rectum  or  by 
transfusion,  in  order  to  flush  the  toxins  through  the  kidneys;  and  in 
the  free  use  of  alcohol,  given  as  it  is  in  typhoid  or  pneumonia,  but  in 
its  maximum  dosage  because  the  patient  exhibits  an  exceptional 
tolerance  to  the  drug  and  unquestionable  benefit  results.  The  treat- 
ment of  hypostasis,  diarrhoea,  vomiting,  and  chills,  is  symptomatic. 
The  temperature  is  seldom  influenced  by  drugs,  though  quinine  (see 
Pneumonia)  may  most  safely  be  given.  The  internal  use  of  germicides 
is  justly  abandoned.  We  have  not  observed  the  slightest  benefit  from 
Crede's  silver  ointment,  though  others  think  it  very  beneficial ;  Crede's 
collargol  has  been  used  with  benefit,  intravenously,  in  doses  of  one  to 
two  and  a  half  drams.  Nuclein  and  5j  to  5ij  of  fresh  brewers'  yeast 
are  also  advised.  The  use  of  Marmoreck's  antistreptococcic  serum 
has  given  no  essential  reduction  in  the  death-rate,  and  its  suggestive 
effects  in  isolated  cases  is  easily  misleading.  Lenhartz  has  used  a 
serum  from  the  blood  of  convalescents  from  septic  cases  with  some 


136  THE  SPECIFIC  IXFECTIOXS 

success.     Surgical  intervention  is  indicated  whenever  definite  accessi- 
ble foci  are  localized. 

PNEUMONIA. 

SynonsmiS. — Fibrinous  pneumonia,  croupous  pneumonia,  lobar 
pneumonia,  pleuropneumonia,  pneumonitis,  lung  fever. 

Definition. — An  acute  infectious  disease  caused  by  tlie  pneumo- 
coccus  (and  occasionally  by  other  bacteria),  self-limited  in  its  course, 
characterized  by  inflammation  of  the  lung  (filling  of  the  alveoli,  and 
often  of  the  bronchioles,  with  a  fibrinous  exudate),  by  involvement  of 
considerable  areas  (lobar  pneumonia),  by  toxaemia,  by  pneumococ- 
caemia  (pneumococci  in  the  blood),  and  by  solution  of  the  fever  by 
crisis.  It  is  not  uncommonly  complicated  by  secondary  infective  pro- 
cesses. 

Frequency. — Pneumonia  constitutes  6.5  per  cent,  of  all  internal 
diseases,  3  to  4  per  cent,  of  all  diseases,  6.6  per  cent,  of  all  deaths 
among  medical  cases  (Liebermeister),  and  8  per  cent,  of  all  deaths 
(E.  F.  Wells). 

That  it  is  a  specific  injection  is  proven  (1)  by  its  frequent  endemic, 
epidemic,  or  even  occasional  pandemic,  prevalence.  It  may  haunt 
certain  dwellings  or  break  out  in  hospitals,  asylums,  or  prisons;  (2) 
by  the  great  frequency  or  constancy  of  the  pneumococcus  in  the 
sputum,  blood,  lung,  and  secondary  metastases;  (3)  by  its  clinical 
course,  its  abrupt  onset  with  general  symptoms,  followed  by  local 
sio-ns,  toxsemia  and  typical  ending,  and  its  cyclical  self-limited  course. 

Bacteriology. — 1.  The  'pneumococcus  or  Diplococcus  pneumoniae 
(Plate  IV.),  was  first  recognized  by  Fraenkel  (1884)  and  Weichselbaum 
(1886),  though  it  was  seen  earlier  by  Sternberg, Pasteur,  Eberth,  Koch, 
Talamon,  Levden,  and  Guenther.  Fraenkel  and  Weichselbaum  first 
demonstrated  its  frequency  and  importance,  and  the  diplococcus  bears 
their  name.  It  is  an  elliptical,  lanceolate,  encapsulated  diplococcus; 
it  is  easilv  seen  in  cover  slips,  it  readily  stains  by  the  Gram  method, 
and  presents  many  cultural  variations.  Its  atrium  in  pneumonia  is  by 
wav  of  the  respiratory  tract,  although  in  sepsis  {q.  v.)  it  may  enter 
the  blood  bv  other  avenues.  From  the  lung  it  may  spread,  chiefly 
through  the  bloodvessels  (as  it  did  in  Fraenkel's  case,  where  it  was 
traced  from  a  pneumonic  focus  through  a  thrombophlebitic  pulmonary 
vein)  to  the  blood  and  to  other  viscera.  "Weichselbaum  believes  that 
it  mav  extend  bv  way  of  the  lymphatics.  It  is  found  in  dust,  in  saliva, 
and  in  30  per  cent,  of  healthy  noses  and  throats,  though  usually  wdth 
attenuated  virulence.  Again,  the  organism  is  virulent,  and  experi- 
mental inoculation  has  produced  pericarditis,  endocarditis,  and  em- 
pvema.  It  has  been  found  in  the  joints,  the  blood,  the  brain,  the 
bone-marrow;  in  otitis  media,  endocarditis,  peritonitis,  cholangitis, 
and  endometritis;  in  the  urine  and  faeces;  and  it  may  pass  from  the 
mother  to  the  foetus.  It  may  be  a  terminal  septic  infection  or  may 
produce  pneumococcus  sepsis,  as  the  typhoid  bacillus  produces  typhoid 


PLATE   IV. 


L.    SCHMIDT.    FEC. 


The  Diplocoecus  Pneumonias,  Stained  ^A^ith  Methylene  Blue 
and  Fuehsin  as  a  Counterstain.  Taken  fronn  the  Sputuni  of 
a  Case   of  Acute  Croupous  Pneunnonia.     (Sinnon. ) 


PNEUMOXIA  137 

bacillsemia.  Until  very  recently  it  was  thought  that  typhoid  and 
pneumonia  were  local  infections  with  general  symptoms,  and  that  the 
presence  in  the  blood  of  their  microbes  was  a  serious  and  a  true  com- 
plication. The  typhoid  bacillus  is  found  in  the  blood  in  95  per  cent,  of 
typhoid  cases,  and  Rosenow,  of  Chicago,  has  found  the  pneumococcus 
in  the  blood  in  about  93  per  cent,  of  pneumonia  patients  (v.  i.).  Indeed 
Prochaska  last  year  found  the  Fraenkel-Weichselbaum  organism  in  all 
of  fifty  cases.  The  pneumococcus  is  probably  the  sole  cause  of  typical 
pneumonia,  but  other  microorganisms  are  sometimes  found. 

2.  The  pneumobacillus  (Friedlander,  1883)  is  Ijj.  long,  one-third 
as  wide  as  long,  with  a  capsule;  it  is  found  sometimes  in  the  healthy 
nose,  is  larger  than  the  pneumococcus,  and  does  not  stain  by  Gram's 
method.  It  has  distinct  biological  and  cultural  characters,  but  its 
relation  to  pneumonia  is  not  established.  It  is  probably  a  mixed 
infection  only. 

3.  Other  bacteria,  such  as  the  typhoid,  colon,  diphtheria,  proteus, 
influenza,  plague,  and  pyogenic  organisms,  have  been  found.  The 
existence  of  psittakosis  pneumonia,  supposed  to  be  contracted  from 
animals,  is  denied  by  Lichtenstern. 

Indirect  Causes. — (a)  Age. — Pneumonia  may  be  seen  even  in  the 
new-born.  Predisposition  to  infection  is  great  up  to  the  sixth  year, 
and  then  much  less  until  the  fifteenth  year.  After  the  fifteenth  year 
its  frequency  increases  after  each  decade.  Over  half  the  cases  of  pneu- 
monia occur  between  the  twentieth  and  fortieth  years,  and  over  80 
per  cent,  between  the  tenth  and  fiftieth  years.  (6)  Sex. — Eighty  per 
cent,  of  cases  are  males.  The  relation  to  trauma  is  still  in  doubt, 
though  contusions  seem  an  occasional  accessory  factor,  (c)  Cold. — - 
Cold  and  wet  are  predisposing  factors.  Pneumonia  prevails  especially 
in  February,  March,  and  April,  when  the  weather  varies,  when  the 
temperature  is  low,  when  the  moisture  is  great,  and  when  the  winds 
are  high.  Three-quarters  of  all  cases  of  pneumonia  occur  in  cold 
months.  It  •  is  possible  that  dust  disseminates  the  dried  sputum. 
Negroes  are  infected  more  frequently  than  whites.  Pneumonia  is 
half  again  as  frequent  in  the  cities  as  it  is  in  the  country.  In  the 
winter  of  1903-4,  when  4,000  persons  died  of  pneumonia  in  Chicago, 
the  author  knew  of  practitioners  in  many  villages  and  towns  not  one 
hundred  miles  distant,  who  did  not  see  a  single  case,  (d)  Individual 
predisposition  is  said  to  be  a  more  important  factor  than  in  any  other 
acute  infection.  Susceptibility  to  pneumonia  is  increased  by  debility, 
overwork,  and  alcoholism,  though  the  disease  also  attacks  the  most 
robust  individuals. 

Toxin. — The  toxin  is  not  isolated,  though  it  is  assumed  that  a  pneu- 
motoxin  exists  and  produces  the  toxsemic  symptoms;  when  an  anti- 
toxin develops,  the  crisis  occurs. 

Immunity. — Immunity  does  not  result  from  one  attack;  as  in 
erysipelas,  recurrence  of  the  disease  is  likely  (in  13  per  cent.,  33  per 
cent.,  even  50  per  cent.) ;  ten,  sixteen,  or  even  twenty-eight  recurrences 
are  known.    Though  immunity  can  be  produced  in  animals,  it  rarely 


138  THE  SPECIFIC  INFECTIOXS 

lasts  longer  than  six  months  (Klemperer,  Foa,  Washbourne),  and  it 
is  doubted  whether  the  serum  has  antitoxic  properties.  It  is  thought 
to  possess  bactericidal  qualities  only. 

General  Clinical  Course. — After  a  very  short  incuhation  of  a  few- 
hours  to  a  day,  the  disease  begins  suddenly.  In  children  it  often 
begins  with  convulsions — in  the  young  with  vomiting,  and  in  older  sub- 
jects with  a  severe  chill,  which  often  occurs  in  apparently  perfect 
health,  during  work  or  sleep.  On  the  first  day  there  is  a  sudden  rise 
of  temperature;  the  face  becomes  red,  even  livid;  the  eyes  are  injected; 
the  pulse  and  respiration  are  accelerated;  the  patient  lies  character- 
istically flat  in  bed;  there  is  much  depression;  thirst,  headache,  and 
a  sudden,  sharp  pain  in  the  side  develop,  accompanied  by  cough  and 
increased  respiration.  On  the  second  day,  the  cough,  pain,  headache, 
and  respiration-rate,  increase,  with  dilatation  of  the  alffi  nasi;  the  ex- 
piration is  short  and  grunting,  and  speaking  is  diflicult;  leukocytosis 
develops.  The  sputum  appears,  or,  if  already  present,  becomes 
bloody;  and  this,  with  the  sudden  fever,  chill,  pain,  and  increased 
breathing,  practically  establishes  the  diagnosis  before  signs  of  con- 
solidation appear,  if  pulmonary  embolism  can  be  excluded.  On  the 
second  or  third  day  there  are  evidences  of  lung  consolidation,  such  as 
the  crepitant  rale,  bronchial  breathing,  and  tympany  which  is  soon 
followed  by  dulness;  high  temperature  develops  (with  slight  morn- 
ing remissions);  the  skin  becomes  dry  and  red;  there  is  increased 
pulse  and  respiration;  herpes,  anorexia,  coated  tongue,  constipation, 
moderate  delirium,  febrile  urine,  and  coughing  attacks,  develop.  The 
coughing  is  frequent  but  short  in  duration,  voids  a  viscid,  red  sputum, 
and  causes  catching  respiration,  pain,  and  broken  sleep.  The  prog- 
nosis cannot  be  made  from  the  symptoms  up  'to  this  time,  since  the 
clinical  course  may  be  unfavorably  modified  (a)  especially  by  collapse 
due  to  myocardial  or  vasomotor  paralysis,  or  to  embolism  of  the  lung 
from  right-heart  dilatation;  (b)  by  profound  toxaemia;  (c)  by  delirium 
tremens;  or  id)  by  death,  though  at  this  stage  it  is  rare.  In  favorable 
cases,  when  the  toxaemia  is  spent,  the  crisis  occurs;  this  usually  happens 
on  the  uneven  days  (the  fifth,  seventh,  or  ninth)  with  gradually  de- 
creasing dulness  and  with  disappearance  of  other  local  findings.  A 
"critical"  fall  of  temperature,  pulse,  and  respiration-rate,  and  relief 
of  nervous  symptoms,  and  sweating,  result.  Lysis  is  less  frequent.  As 
a  general  statement,  the  toxaemia  is  the  dominant  feature  of  pneu- 
monia, and  the  consolidation  is  decidedly  secondary.  Furthermore, 
the  degree  of  toxaemia  has  no  necessary  or  constant  relation  to  the 
amount  of  consolidation,  just  as  the  toxaemia  of  typhoid  does  not  de- 
pend on  the  presence  or  degree  of  the  intestinal  changes. 

Analysis  of  Individual  Symptoms. — l.  Onset. — Prodromes  occur 
in  25  per  cent,  of  the  cases  (Grisolle),  mostly  in  men  between  thirty 
and  forty  years,  and  rarely  last  more  than  five  days;  anorexia,  depres- 
sion, headache,  bronchitis,  backache,  and  low  fever,  may  be  noticed. 
In  one  of  the  author's  cases  a  pneumococcus  infection  began  in  the 
throat,  ihen  invaded  the  larynx,  and  only  after  three  weeks  invaded 


PNEUMONIA 


139 


the  lung.  The  organism  was  obtained  at  post-mortem.  In  four 
cases,  low  fever  and  hsematemesis  for  five  to  seven  days  suggested 
tuberculosis.  In  the  two  coming  to  autopsy,  no  tuberculous  foci  were 
found.  In  /5  per  cent.,  however,  the  onset  of  pneumonia  is  sudden. 
Chill,  convulsions,  vomiting,  and  fever,  after  a  short  incubation, 
usually  mark  the  brusque  onset.  Repeated  chilly  sensations,  occur- 
ring when  the  heart  is  weak,  do  not  as  accurately  designate  the  onset 
as  does  an  initial  rigor.  A  chill  is  present  in  75  per  cent,  of  the  cases, 
and  in  no  other  acute  disease  except  malaria  is  the  chill  so  severe  and 
constant;  it  lasts  from  a  quarter  to  half  an  hour.  The  onset  is  atypical 
in  senile  pneumonia,  and  also  when  it  occurs  in  the  course  of  other 
diseases, — e.g.,  delirium  tremens,  typhoid,  variola,  and  psychoses, — 
and  the  chill,  cough,  dyspnoea,  pain,  and  sputum,  are  often  absent,  so 
that  the  existence  of  pneumonia  may  not  be  suspected. 

2.  Fever.— The  usual  course  of  the  fever  is,  first,  a  very  sudden 
rise,  especially  in  menstruating  women   (von  Jiirgensen);    the  fever 


Fig.  13. 

Day 

1 

2 

3 

4 

5 

6 

7 

TEMP. 

105 

104 

k 

1 

/ 

,/ 

Vl 

103 

/ 

V 

V 

V 

102 

/ 

101 

100 

B 

99 

' 

c 

1 

98 

Fever-curve  of  typical  case  of  pneumonia:   A,  sudden  rise;  B,  pseudocrisis;  C,  crisis. 

is  then  continuous,  often  with  not  more  than  1°  or  2°  variation  for  a 
few  days ;  in  three  quarters  of  the  cases  the  maximum  fever  is  between 
102°  and  105°.  It  may  then  remit,  which  is  of  good  prognostic  import; 
remittent  fever  throughout  the  disease  occurs  in  some  cases.  Re- 
crudescences occur  when  consolidation  passes  from  one  lobe  to  an- 
other. The  fever  is  lower  or  even  absent  in  the  aged,  in  alcoholics, 
and  in  cases  of  secondary  pneumonia.  Fever  produces  a  marked 
loss  of  weight  (twenty  to  thirty  pounds).  The  rise  preceding  the  crisis 
(perturbatio  critica)  may  be  mistaken  for  an  ante-mortem  rise.     In 


140 


THE  SPECIFIC  INFECTIONS 


both  conditions  there  may  be  delirium,  convulsions,  chill,  or  irregular 
pulse.  A  pseudocrisis  may  deceive  the  uninitiated  physician,  when 
the  fever  resumes  its  original  elevation.  Crisis  occurs  in  60  to  80  per 
cent,  of  cases,  usually  on  uneven  days,  as  noted  by  Hippocrates, — the 
fifth,  seventh,  ninth,  or  eleventh  days, — and  usually  between  evening 
and  early  morning.  It  very  rarely  occurs  on  or  before  the  third  day. 
It  marks  the  end  of  the  toxaemia  but  not  of  the  consolidation.     This 


Days 

1 

2 

3 

Fig.  14 
4         5 

6 

7 

8 

9 

10 

TEMP. 

105 

104 

\ 

103 

h 

/ 

\k 

1 

^   / 

lOi 

/ 

/ 

y 

A 

7 

\h 

101 

/ 

/ 

\ 

H 

V 

/ 

y\ 

A 

100 

V 

r 

1/ 

M 

Ai 

\ 

99 

\ 

I 

sAi 

\ 

V 

Pneumonia;    remittent  (subcontinuous)  fever. 

requires  several  days  more.  In  six  to  ten  hours  the  temperature  falls 
to  (or  below)  normal,  accompanied  by  sleep,  euphoria,  lessened  pulse 
and  respiration,  lateritious  deposits,  and  reappearance  of  the  chlorides 
in  the  more  abundant,  limpid  urine,  and  "critical"  sweating,  or  even 
diarrhoea.  The  fall  may  measure  even  10°  or  11°  and  the  pulse  may 
reach  30.     The  precritical  elevation  and  the  beginning  of  the  crisis 

Fig.  15. 


Uiiys 

28 

1 

2 

3 

4l5 

G 

7 

8 

9  I10|11|12|13 

14 

15 

le 

17 

181 19 

20 

21 

22 

23 

24 

25 

26 

27 

28  29 

30 

inr. 

104 

103 

1 

1 

1 

102 

. 

i 

^\ 

n 

J 

P 

1 

101 

I 

A 

J 

n\\^ 

^ 

J 

1 

100 

A 

\  1 

/ 

w\ 

' 

I 

1 

/ 

r 

r 

A 

A 

99 

^ 

kf\ 

/^ 

J 

VN 

\J 

/ 

V 

;  " 

I 

n 

{-r 

1     A        K 

fi 

^ 

98 

V 

^/' 

V 

/  1 

' 

J 

\/v\/ 

V^ 

J 

Y" 

1- 

97 

V 

( 

1 

1 

' 

^ 

•^  1 

_ 

_ 

1 

Pneumonia  fever-curve:   exceptionally  protracted  though  uncomplicated  fever. 

may  be  attended  by  alarming  symptoms,  such  as  weak,  irregular  pulse 
and  collapse.  Lysis  occurs  in  20  per  cent,  of  the  cases.  It  is  likely  to 
occur  when  the  fever  lasts  more  than  ten  days,  but  lingering  fever 
may  indicate  progression  in  other  lobes  and  such  complications  as 
empyema  or  endocarditis.  Lysis  may  be  (1)  gradual  and  continuous, 
or  (2)  slow  and  remittent. 


PNEUMONIA  141 

3.  Respiratory  Findings. — {A).  Pain. — Pain  in  the  side  is  pleural, 
though  sometimes  muscular.  Its  presence  in  90  per  cent,  of  the  cases 
makes  it  of  diagnostic  value,  since  it  is  the  most  frequent  respiratory 
symptom.  It  appears  early,  is  increased  by  coughing  or  motion,  and 
is  sharp  and  sometimes  agonizing.  It  is  usually  well  localized  over  the 
consolidated  focus,  but  in  8  per  cent,  may  be  referred  along  the 
lower  intercostal  nerves  to  the  abdomen,  in  children  especially,  and 
sometimes  in  adults.  Appendicitis  is  thus  simulated  in  2  per  cent. 
Sometimes  the  pain  is  located  over  the  gall-bladder,  or  on  the 
opposite  side  of  the  chest.  Pain  is  absent  in  central,  secondary,  or 
upper-lobe  pneumonias;  in  the  aged,  and  often  in  children;  and  in 
cases  with  great  delirium. 

{B).  Dyspn(ea. — Dyspnoea  is  frequent;  it  is  caused  by  pain  and 
especially  toxaemia,  but  also  by  temperature,  cyanosis,  diminished 
respiratory  area,  bronchitis,  and  complicating  pulmonary  oedema,  and 
scoliosis. 

(C).  The  Respiration-kate. — The  respiration-rate  is  practically 
always  increased  to  24  or  40,  (or  more  in  children) ;  and  in  two-thirds 
of  all  cases,  it  ranges  between  30  and  50;  it  almost  never  rises  to  60 
or  80  except  in  the  death  agony,  but  such  frequency  is  common  in 
miliary  tuberculosis.  The  author  once  saw  a  rate  of  96  with  recovery; 
the  pulse  was  90.  Dilatation  of  the  nares  is  said  to  be  ominous,  but 
seems  to  the  author  common  in  ordinary  cases.  Alteration  of  the  pulse 
and  respiration  ratio  was  first  noted  by  von  Jiirgensen;  the  normal 
ratio  of  1  to  4  or  4.5  becomes  1  to  3  or  2.  On  very  rare  occasions  the 
respiration-rate  may  be  normal.  Thus,  in  one  instance  with  the  entire 
right  lung  consolidated,  respiration  was  18  (without  medication). 

(D).  The  Cough. — The  cough  always  irritates,  is  sometimes  dan- 
gerous, and  seldom  relieves  the  patient.  It  is  usually  present  from  the 
beginning  of  the  disease  to  the  crisis,  and  almost  invariably  occurs 
in  lower-lobe  pneumonia,  but  is  often  absent  in  upper-lobe  consoli- 
dation, in  terminal  or  secondary  pneumonia,  in  cases  where  there 
is  much  delirium,  in  the  aged,  and  the  young.  It  is  sometimes 
pleuritic. 

{E).  The  Sputum. — The  sputum  is  at  first  transparent,  mucous,  and 
very  scanty.  It  soon  becomes  viscid,  and  is  difficult  to  raise,  and  to 
expectorate,  as  it  adheres  to  the  mouth  and  lips.  It  is  so  viscid  that 
the  sputum-cup  may  be  inverted  without  any  flow  of  the  sputum.  In 
two  days  it  becomes  red,  and  rusty  (80  per  cent,  of  cases).  Later,  the 
sputum  becomes  more  abundant,  averaging  between  one  and  seven 
ounces  daily,  but  is  rarely  very  abundant  or  fluid.  Increased  fluidity 
may  result  from  weak  heart,  or  decreased  coagulability  of  the  blood. 
Rusty  sputum  is  often  absent  in  children  who  swallow  their  sputum ; 
in  cases  of  upper-lobe  consolidation,  in  which  there  is  less  hemorrhage, 
less  consolidation,  and  less  cough  to  dislodge  exudation;  and,  finally, 
it  is  often  absent  in  the  senile  and  secondary  pneumonias,  possibly 
because  of  very  early  gray  hepatization.  The  cause  of  unusual  color 
in  the  sputum,  such  as  lemon-  or  brick-color,  is  unknown ;  it  is  some- 


142  THE  SPECIFIC  INFECTIONS 

times  observed  in  pulmonary  oedema,  or  in  incipient  gangrene,  and 
renders  the  prognosis  uncertain.  Safranin  color  (sputum  croceum) 
indicates  resolution.  The  rusty  sputum  is  of  great  diagnostic  value, — 
e.  g.,  in  the  beginning  of  the  disease  or  in  central  pneumonia — and 
generally  is  of  good  import.  Fibrin  threads  (or  "casts")  of  the  bron- 
chioles are  usually  seen  between  the  third  and  seventh  days.  On 
shaking  the  sputum  in  water  and  catching  the  shreds  on  a  slide  they 
appear  clubbed  at  their  alveolar  ends.  They  are  almost,  but  not 
wholly,  pathognomonic,  since  Laennec  found  them  in  tuberculosis, 
and  in  fibrinous  bronchitis.  They  consist  of  fibrin,  white  cells,  fatty 
cells,  and  epithelium.  Thinner  casts,  analogous  to  the  cylindroids 
of  the  urine,  and  spirals,  are  sometimes  found.  The  sputum  is  rich 
in  chlorides,  especially  in  calcium  chloride.  Microscopically  the  spu- 
tum contains  blood  cells,  various  epithelia,  the  pneumococci  (found 

Fig.  16. 


Fibrinous  coagulum  from  a  case  of  croupous  pneumonia.     (Bizzozero.) 

first  by  Wolff  in  sputum  and  by  Weichselbaum  in  the  lung),  and  often 
streptococci. 

(F).  Lung  Pathology. — The  lung  pathology  was  developed  in 
1819,  by  Laennec,  who  was  the  first  to  accurately  separate  pneu- 
monia from  pleurisy.  He  described  three  stages.  (1)  The  stage  of 
hypercemia  is  very  exceptionally  observed  unless  the  subject  dies  in 
twenty-four  to  thirty-six  hours,  because  hepatization  (v.  i.)  develops 
rapidly;  hypersemia  is  most  often  seen  at  the  edges  of  the  consoli- 
dated lung  where  the  pneumonia  is  beginning  to  extend.  The  lung 
crepitates  and  floats,  though  less  than  normal;  it  is  red,  voluminous, 


PNEUMONIA  143 

and  tears  readily, — [i.e.,  it  has  lost  its  elasticity],  and  exudes  a  sero- 
sanguineous  fluid  on  section.  Under  the  microscope,  congestion,  serum, 
and  diplococci  in  the  alveoli,  are  observed.  The  alveolar  epithelial 
cells  swell  and  desquamate,  which,  according  to  some  observers,  are 
the  primary  changes.  (2)  In  the  stage  of  red  hepatization,  the  lung  is 
evenly  red,  friable,  airless  (not  wholly  so  in  pneumonia  of  an  upper 
lobe),  and  sinks  when  put  into  water.  Its  weight  is  increased  ten  to 
fifty  ounces.  The  lung  is  enlarged  to  the  size  of  deepest  inspiration 
(Rokitansky,  who  developed  the  gross  anatomy  of  pneumonia),  and 
has  marks  of  the  ribs  on  its  fibrin-coated  surface.  On  scraping  the 
cut  surface,  fibrinous  casts  or  plugs  of  the  bronchioles  are  observed. 
The  lung  is  granular  on  section  (Laennec),  which  results  from  exuda- 
tion into  the  alveoli.  These  granulations  are  smaller  in  the  young 
and  are  larger  in  patients  with  emphysema.  They  are  seen  best  with 
oblique  illumination.  Under  the  microscope,  coagulated  blood  and 
exudate,  alveolar  epithelium,  injected  bloodvessels,  emigration  of 
leukocytes,  diplococci,  and  meshes  of  fibrin,  are  noted.  (3)  In  the 
stage  of  gray  hepatization,  the  granulations  are  grayish-yellow,  and  are 
not  red  because  the  blood  is  absorbed;  they  are  larger  and  looser 
than  in  the  second  stage.  The  connective  tissue  is  grayer  than  the 
granulations,  and  is  sharply  defined  by  the  lung  pigment.  It  has  been 
claimed  that  death  always  occurs  if  this  stage  is  reached.  If  the 
patient  lives,  the  granulations  disappear;  the  lung  exudate  becomes 
semi-fluid  (purulent  infiltration);  the  pus  can  be  washed  out;  there 
is  a  fatty  emulsion,  and  resorption  occurs  by  the  lymphatic  vessels 
and  not  by  evacuation  through  the  sputum.  Enzymes  (ferments)  dis- 
solve the  exudate;  the  products  of  this  autolysis  are  excreted  by  the 
kidneys. 

Seat  of  pneumonia:  The  lobar  process  begins  at  the  hilum  and 
extends  to  the  pleura,  which  is  usually  inflamed.  If  it  remains  at  the 
hilum  it  is  called  central  pneumonia  (1.7  per  cent.);  if  the  entire  lung 
is  involved,  it  is  termed  pneumonia  totalis  or  massiva;  the  terms 
"double  pneumonia"  and  "crossed  pneumonia"  are  self-explanatory. 
The  lobes  are  involved  in  the  following  order  of  frequency:  (1) 
Right  lower  lobe;  (2)  left  lower;  (3)  right  middle;  (4)  right  upper; 
(5)  left  upper  lobe.  Jiirgensen's  collation  of  16,614  cases  of  pneu- 
monia shows  that  the  right  lung  is  affected  in  53  per  cent.,  the  left  in 
37  per  cent.,  and  both  lungs  in  10  per  cent.  Fraenkel  found  the 
upper  lobes  involved  in  16  per  cent,  and  the  lower  in  84  per  cent. 

(G).  Physical  Signs. — The  physical  signs  develop  in  the  lungs  only 
after  twelve  to  twenty-four  hours,  or  later. 

I.  Inspection. — The  decubitus  is  variable.  It  is  dorsal  in  lower- 
lobe,  and  erect  in  upper-lobe  pneumonia;  the  patient  at  first  lies  on 
the  sound  side  to  avoid  pain;  on  the  diseased  side  later,  for  better 
expansion  of  the  sound  lung.  The  spinal  column  is  concave  toward 
the  diseased  lung  for  its  better  immobilization.  The  excursion  is  less 
on  the  diseased  side  because  of  pain.  Litten's  diaphragmatic  sign  is 
absent  and  the  sound  lung  is  vicariously  active.     The  diseased  side 


1-14  THE  SPECIFIC  IXFECTIOXS 

is  larger  by  one-half  to  one  inch.  The  accessory  muscles  of  respira- 
tion are  active  and  dilatation  of  the  nares  is  seen.  Systolic  pulsation 
of  the  lung  occurs  when  the  lingual  lobe  is  consolidated,  or,  in  the 
first  stage,  when  the  heart  beats  against  semifluid  exudation  (Graves). 

II.  Palpation. — This  detects  the  lessened  excursion  more  readily 
than  does  inspection;  vocal  fremitus  is  usually  increased  because  of 
better  sound  propagation,  fremitus  being  normally  greater  on  the 
right  than  on  the  left  side.  It  is  decreased  (1)  by  occlusion  of  the 
bronchus  by  fibrinous  plugs,  which  are,  however,  usually  dislodged  by 
having  the  patient  cough;  (2)  by  coincident  pleural  effusion;  (3)  by 
great  consolidation  (Gerhardt),  in  which  the  chest  wall  becomes  tense. 
It  is  claimed  that  the  consolidated  side  is  the  warmer.  Pleural  fric- 
tion may  be  felt. 

III.  Percussion. — (1)  A  tympanitic  note  is  obtained  in  the  first 
stage  (Skoda's  resonance).  This  is  caused  by  decreased  elasticity  of 
the^  lung  and  therefore  decreased  tension  and  amplitude  of  vibration, 
which  is  due  to  the  swelling  of  the  alveolar  epithelium  and  turgescent 
capillaries.  This  condition  may  last  as  long  as  two  days,  and  causes 
doubt  as  to  the  side  involved,  especially  when  pain  is  bilateral  and 
breathing  indeterminate  (whence  the  value  of  crepitant  rales).  Tym- 
pany in  the  later  stages  is  not  uncommon  in  upper-lobe  pneumonia 
where  exudation  is  usually  incomplete.  It  is  rare  in  lower-lobe  pneu- 
monias but  may  occur  over  an  upper  lobe  in  total  pneumonia  from  the 
air  in  the  bronchus.  It  may  be  attributed  to  the  stomach  (Finckler)  in 
cases  of  left  lower-lobe  pneumonia;  to  some  moderate  compression, 
— e.  g.,  of  right  upper  lobe  when  right  middle  and  lower  are  con- 
solidated; to  the  normal  lung  lying  over  deeper  consolidation  or  to 
resolution.  Tympany  may  remain  days  or  weeks  after  the  crisis. 
Careful  watching  of  the  tympany,  during  the  acute  stage,  often  leads 
to  detection  of  extension,  which  is  shown  by  relaxation  of  the  lung 
tissue,  contiguous  to  areas  already  consolidated.  (2)  Dulness  is 
usually  found  on  the  second  day.  It  is  the  percussion  sign  of  the 
second  stage.  When  complete,  it  corresponds  to  the  lobe  confines, 
which  are  outlined  in  Fig.  33  under  article,  Pleurisy.  The  dulness 
is  not  absolute.  It  is  usually  first  detected  in  the  posterior  axillarv 
line  in  lower-lobe  pneumonia  and  generally  is  more  complete  behind 
than  in  the  front  of  the  chest  and  more  in  a  lower-  than  in  an  upper- 
lobe  involvement.  Dulness  is  difficult  to  detect  if  the  area  is  not  at 
least  1  by  2  inches,  or  if  it  is  deeper  than  2  inches  from  the  surface. 
It  is  absent  in  central  pneumonia.  It  disappears  with  resolution. 
Wintrich's  palpatory  percussion  is  most  valuable.  Wintrich's  change 
of  pitch  (on  opening  the  mouth)  is  heard  in  upper-lobe  pneumonia, 
where  the  percussion  wave  is  conveyed  to  the  bronchus  more  often 
than  in  lower  pneumonia.  Cracked-pot  resonance  over  the  edge  of 
the  consolidation  bordering  on  sound  tissue  is  due  to  irregular  tension, 

IV.  AiLscultation. — Decreased  breathing  is  often  noticed  at  first 
(Grisolle).  Stokes  diagnosticated  the  first  stage  by  sudden  local 
puerile  breathing  with  fever  and  by  disordered  breathing. 


PNEUMONIA  145 

First  Stage. — The  crepitatit  rale  of  Laennec  remains  the  auscultatory 
sign  of  the  first  stage;  but,  as  Laennec  stated,  it  is  not  absolutely  spe- 
cific, because  it  occurs  also  in  tuberculosis,  oedema,  infarct,  hypostasis, 
and  bronchiolitis.  It  probably  has  its  origin  in  the  viscid  exudate 
in  the  finest  tubules  and  in  the  alveoli.  Some  consider  it  pleural.  It 
is  coarser  in  the  aged  and  in  children  because  the  large  tubes  are 
more  involved.  It  is  heard  at  the  height  of  inspiration  as  a  succes- 
sion or  shower  of  delicate  crackles.  When  not  heard,  a  coughing 
effort  may  elicit  the  crepitant  rale.  It  often  disappears  after  a  num- 
ber of  deep  inspirations;  e.g.,  when  it  is  demonstrated  to  a  class, 
only  the  first  students  hear  it.  Dislodged  plugs  may  occasion  expira- 
tory rales.  The  crepitant  rale  disappears  during  the  second,  and 
reappears  in  the  third  stage. 

Second  Stage. — The  distinct,  intense  bronchial  breathing  is  due  to 
better  transmission  of  the  bronchial  sounds  through  the  solidified 
lung.  It  sounds  as  though  nothing  intervened  between  the  lung  and 
the  stethoscope  and  it  is  especially  clear  and  near  when  the  ear  is 
placed  directly  on  the  chest.  It  is  absent  or  partial  in  central  pneu- 
monia, especially  anteriorly,  in  coincident  pleurisy,  and  in  obstruction 
of  the  bronchi  by  mucous  or  fibrinous  casts.  In  the  latter  case,  several 
coughs  usually  loosen  the  obstruction  and  restore  the  bronchial  breath- 
ing. Bronchopho7iy,  due  to  the  voice  sounds  being  better  transmitted 
through  the  consolidated  area,  is  heard  when  the  patient  counts  or 
speaks,  but  especially  after  each  involuntary  expiratory  grunt.  A^goph- 
ony  is  occasionally  heard,  as  well  as  Baccelli's  phenomenon  (auscul- 
tatory whispering).  The  crepitant  rale  disappears  in  this  stage, 
except  at  the  edges  of  the  hepatization  where  extension  may  be 
taking  place. 

Third  Stage. — The  crepitant  rale  reappears  and  is  then  known  as 
the  rale  redux. 

4.  Circulation. — (a)  The  pulse  rate  is  usullay  100  to  120;  in 
children  it  may  rise  to  200.  It  is  also  rapid  in  the  aged,  and  in  cases 
with  severe  toxaemia.  In  adults,  a  rate  of  130  to  140  makes  the  prognosis 
less  favorable.  If  the  rate  is  slow  at  the  height  of  the  disease  the  prog- 
nosis is  grave,  for  heart  or  brain  complications  are  indicated  (Traube). 
Irregulari.ty  and  gallop-rhythm  (one  systolic  tone  and  two  diastolic 
tones)  are  of  poor  prognostic  import.  Antecritical  irregularity  fre- 
quently occurs.  The  pulse  is  usually  deceptive,  because  its  fulness 
is  of  no  value  in  prognosis.  It  is  not  often  dicrotic.  Extensive  pneu- 
monias may  compress  the  subclavian  artery,  making  the  pulse  smaller 
in  one  wrist  than  in  the  other.  In  the  right  heart,  dilatation  from 
toxaemia  may  occur;  the  second  pulmonic  tone  is  accentuated  but 
this  is  not  observed  when  the  right  heart  becomes  greatly  weakened. 
There  are  functional  bruits,  especially  in  children.  In  very  rapid 
cardiac  action,  the  two  heart  tones  sound  alike,  resembling  the  foetal 
heart  tones  (embryocardia).  (6)  Collapse  is  usually  due  to  myo- 
cardial or  to  central  vasomotor  paralysis  and  may  occur  at  the  onset, 
acme,  defervescence,  or  convalescence,     (c)  The  blood  shows  anaemia, 

10 


146  THE  SPECIFIC  INFECTIONS 

and  Bollinger  suggests  that  the  oligsemia,  resulting  from  large  exudates, 
may  explain  some  cases  of  collapse.  The  fibrin  increase  is  readily 
noted  in  fresh  blood  preparations.  A  polymorphonuclear  leukocytosis 
of  15,000  to  30,000  (or  even  100,000)  appears  early,  and  lasts  slightly 
longer  than  the  fever.  In  Cabot's  counts,  the  leukocytes  ran  between 
15,000  and  30,000  in  75  per  cent,  of  his  cases.  The  eosinophiles  are 
decreased  or  wholly  absent  until  the  affection  reaches  its  height, 
whence  the  favorable  significance  of  their  reappearance.  The  lymph- 
ocytes are  decreased.  During  convalescence  many  myelocytes  appear. 
The  white  count  remains  high  in  delayed  resolution  or  with  complica- 
tions. A  low  count  is  generally  unfavorable.  Pneumohoemia  (pneumo- 
cocci  in  the  blood)  was,  until  recently,  considered  of  bad  prognostci 
import  and  it  was  once  stated  that  but  15  per  cent,  of  cases  of  pneumo- 
hsemia  recover,  but  now  it  is  not  considered  of  great  prognostic  value. 
Rosenow  found  pneumococci  in  blood  cultures  in  93  per  cent.,  and  in 
smears  in  42  per  cent.  They  were  most  abundant  on  the  fourth  or 
fifth  days,  and  few  in  numljer  before  or  at  the  crisis.  In  making 
cultures,  half  a  dram  of  blood  is  taken  and  mixed  with  98  or  99  parts 
of  bouillon.  Prochaska  found  pneumococci  in  100  per  cent.,  when  two 
or  three  drams  (10  c.c.)  of  blood  were  taken  for  cultivation;  they  are 
probably  present  in  all  cases,  though  some  think  that  they  appear  only 
when  the  protective  resistance  of  the  tissues  is  lost  and  death  is  immi- 
nent; pneumohsemia  has  been  found  before  hepatization.  Rosenow 
noted  increased  agglutinative  power  of  the  serum  until  the  crisis  occurs. 

5.  The  Digestive  System. — There  is  the  febrile  tongue,  thirst,  and 
anorexia.  Vomiting  results  from  cerebral  toxaemia  (especially  in  chil- 
dren), vagus  irritation,  coughing,  or  alcoholic  pharyngitis.  The  dis- 
tressing, sometimes  dangerous,  tympany  and  the  occasional  diarrhoea 
are  usually  toxsemic.  Constipation  is  the  rule.  There  is  often  some 
intumescence  of  the  liver.  Fraenkel  found  splenic  tumor  in  15  per 
cent,  of  all  cases  and  in  40  per  cent,  of  fatal  cases. 

6.  The  Skin. — The  red  cheek  on  the  affected  side  was  known  to 
Aretseus.  The  skin  is  usually  dry,  but  miliaria  and  sweating  may  be 
seen,  especially  in  children.  Herpes  is  found  more  often  than  in  any 
other  disease  (30  to  50  per  cent.)  It  appears  from  the  third  to  fifth 
day  or  later,  chiefly  on  the  lips,  nose,  mouth,  cheek,  ear,  or  rarely  on 
the  anus  or  genitalia;  Howard  found  causal  changes  in  the  Gas- 
serian  ganglion.  Herpes  is  of  diagnostic  value,  e.  g.,  from  typhoid,  and 
is  generally  of  favorable  import.  Rarer  eruptions  are  erythema,  rose- 
olse,  urticaria,  purpura,  or  pemphigus.  The  lymph-glands  are  enlarged 
in  25  per  cent,  of  the  cases. 

7.  The  Urine. — Characteristic  fever  urine  is  found,  and  the  urea 
is  increased  threefold,  especially  after  the  crisis  from  over  production 
and  accumulation  during  the  fever  and  from  the  resolving  exudate. 
The  uric  acid,  ammonium,  and  creatin,  are  increased.  The  chlorides 
are  decreased  from  225  grains  daily  to  30  grains,  or  they  may  be  absent 
until  the  crisis  or  two  days  later,  when  they  reappear  in  increased 
quantities  (first  observed  by  Rottenbacher) ;  no  satisfactory  explana- 


PNEUMONIA  147 

tion  for  the  decrease  of  the  chlorides  is  known.  The  sulphates  and 
phosphates  are  decreased.  Pick  notes  that  the  urine  often  becomes 
neutral  or  alkaline  after  twenty-four  to  forty-eight  hours;  this  is  due 
to  sodium  deposit  in  the  lungs,  which  condition  lasts  from  twenty-four 
to  thirty-six  hours.  Albuminuria  and  cylindruria  appear  in  about  50 
per  cent,  of  the  cases;  peptonuria  and  acetonuria  are  not  uncommon, 
and  the  diazo  reaction  appears  in  20  per  cent.  Hsematuria  is  found 
in  1.6  per  cent.  Nephritis  seldom  occurs  (1  to  2  per  cent.),  and  uraemia 
is  very  uncommon.  Pneumococci  have  been  found  in  the  urine  and 
in  the  glomeruli  (Koch,  Nauwerck). 

8.  The  Nervous  System. — Headache  is  almost  constant.  There 
may  be  insomnia,  restlessness,  or  sopor,  and  the  latter  is  always  omi- 
nous. Delirium  (22  per  cent.)  occurs  in  adults,  especially  in  cases  of 
upper-lobe  pneumonia,  alcoholism,  or  marked  toxaemia.  Delirium 
and  other  nervous  symptoms  resulting  from  exhaustion  may  occur 
at,  or  even  for  a  week  after,  the  crisis.  Venesection  in  former  times 
greatly  increased  the  percentage  of  delirium.  The  patellar  reflexes 
are  often  absent  and  the  pupils  may  be  dilated  or  sluggish.  Con- 
vulsions, coma,  and  rigid  neck,  in  children,  result  from  toxaemia  of 
the  more  sensitive  young  brain,  from  complicating  otitis,  from  brain 
cedema,  or  from  actual  meningitis.  Hemiplegia  may  result  from  (1) 
brain  oedema  or  anaemia,  or  (2)  arteriosclerosis  and  weakened  heart. 

Mechanism  of  Death  in  Pneumonia. — Death  is  rare  in  the  first 
two  days.  If  it  occurs  within  this  time,  its  cause  is  usually  some 
antecedent  malady  such  as  nephritis  or  typhoid.  (1)  Toxcemia  is 
all-important  in  its  action  on  the  heart,  brain,  and  vasomotor  nerves. 
Death  results  with  a  rapid  pulse,  rapid  respirations,  algid  extremities, 
and  obtunded  sensorium.  (2)  The  extent  of  pneumonia  is  the  least 
important  factor.  A  massive  pneumonia  in  a  robust  person  causes 
less  disturbance  than  a  very  small  patch  in  a  nephritic  patient.  There 
is  no  parallelism  between  the  area  hepatized  and  the  resulting  toxaemia. 

(3)  Pulmonary  cedema  is  either  mechanical  (cardiac)  or  inflamma- 
tory— i.  e.,  the  first  stages  of  an  incompletely  developed  pneumonia. 

(4)  Pneumococci  in  other  tissues,  e.  g.,  pneumococcic  meningitis,  endo- 
carditis, and  pericarditis. 

Complications. — These  are  fortunately  few  as  compared  with  those 
of  typhoid  but  they  are  severe. 

1.  Pleurisy. — Pleurisy  is  so  constant  that  the  name  of  pleuro- 
pneumonia is  rather  justified,  the  pleura  being  covered  with  a  very 
thick,  tenacious,  curdy  exudate.  It  is  usually  due  to  the  pneumo- 
coccus;  if  due  to  the  streptococcus,  it  is  a  complication  of  great  dan- 
ger. Efi^usive  pleurisy  is  said  to  occur  in  5  to  15  per  cent.,  though 
Fraenkel  saw  serofibrinous  pleurisy  in  but  1  per  cent,  in  1,000  cases. 
Pleuritis  is  para-  or  metapneumonic,  serofibrinous  (5  per  cent.)  or 
purulent  (2  per  cent.),  febrile  or  afebrile.  The  presence  of  leukocytosis 
in  a  pleurisy  may  indicate  a  previous  unobserved  or  overlooked  pneu- 
monia. Pneumonia  may  exist  on  one  side  and  pleurisy  on  the  other, 
— e.  g.,  an  upper-lobe  pneumonia  with  contralateral  pleurisy  (Traube). 


148  THE  SPECIFIC  INFECTIONS 

The  author  has  seen  two  such  cases.  The  prognosis  is  not  necessarily 
unfavorable,  even  when  operation  for  pneumococcic  empyema  is  re- 
fused. Interlobular  empyema  is  most  serious,  because  it  so  often 
escapes  detection.  Pneumococcic  empyema  occurs  in  2  per  cent,  of 
cases  of  pneumonia  and  is  notable  since  the  pneumococcus  so  seldom 
provokes  suppuration  in  the  lung.  Its  symptoms  are  discussed  under 
pleurisy. 

2.  Endocarditis. — Acute  endocarditis  complicates  pneumonia  in 
1  per  cent.  (Chvostek)  of  all  cases  and  in  about  5  per  cent,  of  fatal 
cases,  though  liigher  figures  are  given,  14  per  cent.  (Kanthack)  and 
16  per  cent.  (Osier);  all  autopsy  figures  are  usually  higher  than  figures 
in  general  practice.  The  pneumococcus  is  found  in  the  vegetations. 
The  valvular  exudate  is  voluminous,  though  ulceration,  valvular  aneu- 
rysm and  perforation  are  less  common  than  in  staphylo-  and  strepto- 
coccic forms.  Endocarditis  develops  especially  on  old  valvular  lesions 
in  the  left  heart  and  most  frequently  on  the  aortic  valves  (Netter, 
Heschl).  The  right  heart  is  involved  three  or  four  times  as  frequently 
as  in  endocarditis  due  to  other  bacteria.  Sixty  per  cent,  of  cases  are 
associated  with  meningitis.  Middle-aged  adults  are  more  often 
affected  than  the  young,  and  women  more  often  than  men.  Symptoms 
may  be  absent.  Endocarditis  is  probable  when  a  murmur,  systolic  or 
particularly  diastolic,  occurs  with  irregular  and  protracted  fever,  chills, 
sweats  and  embolism  (50  per  cent.).  Symptoms  may  directly  follow 
the  pneumonia  or  develop  after  one-half  to  one  week  of  normal  tem- 
perature. The  endocarditis  is  malignant  in  80  percent,  of  cases;  in 
the  balance,  milder  endocarditis  occurs;  25  per  cent,  of  cases  of  ulcer- 
ative endocarditis  are  pneumococcic.  Fever  is  sometimes,  and  leuko- 
cytosis frequently,  absent.  (Vide  chapters  on  Ulcerative  Endo- 
CAEDiTis  and  Septicopy.emia.) 

3.  Pericarditis. — This  is  dangerous  though  not  necessarily  fatal. 
Some  figures  place  its  post-mortem  frequency  at  5  to  15  per  cent, 
but  Fraenkel  estimates  it  at  seven-tenths  of  1  per  cent.  About  60  per 
cent,  of  cases  are  latent  ^because  the  pericardial  rub  is  frequently 
absent.  Pericarditis  occurs  more  often  in  children  than  in  adults  and, 
in  all  cases,  chiefly  at  the  height  of  the  disease.  Effusive  pericarditis 
is  less  common  than  the  fibrinous  form.  It  is  more  common  when 
the  left  lung  is  involved. 

4.  Arteritis  and  thrombophlebitis  are  far  less  frequent  than  in 
typhoid,  but  nearly  every  clinician  encounters  a  few  cases.  Steiner 
collected  forty-eight  cases  of  venous  thrombosis  (1903);  it  most  often 
develops  in  convalescence  and  usually  (75  per  cent.)  heals,  though 
early  embolism  or  permanent  venous  obstruction  may  develop. 

5.  Nervous  Complications. — The  chief  nervous  complications  are 
delirium  tremens,  meningitis,  or,  less  frequently,  Landry's  ascending 
paralysis,  cerebral  thrombosis,  embolism,  encephalitis,  and  neuritis. 
Meningitis,  first  observed  by  Immermann  and  Heller,  varies  in  fre- 
quency with  the  epidemic;  it  occurs  in  5  per  cent,  of  autopsies,  and 
in  three-tenths  of  1  per  cent,  of  all  clinical  cases.    It  occurs  in  asthenic 


PNEUMONIA  149 

patients,  in  upper-lobe  pneumonia,  and  is  often  accompanied  by 
endocarditis.  Symptoms  are  often  wholly  lacking.  One  of  the  author's 
cases  died  at  the  dinner-table  a  week  after  apparently  complete  con- 
valescence, and  the  autopsy  showed  a  quarter  inch  of  pus  over  the 
convexity.  The  usual  meningitic  symptoms  develop  if  infection 
reaches  the  base  of  the  brain.  This,  however,  is  not  usual.  Lumbar 
puncture  may  determine  the  diagnosis,  which  is  more  easily  made  if 
meningitis  occurs  in  convalescence.  The  prognosis  is  considered  ab- 
solutely unfavorable,  yet  Achard  and  the  author  have  each  seen  recov- 
ery in  cases  which  were  proven  bacteriologically  by  lumbar  puncture. 

6.  Alimentary  Complications. — These  are  few.  Croupous  gastritis 
and  enteritis,  parotitis  or  peritonitis  {q.  v.),  are  not  frequent.  Dieu- 
lafoy  described  a  hemorrhagic  ulcerative  gastritis,  caused  by  pneumo- 
coccic  embolism  and  attended  by  gastrorrhagia.  Icterus  is  frequent 
in  some  epidemics.  Its  average  frequency  is  about  1  per  cent.,  though 
Chvostek  saw  it  in  21  per  cent,  of  his  cases.  Its  causes  are  variable; 
(a)  lessened  excursion  of  the  diaphragm  in  right  lower-lobe  pneu- 
monia; (6)  hepatic  stasis;  (c)  duodenal  catarrh;  (d)  hsematogenous 
jaundice  resulting  from  absorption  of  the  hemorrhagic  exudate  in  the 
lung  or  toxsemic  solution  of  the  red  blood-cells  (haemolysis).  Pneu- 
mococcic  involvement  of  the  peritoneum  will  be  described  under 
Peritonitis. 

7.  Lung  Complications. — Suppurative  mediastinitis  was  first  ob- 
served by  Weichselbaum,  who  regards  it  as  the  connecting  link  between 
pneumonia,  meningitis,  and  pericarditis.  Pulmonary  induration 
(cirrhosis  of  the  lung)  may  follow  incomplete  resolution,  especially 
after  repeated  attacks  of  pneumonia  (Charcot);  it  is  usually  febrile. 
Abscess  is  not  frequent  (5  per  cent.,  Laennec,  or  once  in  1,200  cases, 
Fraenkel).  Skoda  emphasized  the  uncertainty  of  its  signs  and  the 
difficulty  in  its  diagnosis,  for  pus  and  elastic  fibers  in  the  sputum, 
and  less  frequently  cholesterin  and  hsematoidin  crystals  may  be  the 
sole  sign,  and  continual  coughing  may  be  the  chief  symptom.  Sup- 
puration may  result  from  the  pneumococcus  or  from  the  pyogenic 
bacteria  proper.  Gangrene  occurs  in  1  to  2  per  cent,  of  the  cases. 
Clinically  it  is  recognized  by  the  horribly  fetid  sputum.  Abscess 
and  gangrene  are  more  fully  treated  under  Diseases  of  the  Lungs. 

8.  Complications  in  the  Joints. — Genuine  rheumatism  may  occur 
with,  before,  or  after  a  pneumonia.  Sixty-eight  cases  of  pneumococcic 
arthritis  (pseudorheumatism)  were  reported  by  Slaughter  (1903). 
The  arthritis  may  be  serous  or  purulent.  The  knee  is  affected  in  30 
per  cent.  Arthritis  is  monarticular  in  62  per  cent,  and  fatal  in  65  per 
cent,  of  the  cases  (Herrick).  Fraenkel  found  the  pneumococcus  con- 
stantly in  the  bone-marrow. 

Clinical  Types  and  Variations. — These  are  as  follows: 

1.  Abortive  Pneumonia. — This  type  is  recognized  by  the  rusty  spu- 
tum, fever  and  respiratory  disturbance,  but  produces  no  hepatization. 

2.  Ephemeral  Pneumonia. — This  type  is  characterized  by  one  day 
of  fever,  and  very  rapid  resolution. 


150  THE  SPECIFIC  INFECTIONS 

3.  Relapsing  Type. — One  attack  occurs  with  fall  of  temperature, 
and  then  the  entire  cycle  recurs.  It  occurs  in  0.3  per  cent.  (Wagner). 
The  recurrent  type  (v.  s.  Immunity). 

4.  Local  Variations. — Apex  pneumonia  is  often  more  severe  and  more 
atypical  in  symptoms  and  signs ;  it  is  frequently  adynamic,  and  pulmon- 
ary and  cerebral  complications  are  rather  more  common.  Migratory 
pneumonia  travels  from  one  part  to  another  (the  so-called  erysipelas- 
pneumonia).  Central  and  massive  pneumonia  (pneumonia  totalis, 
affecting  an  entire  side)  will  be  considered  under  diagnosis. 

5.  In  Children. — An  abrupt  onset  occurs  without  chill  (before  the 
seventh  year)  but  with  vomiting  (50  per  cent.)  or  convulsions  (7  per 
cent.)  and  other  cerebral  or  meningeal  symptoms.  Cough  is  often 
absent,  no  sputum  appears,  and  the  pain  (third  to  fifth  year)  is  referred 
to  the  abdomen  but  without  tenderness  there.  Pain  is  a  more  impor- 
tant symptom  than  increased  respiration,  which  occurs  with  any  ele- 
vation of  temperature.  The  respirations  may  number  eighty  in  cases 
under  two  years  of  age;  in  older  children,  fifty.  Crepitant  rales  are 
usually  absent  because  of  the  superficial  breathing  caused  by  pain. 
Latency  of  physical  signs,  such  as  absence  of  bronchial  breathing, 
bronchophony,  or  dulness,  is  sometimes  noted.  Localization  is  more 
often  central,  apical,  or  migratory.  The  fever  may  rise  more  slowly 
and  lysis  is  more  frequent  than  in  adults.  Riviere  found  croupous 
pneumonia  as  frequently  (or  more  frequently)  in  children  under  two 
years  as  in  those  above  two  years.  In  118  cases  reported  by  Morse, 
50  of  them  occurred  in  the  first,  and  68  in  the  second  year  of  life. 

6.  In  the  Aged. — Pneumonia  is  frequently  latent,  insidious,  and 
asthenic,  with  ill-marked  signs,  without  chill,  even  without  fever, 
and  often  without  cough,  pain,  or  sputum. 

7.  In  Alcoholics. — The  same  latency  or  lack  of  type  may  be  noted. 
In  alcoholics  the  clinical  picture  of  delirium  tremens  masks  the  lung 
lesion. 

8.  Asthenic  Pneumonia. — In  asthenic  "typhoid,"  "biliary,"  or 
"toxic"  pneumonia,  toxaemia  is  dominant,  there  are  high  fever,  en- 
larged spleen,  albuminuria,  often  icterus,  mixed  infections,  severe 
complications,  such  as  meningitis  or  gangrene,  and  high  mortality. 
These  asthenic  cases  contrast  strongly  with  what  we  might  call "  walking 
pneumonia."  The  author  has  had  two  patients  who  worked  through- 
out the  clinical  course. 

9.  Pneumonia  Secondary  to  Other  Diseases. — Pneumonia  may  be 
secondary  to  tuberculosis,  emphysema,  arteriosclerosis,  hepatic  cir- 
rhosis, nephritis,  diabetes,  typhoid,  influenza,  diphtheria,  and  plague. 
Anaesthesia  by  ether  is  thought  to  predispose  toward  pneumonia  by 
irritation  of  the  respiratory  tract.  The  nose  and  mouth  should  be 
cleansed  before  ansesthetization  to  remove  native  fferms.  The  fre- 
quency  of  ether  pneumonia  in  abdominal  operations  suggests  the 
possibility  of  embolism  as  a  factor. 

Various  microorganisms  are  found — colon  bacillus,  streptococcus, 
etc.     The  physician  may  often  fail  to  recognize  this  type  because 


PNEUMONIA  151 

it  is  atypical,  ill  developed,  or  masked  by  the  primary  disease. 
Pathologically,  the  hepatization  is  rarely  typical  and  is  more  lobular 
than  lobar;  the  lung  section  is  smooth  and  moist,  and  the  exudation 
is  more  cellular  than  fibrinous. 

10.  Delayed  or  Imperfect  Resolution. — Normal  resolution  is  chiefly 
effected  by  lymphatic  absorption,  for  the  sputum  voids  but  little  of 
the  exudate,  (a)  Slow  resolution  may  require  several  weeks  or  even 
months,  especially  in  apical  involvement,  and  is  more  often  seen 
after  lysis  than  crisis.  The  toxsemia  disappears  but  dulness  and 
bronchial  breathing  persist.  (6)  Imperfect  clearing  up  of  the  lung 
may  be  caused  by  abscess  formation,  old  pleuritic  adhesions,  fresh 
pericarditis,  or  inflammatory  involvement  of  the  connective  tissue 
and  lymphatic  vessels.  Induration  of  the  lung  by  organization  of 
the  exudate  is  usually  febrile  (Fraenkel).  (c)  The  so-called  pneu- 
monia migrans  is  a  pneumonia  which  slowly  progresses  from  one  part 
to  another. 

Diagnosis. — Mistakes  are  rare  in  the  diagnosis  of  primary,  frank 
pneumonia  in  adults — they  occur  mostly  in  cases  of  aged  individuals, 
of  alcoholics,  of  children,  and  in  cases  of  pneumonia  secondary  to 
cancer,  nephritis,  diabetes,  etc.  Therefore,  all  cases  with  chronic 
disease  must  be  closely  examined  when  the  respiration,  pulse,  and 
temperature  rise,  or  when,  even  without  these  or  other  symptoms,  the 
subject  of  chronic  disease  is  not  doing  well. 

1.  Onset  Symptoms. — The  chill  in  adults,  convulsions  in  children, 
which  occur  also  in  such  other  diseases  as  nephritis,  infantile  palsy, 
and  alimentary  catarrh,  vomiting  in  the  very  young  or  in  adolescents, 
suggest  the  possible  onset  of  lobar  pneumonia.  Chill,  pain  in  the 
side,  sudden  high  fever,  and  rusty  sputum,  are  almost  sure  symptoms, 
because  pneumonia  is  practically  the  only  disease  in  which  they  occur. 
Care  must  be  taken  to  avoid  the  chief  diagnostic  confusion — infarct 
of  the  lung — in  which  the  same  symptoms  may  obtain,  but  in  which 
the  sputum  is  reddish,  is  not  viscid,  is  usually  darker,  and  far  more 
abundant  than  in  pneumonia.  In  25  per  cent,  of  cases  the  onset  of 
pneumonia  is  not  typically  brusque,  but  the  physical  findings  of  pneu- 
monia are  present  without  a  history  suggestive  of  the  disease ;  indeed 
it  may  rather  be  suggestive  of  simple  pleurisy,  grippe,  etc.  The  pro- 
fession regards  pneumonia  as  a  disease  with  a  severe  onset,  but  the 
laity,  and  with  reason,  emphasize  the  importance  of  antecedent  ex- 
posure, colds,  or  bronchitis.  The  prodromes  of  pneumonia  are  too 
often  disregarded  by  physicians,  even  when  they  carefully  exclude 
pneumonia  which  is  strictly  secondary  to  other  acute  or  chronic  dis- 
ease. In  a  very  appreciable  percentage  of  cases  the  prodromata  are 
not  brief  and  may  last  longer  than  two  or  three  days,  or  even  a  week. 

2.  Diagnosis  from  the  Physical  Findings. — The  physical  findings  are 
usually  detected  in  the  typical  case  upon  thorough  examination,  and 
as  a  rule  usually  appear  within  two  days  after  the  characteristic  symp- 
toms of  onset.  They  are  the  well  known  lessened  expansion  on  the 
side  of  the  lesion;    increased  vocal  fremitus;    distinct  dulness;    bron- 


152  THE  SPECIFIC  INFECTIONS 

chial  breathing;  the  crepitant  rale;  the  grunting,  abbreviated,  ex- 
piratory "huh"  sound,  and  a  bronchial  tone  to  the  whispered  or 
louder  voice  sounds.  Typical  as  are  these  simple  findings  in  their 
usual  grouping,  and  easily  recognized  as  they  are  when  the  student 
or  practitioner  has  once  heard  and  learned  them,  nevertheless  many 
conditions  modify  their  classical  appearance  and  character.  Thus, 
the  fremitus  is  decreased  in  massive  consolidations  which  render  tense 
the  chest  wall,  in  coincident  pleural  effusions  or  in  fibrinous  plugging 
of  the  bronchi.  The  latter  may,  however,  usually  be  dislodged  by 
repeated  coughing.  The  dulness  is  found  only  in  hepatization  which 
is  nearly  complete  and  is  both  preceded  and  followed  by  a  tympanitic 
note.  The  crepitant  rale  is  found  only  in  the  first  and  third  stages, 
but  in  almost  every  case  can  be  found  in  some  part  of  the  affected 
lung.  Bronchial  breathing  is  rudimentary  or  absent  in  incomplete 
hepatization,  is  often  so  in  upper-lobe  pneumonias,  in  complicating 
effusive  pleurisy,  and  in  obstructed  bronchi.  These  physical  symp- 
toms are  pathognomonic  only  in  connection  with  the  cyclic  course 
of  the  disease,  the  symptoms  of  onset,  the  disturbed  pulse  and  respi- 
ration ratio,  the  pneumohsemia,  diminished  chlorides,  herpes,  leuko- 
cytosis and  crisis. 

3.  Localization. —  Massive  pneumonia  (total  pneumonia  of  one 
side)  not  infrequently  simulates  pleurisy,  because  fibrinous  plugging 
of  the  bronchi  is  not  uncommon^  and  prevents  bronchial  breathing, 
bronchophony,  and  the  crepitant  rale;  and  again,  the  fremitus  may 
be  absent  together  with  some  slight,  although  rarely  essential,  luxa- 
tion of  neighboring  viscera.  Consideration  of  the  onset,  the  later 
cyclic  course,  and  the  dislodging  of  the  plugs  by  forcible  coughing, 
almost  invariably  determine  the  diagnosis.  Too  much  is  generally 
said  about  central  pneumonia.  Such  cases  exist  beyond  doubt, 
but  considerable  conservatism  is  necessary  in  their  diagnosis.  All 
pneumonias  are  central  in  their  incipiency  but  rarely  remain 
so.  The  author  lately  demonstrated  a  case  in  clinic  in  which 
everything  pointed  to  pneumonia,  but  the  local  findings  did  not  ap- 
pear for  a  week,  although  they  were  carefully  searched  for  twice 
a  day. 

4.  In  Children. — Pneumonia  in  children  may  be  mistaken  for 
abdominal  disease,  for  pleurisy,  or  for  brain  affections.  The  "cere- 
bral pneumonia"  of  Rilliet  and  Barthez  may  be  (a)  convulsive,  occur- 
ring under  two  years,  with  fever,  vomiting,  and  convulsions;  but  the 
evenly  high  fever  is  very  suggestive  even  if  the  cough  and  dyspnoea 
are  obscured  by  the  brain  symptoms;  or  (6)  meningeal,  occurring 
between  the  second  and  sixth  years;  but  the  pulse  is  not  slow,  and 
there  is  no  deep  breathing,  nor  change  of  color  in  the  cheeks,  as  is 
observed  in  meningitis. 

5.  Differentiation  from  Pleurisy. — The  differentiation  is  usually  easy, 
but  confusion  is  unfortunately  common. 

The  history  may  be  suggestive  but  it  can  l>e  indefinite,  especially  in 
hospital  cases. 


PNEUMONIA 


153 


Pneumonia- 


-Pleuritic  Effusion. 


Onset  sudden,     with     chill,     vomiting, 
herpes. 

Friction  less  common;    may  be  present. 

Cyclical  short  course;    high  fever,  crisis. 

Sputum  rusty. 
Leukocytosis. 

Ectasia  absent. 

Fremitus   increased    (coughing    usually 
dislodging  bronchial  plugs). 


Dulness,  preceded  and  succeeded  by 
tympany  (tympany  or  partial  dul- 
ness in  upper-lobe  pneumonia  is 
not  uncommon). 


Crepitant  rales,  bronchial  breathing  (un- 
less bronchus  is  plugged),  and  bron- 
chophony. 


No  essential  luxation  of  heart,  liver  or 
spleen  (except  the  slightest  in  pneu- 
monia massiva). 

Paracentesis  negative. 


Gradual;  chilly  sensations  rather  than 
rigor. 

Usually,  at  some  time  in  the  clinical 
course. 

Longer  duration,  lower  fever,  lysis. 
Often  tuberculous  foci  at  apex,  etc. 

Mucous,  if  any. 

Usually  absent,  unless  purulent  or  com- 
plicating a  pneumonia. 

Present. 

Absent  over  effusion  unless  irregular 
adhesions  bind  the  lung  in  places  to 
the  chest  wall;  increased  above  over- 
compressed  lung  or  in  the  inter- 
scapular region. 

Flatness,  increased  downward;  enter- 
ing Traube's  space  on  the  left  side, 
unless  adhesions  forbid.  Level  may 
occasionally  shift  with  change  of 
position.  (See  Fig.  33  under  Pleu- 
risy). 

Decreased  or  absent  respiratory  murmur; 
we  may  have  bronchial  breathing  in 
interscapular  region  from  compres- 
sion, or  even  through  the  fluid,  both 
in  adults  and  children;  segophony. 

Luxation  of  viscera  named,  is  usual  but 
not  invariable,  even  in  large  effusions. 


Tapping  nearly  always  decides  doubtful 
cases;  fluid  is  found  over  the  flat  area. 


In  lung  tumors,  bronchial  breathing,  bronchophony,  duhiess,  red 
(or  green)  sputum,  are  also  noted,  but  the  history  suffices  for  differen- 
tiation. In  acute  tuberculous  infiltration,  the  course  differentiates  it 
from  upper-lobe  pneumonia  by  the  gradual  onset,  in  which  cough 
sputum,  and  typical  physical  findings  are  absent.  Many  mistakes 
in  both  directions  are  made,  simply  by  forgetting  that  pneumonia 
may  occur  in  the  apices,  in  which  the  incomplete  exudation  may  im- 
part a  tympanitic  note,  and  that  the  breath  sounds  are  not  always 
typically  bronchial,  at  least  anteriorly.  In  some  cases  tuberculous 
pneumonia  may  commence  like  lobar  pneumonia  (see  Acute 
Pneumonic  Form,  under  Course  of  Pulmonary  Tuberculosis). 

Prognosis. — Pneumonia  is  the  most  fatal  acute  disease  and  even 
has  a  greater  death-rate  than  tuberculosis.  In  1903,  4,629  persons 
died  of  pneumonia,  in  Chicago,  and,  in  1904,  8,360  died  of  it  in  New 
York  City.     From  1851  to  1890,  the  mortality,  in  Chicago,  from  tuber- 


154  THE  SPECIFIC  IXFECTIOXS 

culosis,  was  35  per  cent,  more  than  from  pneumonia.  From  1891  to 
1901,  the  pneumonia  death-rate  was  9  per  cent,  more  than  the 
tuberculosis  mortaHty. 

There  are  various  prognostic  factors :  (a)  Tlie  virulence  of  the  pneu- 
mococcus,  which  varies  from  year  to  year  (5  per  cent,  mortality  in  one 
year,  31  per  cent,  in  another,  Brandes).  The  mortality  of  85,000  cases 
in  the  German  army  was  3i1j  per  cent.,  but  these  are  necessarily 
selected  cases.  In  hospitals  the  mortality  ranges  between  20  and  40 
per  cent.,  and  is  due  to  alcoholism,  to  excesses,  and  to  overwork.  In 
465,400  collected  cases,  E.  F.  Wells  found  20  per  cent,  the  average 
death-rate. 

(b)  Age. — According  to  Fraenkel,  the  mortality  is:  one  to  five 
years,  30  per  cent.;  five  to  ten  years,  3  per  cent.;  ten  to  twenty  years, 
5  per  cent.;  twenty  to  thirty  years,  8  per  cent.;  thirty  to  forty  years, 
25  per  cent.;  forty  to  fifty  years,  39  per  cent.;  fifty  to  sixty  years,  43 
per  cent. ;  sixty  to  seventy  years,  53  per  cent. ;  seventy  to  eighty  years, 
87  per  cent.  The  aged  succumb  readily;  long  ago  Cruvelhier  spoke 
of  pneumonia,  in  this  connection,  as  the  most  formidable  scourge, 
and  Peter  characterized  pneumonia  as  the  natural  end  of  old  people. 
Morse,  in  118  children,  found  the  mortality  36  per  cent,  in  the  first 
year  and  19  per  cent,  in  the  second;  Reviere,  25  per  cent,  in  the  first, 
15  per  cent,  in  the  second  year,  and  2  per  cent,  in  older  children. 

(c)  Sex. — The  mortality  is  50  to  100  per  cent,  higher  in  women;  in 
pregnancy  the  disease  is  always  severe. 

(d)  Location. — Right-sided  pneumonia  is  more  fatal  than  left- 
sided  pneumonia,  and  the  upper-  is  more  fatal  than  lower-lobe 
involvement.     Extension  from  lobe  to  lobe  is  serious. 

(e)  Unfavorable  Conditions. — These  are  hepatic  cirrhosis  and  ne- 
phritis, in  which  the  death-rate  is  almost  100  per  cent.;  delirium 
tremens  and  inveterate  alcoholism,  in  which  it  is  45  to  50  per  cent., 
cardiovascular  disease,  scoliosis,  and  high  altitude,  render  the  dis- 
ease dangerous. 

(/)  Unfavorable  Symptoms. — These  are  long  prodromata,  hyper- 
pyrexia, enteritis,  marked  jaundice,  albuminuria,  severe  pain,  marked 
cyanosis,  pulmonary  oedema,  diffuse  bronchitis,  and  a  white  cell- 
count  under  10,000.  Sears  and  Larabee  found  the  mortality  9  per 
cent,  with  the  respirations  under  30,  15  per  cent,  under  40,  and  60  per 
cent,  over  60  per  minute;   and  50  per  cent,  with  the  pulse  over  130. 

(g)  Unfavorable  Complications. — Endocarditis  and  meningitis  are 
almost  always  fatal;  abscess,  gangrene,  and  arthritis  are  always  serious; 
pericarditis  is  fatal  in  50  to  75  per  cent,  of  the  cases. 

Strictly  speaking,  death  is  due  in  almost  all  cases  to  cardiac  toxxBinia. 
Mechanical  overwork  of  the  heart  or  diminished  respiratory  space  are 
of  small  importance. 

Treatment. — {A).  Prophylaxis. — Prophylaxis  concerns  disinfection 
of  the  sputum,  cleansing  of  the  room,  isolation,  and  maintenance  of 
the  physiological  resistance.  Cleansing  of  the  nose  may  be  of  value 
in  prevention. 


PNEUMONIA  155 

{B).  Serotherapy. — Serotherapy  has  not  proved  successful,  and 
pneumonia  remains  a  self-limited  disease. 

(C).  Hygiene. — The  hygiene  is  the  same  as  in  typhoid.  Quiet 
should  be  ma^intained,  the  mouth,  especially,  should  be  cared  for,  and 
the  patient  should  be  clothed  with  a  light  flannel  jacket  open  down 
the  back. 

(D).  Diet. — The  diet  consists  of  milk,  eggs,  and  cereals. 

{E).  Symptomatic  Therapy. — 1.  The  Chill. — The  chill  is  rarely 
seen  by  the  physician,  but  the  same  measures  are  indicated  as  in 
malaria. 

2.  Cough. — For  the  cough,  nauseating  expectorants  are  to  be  avoided 
and  codeine  gr.  j,  and  carbonate  of  ammonium  gr.  iij,  should  be  given 
every  two  to  four  hours.  If  these  are  ineffectual,  or  disturb  the  stom- 
ach, morphine  is  indicated  (v.i.). 

3.  Pain. — For  pain,  the  chest  should  be  firmly  strapped  with  adhe- 
sive plaster,  applied  in  several  oblique  directions  so  that  the  pieces 
cross  each  other.  Morphine  does  not  essentially  depress  respiration 
but  rather  lessens  the  irritability  of  the  respiratory  centre  and  re- 
lieves pain.  Poultices  can  be  more  easily  endured  than  ice,  but 
neither  are  essential.  Blisters,  leeches,  and  the  Paquelin  cautery  are 
superfluous.  In  pneumonia,  general  is  far  more  important  than  local 
treatment. 

4.  Heart. — Care  of  the  heart  is  the  main  objective  in  the  treatment. 
Constant  watching  is  imperative  lest  the  delirious  patient  leave  his 
bed,  and  it  is  a  safe  rule  to  consider  all  pneumonics  delirious.  Sitting 
up  to  drink,  defecate,  or  urinate,  should  never  be  allowed,  as  pneumonia 
is  a  disease  of  sudden  and  alarming  changes  and  there  is  constant 
danger  of  sudden  death.  No  therapeutic  measure  should  be  em- 
ployed which  depresses  the  heart,  and  therefore  antipyrin,  antimony, 
aconite,  and  pilocarpine,  are  always  to  be  avoided. 

Cardiac  Stimulation. — Strychnia. — Strychnia,  grs.  2^0  to  30  every 
two,  three,  or  four  hours,  is  the  best  heart  tonic,  and  should  be 
given  in  every  case  because  of  the  cardiac  and  vasomotor  instability 
which  often  develops  without  warning.  Vasomotor  paralysis  and 
collapse  are  attended  by  accumulation  of  blood  in  the  abdominal 
vessels.  Von  Basch  observed  that  pallor  of  the  retinal  vessels  followed 
section  of  the  splanchnic  nerve.  Gottlieb  prefers  caffeine  and  camphor 
to  strychnine  for  vasoparesis.  He  holds  that  the  dosage  of  strychnine 
necessary  to  constrict  the  vessels  is  too  nearly  the  dose  likely  to  pro- 
duce convulsions.  The  opinion  of  the  distinguished  pharmacologist 
will  not  receive  general  support  from  clinicians  and  practitioners. 
In  the  collapse  caused  by  acute  toxaemia  or  other  conditions,  the  vaso- 
dilatation is  general,  but  particularly  concerns  the  deep  abdominal 
vessels.  Strychnine  is  here  indicated,  not  only  because  of  its  general 
effects  but  because  of  its  powers  of  vasoconstriction  on  the  deep  ves- 
sels, since  it  is  known  that  the  drug  tones  the  abdominal  vessels, 
(while  the  vascular  tonus  in  the  skin  and  brain  is  not  increased),  and 
thereby  flushes  the  brain  vessels  and  stimulates  the  bulbar  vasomotor 


156  THE  SPECIFIC  IXFECTIOXS 

and  other  vital  centres.  Cold  has  an  analogous  effect  on  the  splanch- 
nic nerve.  The  drug  stimulates  (1)  the  central  nervous  system;  (2) 
the  digestive  tract,  the  secretions,  and  peristalsis;  (3)  the  circulation, 
the  heart-muscle,  and  chiefly  the  vasomotor  centre,  and  (4)  the  respi- 
ratory centre. 

Administration. — Some  strychnine  remains  in  the  system  from  three 
to  eight  days,  though  some  is  destroyed  at  once  by  the  liver,  and  some 
is  quickly  eliminated  by  the  kidneys.  If  the  kidneys  or  liver  are  dis- 
eased or  functionally  tardy,  as  they  are  in  old  age,  the  drug  may  ac- 
cumulate. Full  doses  sometimes  produce  nervousness,  irregular  heart, 
palpitation,  or  renal-vessel  spasm,  as  does  digitalis.  Strychnine  is 
absorbed  more  quickly  by  rectum  than  by  the  stomach.  Hypodermic 
administration  gives  less  chance  for  the  liver  to  destroy  the  drug  than 
does  administration  by  mouth. 

Ammonia. — The  preparations  of  ammonia  are  of  the  greatest  clin- 
ical importance.  They  temporarily  stimulate  the  heart-muscle,  in- 
crease its  frequency,  and  constrict  the  vasomotor  system,  thereby 
raising  arterial  tension.  Its  effects  are  soon  observed  in  local  flush- 
ing, subjective  warmth,  tension  in  the  temples,  a  sense  of  exhilaration, 
and  increase  in  the  urine,  sweat,  and  mucous  secretion.  The  prime 
indication  for  ammonia  is  sudden  and  functional  cardiac  adynamia, 
which  occurs  at  the  crisis.  It  is  a  local  irritant  to  the  skin  and  to  the 
subcutaneous  tissues  as  well  as  to  the  respiratory  and  alimentary 
mucosfe,  and  therein  lie  its  therapeutic  value  and  its  clinical  disad- 
vantages. Its  irritant  or  stimulant  properties  upon  the  nose,  mouth, 
and  upper  respiratory  tubes  cause  a  sudden  reflex  stimulation  of  the 
respiratory  and  circulatory  centres,  which  follows  its  application  to 
the  nose,  and  its  use  as  smelling-salts;  and  cause  the  centripetal 
stimulation,  which  travels  from  the  throat,  oesophagus,  and  stomach, 
to  the  brain,  long  before  the  drug  is  absorbed.  Untoward  action  is 
frequently  observed  in  gastric,  intestinal,  renal  and  bronchial  irrita- 
tion resulting  from  overdoses,  and  also  in  undue  irritation  or  necrosis 
following  subcutaneous  administration.  The  corrosiveness  and  fugi- 
tive action  of  ammonium  carbonate  are  both  very  relative  contra-indi- 
cations,  and  are  ob^dated  by  administration  of  small  and  frequent 
doses,  gr.  iij  every  two  hours. 

Digitalis. — Digitalis  was  recommended  by  Traube  and  Petrescu, 
who  considered  75  to  150  (!)  grains  necessary  for  good  results.  The 
administration  of  these  large  doses  simply  proves,  in  the  author's 
opinion,  that  the  digitalis  is  not  absorbed.  It  is  claimed  that  exuda- 
tion is  modified  and  that  leukocytosis  is  increased.  Personally,  the 
author  has  never  seen  digitalis  produce  such  good  result  as  strychnine 
does,  but  he  has  repeatedly  noticed  toxic  symptoms  appear  at  the 
crisis  when  the  repeated  doses  were  absorbed  together.  Collapse 
may  occur.  Digitalis  should  be  used  only  as  a  last  resort,  m  ij  to  v  of 
fluid  extract  (the  most  reliable  preparation)  should  be  given  hypoder- 
matically.  The  author  believes  digitalin  is  almost  inert  (see  Treat- 
ment OF  Valvular-  Heart  Disease). 


PNEUMONIA  157 

Alcohol. — The  chief  interest  centres  in  its  action  upon  the  circu- 
lation. For  years  it  has  been  called  a  heart  stimulant,  though  important 
objections  have  been  raised  to  this  statement.  The  frequency  of  the 
heart's  action  is  increased,  but  it  is  known  beyond  all  doubt  that  the 
drug  acts  as  a  vasodilator  or  as  a  blood  distributor.  No  pharmacol- 
ogist now  holds  that  alcohol  stimulates  the  heart  as  do  digitalis, 
strychnine,  or  camphor.  Some  clinicians  use  alcohol  for  weakened 
circulation  in  typhoid,  pneumonia,  or  sepsis,  and  obtain  good  results. 
Other  practitioners  refuse  to  employ  it  because  it  is  narcotic  to  the 
nervous  system  and  to  the  vital  respiratory,  circulatory,  and  vasomotor 
centres  in  the  lower  brain.  Some  of  the  latter  class  refuse  to  use  it 
on  account  of  prejudice  and  others  base  their  opinions  on  the  labora- 
tory results  given  above.  It  must  be  admitted,  however,  that  alcohol 
has  some  good  effects.  Direct  cardiac  stimulation  by  alcohol  per  se 
is  impossible,  except  in  preparations  like  champagne  which  contain 
other  ingredients.  Alcohol  was  first  recommended  by  Todd  for  fevers. 
It  is  effective  in  all  varieties  of  sepsis.  It  protects  tissues  from  exces- 
sive waste  and  is  well  tolerated  in  nearly  all  cases.  There  is  no  danger 
of  cardiac  collapse  when  it  is  withdrawn  in  convalescence.  Jiirgen- 
sen  gives  it  in  all  cases,  using  red  Bordeaux  wine  as  a  routine  proce- 
dure, especially  if  cool  baths  are  employed.  If  the  heart  becomes 
weaker,  Bordeaux  is  replaced  by  the  stronger  sherry  or  port;  then  by 
rum,  cognac,  champagne,  or  whiskey  in  hot  water,  and  tea  or  coffee, 
which  can  also  be  given  by  rectum.  Alcohol  is  invaluable,  whatever 
its  action;  it  is  second  only  to  strychnine  and  is  indicated  by  collapse 
or  cardiac  toxaemia  in  which  hot  whiskey  and  water  unquestionably 
stimulate  by  reflex  action  on  the  throat  and  stomach. 

Ether. — Dram  doses  may  be  injected  for  urgent  cardiac  symptoms, 
but  it  is  apt  to  produce  sloughing. 

Opiates. — It  is  the  author's  personal  belief  that  opium  and  morphine 
are  not  sufficiently  recognized  as  vascular  and  cardiac  tonics.  Many 
clinicians  withhold  opiates  in  pneumonia  even  when  the  drug  is  indi- 
cated by  maniacal  outbursts,  active  delirium,  and  harrassing  coughing 
or  pain,  because  it  depresses  respiration,  and  ill  effects  upon  the  circu- 
lation are  feared.  When  used  freely,  it  decreases  the  irritability  of  the 
respiratory  centres,  and  thereby  lessens  cough  and  dyspnoea,  and  the 
attendant  headache  and  insomnia,  and  it  almost  invariably  acts  as  a 
strong  cardiovascular  tonic.  Its  effects  on  diseased  kidneys  are  not 
to  be  feared  with  ordinary  care  in  administration.  Morphine  will 
of  itself  help  to  sustain  life,  and  in  several  most  critical  cases,  where 
the  author  has  watched  its  effects  for  consecutive  hours,  its  hypodermic 
use  has  strengthened  and  regulated  respiration  even  when  Cheyne- 
Stokes  respiration  was  marked.  When  the  heart  weakens,  its  force 
will  often  be  renewed  by  morphine.  It  is  a  most  valuable  adjunct  to 
the  true  cardiovascular  stimulants,  either  those  which  have  continued 
action,  as  strychnine  and  digitalis,  or  those  whose  action  is  more  fugi- 
tive, such  as  camphor,  ammonia,  or  caffeine,  which  latter  has  an 
excellent  effect,  given  by  rectum,  in  neutralizing  the  effects  of  opiates. 


158  THE  SPECIFIC  INFECTIONS 

Camphor. — Camphor  in  grains  i  to  ij,  hypodermaticaUy  in  10 
parts  of  sterilized  oil,  every  two  to  four  hours,  is  an  excellent  diffusive 
stimulant  for  the  heart  and  brain. 

Saline  Infusions. — These  are  indicated  in  profound  toxaemia  with 
weak  heart.  Two  drams  of  salt  in  one  quart  of  water  are  the  rough 
proportions  of  the  physiological  salt  solution.  They  are  the  "lavage 
of  theblood"  of  French  writers,  who  combine  them  with  venesection. 
Although  once  violently  abused,  venesection,  which  has  been  employed 
since  the  time  of  Hippocrates,  has  again  come  more  into  vogue.  It 
is  valuable  at  the  very  onset  in  the  robust  for  severe  pain,  active  de- 
lirium, and  urgent  dyspnoea,  and  later  when  great  engorgement  of 
the  right  heart  occurs.  It  rather  promotes  heart  thrombosis  and  de- 
layed resolution.     Heart  stimulants  must  be  used  with  phlebotomy. 

Oxygen.^Oxygen  is  said  to  relieve  dyspnoea,  and  has  been  used 
as  an  adjunct  to  the  heart  stimulants,  but  recent  studies  have  shown 
that  it  is  often  irritating  and  injurious.  A  mouth-piece  should  not  be 
employed,  or  at  least  not  held  closely  over  the  mouth,  but  merely 
near  it. 

Atropine. — Atropine  is  valuable  in  collapse  with  low  temperature 
and  clammy  skin.  The  aggregate  dosage  should  not  exceed  one- 
fortieth  of  a  grain. 

5.  Antipyretics. — A  high  temperature  is  not  per  se  injurious.  In- 
deed, Cantani  proved  that  cases  with  fever  between  103°  and  105°  pro- 
gress most  favorably  and  that  those  with  temperature  above  or  below 
these  limits  have  a  more  severe  course.  Von  Jiirgensen  insists  that 
all  measures  or  remedies  which  suddenly  reduce  the  temperature  must 
be  avoided.  They  are  especially  injurious  at  the  crisis,  when  the 
heart  sometimes  staggers  under  the  sudden  fall  of  the  fever. 

Hydrotherapy  is  opposed  by  many.  Marchand  considers  that  it 
promotes  chronic  induration  of  the  lung,  though  Liebermeister  les- 
sened the  mortality  in  his  cases  by  9  per  cent.  The  tonic  vasomotor 
effects  are  thought  to  outweigh  the  element  of  shock.  It  is  less  indi- 
cated in  children  and  is  contraindicated  in  the  very  obese,  the  weak, 
or  the  aged.  Cool  sponging  with  water  and  alcohol  is  the  safest  method. 
Quinine  gives  no  antipyretic  effect  except  in  doses  of  thirty  grains 
or  more.  Its  administration  is  advocated  by  Aufrecht,  Jiirgensen  and 
See,  who  give  thirty  grains  at  6  to  8  p.m.,  thereby  bringing  about  a 
slow  reduction  of  temperature  without  cardiac  depression.  Aufrecht 
combines  it  with  iron. 

6.  Neevous  Symptoms. — These  are  toxtemic,  but  should  be  con- 
sidered with  regard  to:  (a)  fever;  the  greater  the  temperature  varia- 
tion, the  more  marked  are  the  nervous  symptoms;  febrile  nervous 
symptoms  are  most  efficaciously  treated  by  baths  or  cool  affusions; 
(6)  anaemia,  the  delirium  of  which  is  relieved  by  morphine,  coffee, 
alcoholic  and  saline  infusions;  (c)  deficient  oxygenation,  in  which 
cold  baths,  cardiants,  and  oxygen  inhalations  are  indicated;  (d)  in- 
somnia, which  is  treated  by  morphia,  bromides,  hyoscine  hydrobro- 
mate,  sulphonal,  and  cool  sponging,  but  never  by  chloral;  (e)  delirium 


DIPHTHERIA  159 

tremens  (g.  v.),m  which  rest  is  absolutely  necessary  and  is  best  secured 
by  the  drugs  named  under  {d)  and  by  alcohol. 
.    7.  Tympany, — (See  Typhoid.) 

8.  loDiDEf?  AND  Cod-liver  Oil. — These  should  be  given  in  delayed 
resolution. 

DIPHTHERIA. 

Definition. — An  acute  specific  infective  disease,  which  usually  be- 
gins in  the  throat  or  upper  air-passages,  and  is  characterized  by  a 
local  yellowish  adherent  membrane  which  is  due  to  the  Klebs-Loeffler 
bacillus,  and  by  constitutional  symptoms  due  to  toxaemia. 

History. — Diphtheria  was  known  to  Hippocrates.  Asclepiades, 
100  B.C.,  performed  the  first  tracheotomy.  The  name  diphtheria 
literally  means  membrane  and  originated  with  Bretonneau   (1821). 

Terms  and  Restrictions. — True  diphtheria  implies  a  membrane 
formed  by  the  Klebs-Loeffler  bacillus  whose  absorbed  toxins  usually 
also  produce  toxaemia.  There  are,  however,  membranes  not  formed 
by  this  bacillus  but  due  to  the  scarlatinal  virus,  streptococci,  pneumo- 
cocci,  staphylococci,  caustics,  etc.  While  these  are  diphtheritic  mem- 
branes in  the  old  anatomical  sense,  they  are  not  diphtheritic  in  the 
bacteriological  sense.  We  must  then  term  them  •pseMdodiphtheritic 
or  necrotic  inflammation,  or  diphtheroid.  Therefore,  clinically,  there 
are  some  discrepancies:  (1)  what  seems  diphtheria,  anatomically,  may 
prove  not  due  to  the  Klebs-Loeffler  bacillus;  (2)  some  apparently 
simple  throat  inflammations,  resembling  angina  or  tonsillitis,  may 
show  no  membrane  or  atypical  membrane,  but  bacteriologically  are 
found  due  to  the  Klebs-Loeffler  bacillus,^ — i.  e.,  are  true  diphtheria; 
(3)  the  diphtheria  bacillus  is  found  in  1  per  cent,  of  perfectly  healthy 
throats;  (4)  there  are  bacilli  which  closely  simulate  the  diphtheria 
bacillus  (v.  ?'.).  The  pseudodiphtheritic  or  diphtheroid  membrane  is 
most  often  due  to  the  streptococcus  and  is  seen  oftenest  in  scarlatina, 
but  also  in  typhoid,  measles,  Vincent's  angina,  syphflis  and  pertussis. 
It  develops  not  merely  in  the  throat,  but  wherever  the  true  diphtheritic 
membrane  may  occur, — e.  g.,  the  larynx,  bronchi,  eyes,  skin,  etc.  As 
a  working  statement,  most  cases  clinically  resembling  diphtheria  are 
proved  diphtheria  by  close  and  repeated  bacteriological  tests.  G. 
Smith  found  the  bacillus  in  72  per  cent,  of  27,000  collected  cases, 
though  Parks  and  Bebee  find  40  per  cent,  of  membranes  diphtheroid — 
a  high  estimate. 

Bacteriology. — The  diphtheria  bacillus  (described  by  Klebs,  1883, 
and  cultivated  by  Loeffler,  1884),  is  1.2  to  2/z  long  and  0.3  to  O.Bjn 
wide,  with  small  round  ends,  or  ends  slightly  enlarged.  It  stains 
readily  by  Gram's  method, by  Loeffler's  methylene  blue,  and  by  carbol 
fuchsin.  There  are  many  irregular  variations  in  form,  such  as  branch- 
ing types,  but  the  serum  culture  always  reveals  the  wedge  or  mallet- 
like forms.  Some  are  very  long,  others  short  and  parallel.  Their 
grouping  is  characteristic,  like  Chinese  letters,  in  lines  set  asymmetri- 


160 


THE  SPECIFIC  INFECTIONS 


cally  at  various  irregular  or  slight  angles.  They  are  immotile  and 
sporeless.  Cultivated  in  all  media,  the  diphtheric  bacillus  overgrows 
other  associated  bacteria  on  blood  serum.  On  blood  serum  mixed 
with  glucose  bouillon,  the  culture  is  visible  in  eight  to  ten  hours  as 
yellow  streaks,  whose  surface  is  slightly  granulated  and  whose  edges 
are  somewhat  thick.  In  twenty-four  hours  the  growths  have  spread 
everywhere,  with  a  wavelike  surface,  high,  undulating  edges,  and  a 

Fig.  17. 


BaciUus  diphtheriae:    A,  its  morphology  on  glycerin-agar-agar;    B,  its  morphology  on  Loeffler's 
blood-serum;  C,  its  morphology  on  acid  blood-serum  mixture  (Abbott). 

succulent,  glistening  appearance.  The  diphtheria  bacillus  is  very 
resistant,  and  though  it  usually  disappears  in  two  or  three  weeks 
after  the  patient  has  shed  the  membrane,  it  may  live  for  weeks  or 
months  in  the  throat  (even  six  to  fifteen  months)  or  for  a  long  period 
in  clothing.  It  is  found  chiefly  in  the  throat  membrane,  and  is  less 
frequently  detected  in  the  submucosa,  heart  (endocarditis),  blood, 
lungs  (bronchopneumonic  foci),  spleen,  liver,  brain,  cord,  kidney  or 
urine.  In  one  report,  it  was  said  to  have  been  found  in  the  blood 
and  viscera  eleven  times  in  fourteen  cases.  Its  presence  in  these  parts 
has  been  explained  by  what  we  may  call  diphtheritemia,  by  post-mor- 
tem migration,  or  by  association  with  other  bacteria,  of  which  the 
streptococcus  is  the  most  important,  being  found  in  septic  types,  in 
bronchopneumonia,  and  in  glandular  suppuration.  Symbiosis  with 
the  streptococcus,  which  is  the  most  common  of  all  secondary  infections 
and  enters  by  the  throat  mucosa,  increases  the  virulence  of  the  diph- 
theria toxin  (Roux  and  Yersin).  Less  important  are  the  staphylo- 
cocci—which  rarely  enter  through  the  throat,  but  when  they  do,  are 
extremely  virulent— the  proteus,  colon  bacillus,  and  'pneumococcus. 

The  action  of  the  bacillus  is  (1)  local,  disturbing  the  tissue,  produc- 
ing necrosis,  and  forming  membrane;    when  inoculated  in  animals. 


DIPHTHERIA 


161 


local  necrosis  develops,  whereon  fibrin  exudes  and  forms  a  membrane 
in  which  the  bacillus  is  found;  the  contiguous  tissues  are  oedematous; 
(2)  general,  forming  toxins  which  are  absorbed  by  the  blood  and  lymph- 
vessels.  Roux  and  Yersin  (1888)  found  that  the  toxins  injected  alone, 
after  killing  the  bacillus,  produce  a  general  intoxication,  but  no  mem- 
brane or  necrosis.  They  succeeded  in  producing  a  paralysis  precisely 
similar  to  the  post-diphtheritic  paralysis.  According  to  Ehrlich  there 
are  two  toxins;  one,  the  toxin,  produces  the  ordinary  acute  phenomena 
of  diphtheria;  and  the  other,  the  toxon,  produces  the  later  anaemia 
and  paralysis.  The  chief  receptors  of  the  virus  are  the  nervous  and 
lymphatic  tissues. 

The  virulence  of  the  germ  varies.  This  is  tested  on  the  guinea-pig 
by  inoculating  it  with  aSo  of  its  body-weight  of  a  forty-eight-hour 
bouillon  culture,  and  by  noting  the  results:  (1)  death  in  three  days 
or  less  results  from  fully  virulent  cultures;  (2)  death  in  three  to  five 
days  from  one  of  medium  virulence;  (3)  death  after  a  longer  time,  or 
only  local  changes  from  weak  cultures. 

Some  bacilli,  known  as  the  pseudodiphtheria  bacillus,  bacillus 
xerosis,  etc.,  microscopically  resemble  the  Hebs-LoefHer  bacillus. 


Pseudodiphtheria  Bacillus. - 


-Diphtheria  Bacillus. 


Luxuriates  on  gelatin  and  peptone  agar.         Sparing  growth. 


Produces  either  an  alkali  or  very  little 
acid  in  culture. 


"Klatsch  preparat"  (adhesion  prepara- 
tion) does  not  develop  in  six  or  eight 
hours,  and  if  it  has,  the  bacilli  are 
arranged  irregularly. 

Are  not  pathogenic  to  guinea-pigs. 
(Some  claim  this  type  is  only  an 
attenuated  form  of  the  real  bacillus.) 

Smaller. 


Growth  on  bouillon  should  produce  in 
twenty-four  hours  enough  acid  to 
neutralize  0.07  gm.  of  a  1-per-cent. 
sodium  hydrate  solution. 

Show  the  bacilli  in  colonies  arranged 
in  parallel  or  crossed  lines  within  six 
or  eight  hours. 

Kills  (v.s.)  in  seventy- two  hours. 
(Some  apparently  genuine  forms  may 
be  nonvirulent.) 


In  the  pseudodiphtheria  bacillus  Neisser's  stain  does  not  bring 
out  the  granules  which  are  present  in  the  true  diphtheria  bacillus, 
in  ox-serum  growths  under  twenty  hours  old;  the  body  of  the  diph- 
theria bacillus  stains  brown  and  its  two  to  four  polar  granules  stain 
a  deep  blue.  (Stain  preparation  for  one  to  three  seconds  in  a  solu- 
tion of  methylene  blue  1.0  gm.,  96  per  cent,  alcohol  20.0,  glacial 
acetic  acid  50.0,  and  water  950.0.  Wash  in  water  and  stain  again 
for  from  three  to  five  seconds  in  solution  of  vesuvin  2.0  and  1000.0 
gm.  boiling  water.)  Another  interesting  and  vital  point  is  that  pseu- 
dodiphtheria bacilli  may  become  virulent  and  may  kill;  they  are  not 
neutralized  by  the  diphtheria  serum  but  only  by  the  pseudodiph- 
theria serum  (Alice  Hamilton,  Spronek,  Ruediger). 

Dissemination. — Diphtheria  is  disseminated  (1)  by  patients  acutely 
ill  with  the  disease;  the  nasal,  throat  and  laryngeal  secretion  or  mem- 
11 


162  THE  SPECIFIC  INFECTIONS 

brane  may  be  coughed  into  the  face  or  mouth  of  one  of  the  family, 
of  the  nurse,  or  of  the  attending  physician.  Infections  in  which  the 
patient  is  not  kept  in  bed  are  especially  dangerous,  for  children 
going  to  school  may  impart  to  others  a  most  virulent  diphtheria, 
though  the  same  bacilli  have  produced  in  them  little  or  no  constitu- 
tional reaction;  (2)  by  healthy  individuals,  in  1  per  cent,  of  whom  the 
.germ  is  found  without  causing  diphtheria,  since  individual  predisposi- 
tion is  almost  as  necessary  to  infection  as  virulence  in  the  microbe; 
(3)  by  fomites,  especially  damp  cloths,  in  which  the  germ  may  live 
for  months;  cultures  have  been  made  from  dry  cloths  after  five  months; 
the  germ  lives  in  gelatin  from  twelve  to  eighteen  months;  (4)  as  the 
germ  may  be  cultivated  in  dust,  it  is  probable  that  it  may  be  spread 
by  the  wind.  Although  the  bacillus  has  been  cultivated  from  cheese, 
milk,  and  eating  utensils,  many  question  this  mode  of  propagation. 
It  is  not  demonstrated  that  domestic  animals  convey  the  disease. 
Diphtheria  is  endemic  in  all  thickly  populated  districts,  and  from 
these,  epidemics  develop  from  time  to  time.  Unlike  scarlatina,  which 
is  growing  milder,  diphtheria  epidemics  are  apparently  growing  in 
virulence,  although  they  are  far  less  malignant  than  in  the  middle  ages 
and  earlier  modern  times. 

Age. — Most  cases  occur  between  the  second  and  fifteenth  years; 
and  most  deaths  occur  between  the  second  and  fourth  years.  Adults 
are  frequently  affected.  Jacobi  has  seen  three  cases  in  the  new-born, 
but  infants  at  the  breast  are  far  less  exposed.  Creeping  children  are 
frequently  attacked,  because  their  hands  and  mouths  come  into  close 
contact  with  dirt  and  dust  (Jacobi).  It  develops  more  frequently  in 
girls  than  in  boys. 

Season. — Most  cases  occur  in  the  cold  months.  Predisposition, 
bad  teeth,  stomatitis,  hypertrophied  tonsils,  nasopharyngeal  and 
bronchial  catarrh,  measles,  and  nervous  affections,  are  predisposing 
factors.  Some  individuals  are  temporarily,  and  some  permanently, 
immune.  One  attack  confers  no  immunity,  and  in  this  respect  diph- 
theria resembles  erysipelas,  pneumonia,  and  rheumatism. 

Ssnnptoms.^ — Baginsky's  classification  of  (1)  local  infection,  (2) 
general  infection,  and  (3)  septic  infection,  is  better  than  the  old 
division  into  mild,  moderate,  and  severe  forms.  Incubation  lasts  from 
two  to  seven  days. 

1.  The  simple  localized  diphtheria  begins  with  fatigue,  sopor, 
pallor,  coated  tongue,  anorexia,  dysphagia,  pain  beneath  the  angle 
of  the  jaw,  and  vomiting.  These  may  be  the  only  symptoms,  but 
usually  there  are  also  chilly  sensations,  fever  and  thirst,  dry  tongue 
and  lips,  pharyngeal  voice,  sometimes  constipation  and  abdominal 
distention.  Infants  sometimes  refuse  the  bottle  on  account  of  nasal 
obstruction. 

The  'pharynx  is  moist,  glistening,  oedematous,  and  reddish,  with 
areas  of  gray,  yellowish-gray,  or  dirty  green  color,  which  vary  in  extent 
from  small  white  bands  to  irregular,  gelatinous  elevations  or  masses, 
and   are  located  on  the  tonsils,   epiglottis,   palate,   pillars,  arch,  or 


DIPHTHERIA  163 

pharynx.  They  are  adherent,  and,  on  removal,  leave  red,  bleeding 
spots  which  are  soon  covered  again  with  membrane.  The  pharyngeal 
tonsil  alone  may  be  involved,  and  this  infection  may  easily  be  over- 
looked withont  careful  systematic  examination. 

The  typical  membrane  is  accompanied  by  fibrinoid  swelling  of  the 
tissue,  fibrin  formation,  emigration  of  cells,  and  necrosis.  The  Klebs- 
Loeffier  bacillus  is  found  on  the  surface  in  pure  cultures,  and  strepto- 
cocci and  staphylococci  may  be  found  more  deeply  situated. 

Wagner,  Weigert,  and  Oertel,  have  shown  that  the  diphtheritic 
membrane  is  composed:  (a)  of  necrobiotic  tissue.  The  superficial 
epithelium,  and,  later,  the  deeper  structures,  are  necrosed;  the  bacilli 
are  found  in  the  superficial  layers,  and  the  necrobiosis  may  be  also 
noticed  in  the  connected  lymph-glands,  and  in  the  internal  organs 
(Weigert's  coagulation  necrosis,  or  hyaline  transformation  of  the  dead 
cells).  (6)  Somewhat  deeper,  the  membrane  is  composed  of  more 
or  less  marked  fibrin  exudation,  which  is  probably  a  conservative, 
walling-off  process,  which  also  pervades  the  tissue  initially  necrosed, 
(c)  In  the  deepest  part  of  the  membrane,  emigration  of  leukocytes 
occurs.  In  most  adults  the  membrane  is  thrown  off  by  the  fourth  or 
fifth  day;   in  children  by  the  seventh  or  eighth  day. 

The  nose  is  not  wholly  free.  The  glands  at  the  angle  of  the  jaw  are 
tender,  and  fever  may  reach  102°  or  103°,  may  be  rather  irregular,  or 
may  be  absent.  The  patient  usually  recovers  in  seven  to  ten  days. 
Otitis,  suppurative  adenitis,  vomiting,  and  albuminuria,  are  less  com- 
mon than  in  the  more  severe  forms. 

The  form  described  is  the  classical  type  of  mild  local  infection. 
Even  though  the  bacilli  may  be  virulent,  the  tissues  and  blood  resist 
the  infection.  There  are  several  deviations  from  this  type  which  are 
often  clinically  misinterpreted:  (I)  In  "catarrhal  diphtheria"  the 
membrane  is  often  absent.  This  type  is  especially  common  in  families 
where  the  more  severe  forms  are  seen.  The  bacilli,  and  redness, 
oedema,  and  swelling,  are  present.  If  a  membrane  develops,  it  may 
be  atypical  and  pultaceous.  (II)  Diphtheria  may  resemble  follicular 
pharyngitis,  and  between  them  there  is  no  absolute  distinction  except 
a  bacteriological  one;  in  diphtheria,  however,  the  red  is  brighter, 
the  tendency  to  fuse  is  greater,  and  the  spots  are  yellow,  gray,  or  green, 
while  in  angina,  the  color  is  duskier,  the  areas  more  discrete,  yellow, 
and  pus-like.  (Ill)  Follicular  tonsillitis  may  be  very  closely  simulated, 
and  may  be  only  distinguished  bacteriologically.  (IV)  In  chronic 
diphtheria,  there  is  a  variable  deposit  upon  a  red,  relaxed,  oedematous 
pharynx.  This  deposit  may  spread  over  the  tongue.  The  glands 
may  be  swollen,  but  usually  there  are  no  general  symptoms.  (V) 
The  latent  diphtheria  of  Huebner,  which  occurs  in  marantic  subjects, 
may  easily  escape  detection. 

2.  The  diphtheritic  general  infection  is  difficult  to  describe  in  all  its 
variations.  It  begins  with  high  fever  and  such  febrile  toxaemic  symptoms 
as  headache,  depression,  insomnia,  sopor,  rapidly  increasing  anaemia, 
anorexia,  dysphagia,  and  vomiting.     Albuminuria  and  nephritis  may 


164  THE  SPECIFIC  INFECTIONS 

appear  later,  with  rapid  respiration  and  the  heart  movement  following 
the  fever,  the  tones  being  dull  and  often  accompanied  by  a  systolic 
murmur.  The  pharynx  is  dark  red,  swollen,  and  glistening,  and  a 
membrane  is  seen  on  the  tonsils  or  pharynx.  This  membrane  is  thin 
and  gray;  it  begins  in  the  form  of  streaks,  or  as  a  thin  veil  over  the 
pharynx;  it  tends  to  spread  very  rapidly  and  sometimes  results  in  a 
diffuse  membrane  with  offensive  secretion.  It  usually  leaves  exempt  the 
hard  palate  as  well  as  the  superior  part  of  the  soft  palate.  The  neck 
is  tender  from  glandular  intumescence.  The  nose  is  often  closed  by  a 
purulent  secretion  and  diffuse  membrane,  and  oral  breathing  results. 
There  is  a  type  peculiar  to  young  children  who,  with  initial  nasal 
symptoms  and  without  appreciable  throat  symptoms,  suddenly  develop 
laryngeal  stenosis,  and,  in  the  pre-antitoxin  days,  almost  invariably  died. 
In  severe  cases  the  heart  is  irregular  with  gallop-rhythm;  there  are 
throat  paralysis,  infiltration  of  the  neck,  dyspnoea,  cyanosis,  albu- 
minous urine,  tympany,  swollen  liver  and  spleen,  ante-mortem  fall 
of  temperature,  and  death  resulting  from  (1)  pneumonia,  (2)  cardiac 
insufficiency,  (3)  nervous  symptoms  or  paralysis  or  (4)  nephritis. 

3.  Septic  diphtheria,  according  to  Baginsky,  is  due  not  to  mixed 
infection  but  to  the  diphtheria  toxins,  and  is  therefore  seldom  observed 
since  the  introduction  of  antitoxin.  Other  writers  maintain  that  strepto- 
coccus and  staphylococcus  infection  determine  this  septic  type.  The 
yellow-gray  exudate  becomes  a  dirty  green  or  brown  from  hemorrhage, 
is  ichorous  and  horribly  fetid,  and  may  reach  the  nose  or  larynx,  causing 
erosions,  necroses,  and  stenosis.  It  often  involves  the  lymph  glands 
(adenitis)  and  connective  tissue  (periadenitis).  The  tongue  is  dry; 
respiration  difficult;  and  nephritis,  generalized  hemorrhage,  or  local 
arterial  ulceration,  failing  pulse,  low  temperature,  swollen  joints,  and 
intumescence  of  the  abdomen,  liver,  and  spleen,  usually  result  fatally. 
In  1884,  66  per  cent,  and,  in  1881,  94  per  cent,  of  cases  of  this  type  died 
(Glaeser). 

Special  Sjmiptoms. — 1.  Fever. — The  fever  in  diphtheria  is  not 
typical.  It  often  rises  to  103°  and  remains  there  for  one  or  two  days, 
when  it  falls  by  lysis,  to  rise  moderately  again  from  the  fourth  to  the 
seventh  day.  It  may  be  maintained  by  otitis,  pneumonia,  adenitis,  and 
other  complications,  or  by  concomitant  diseases,  such  as  measles, 
scarlatina,  or  tuberculosis.  The  temperature  of  sepsis  may  develop.  A 
preagonal  perturbation  may  be  observed,  or  there  may  be  ante-mortem 
collapse.  Algidity  is  due  to  febrifuge  toxins,  as  it  is  in  perforative 
peritonitis.  These  statements  apply  chiefly  to  cases  untreated  with 
antitoxin. 

2.  The  Blood. — Leukocytosis  develops  in  90  percent,  of  diphtheria 
cases,  and  is  of  the  polymorphonuclear  type.  When  absent,  the  infection 
is  either  very  severe  or  very  slight.  It  does  not  correspond  to  the  sever- 
ity of  the  disease  nor  to  the  fever  curve.  It  disappears  in  favorable 
cases,  and  persists  in  those  which  are  severe. 

Special  Localizations  of  Diphtheria. — 1.  Diphtheritic  Rhinitis. — 
Diphtheritic  rhinitis,  catarrhal   or  croupous,  due  to  the   diphtheria 


DIPHTHERIA  165 

bacillus,  may  usher  in  the  disease  or  accompany  the  benign  or  more 
usually  the  severe  forms.  The  serous  and  often  sanious  or  bloody  nasal 
discharge  excoriates  the  alse  nasi,  lips  and  cheeks;  membrane  is  often 
expelled;  infection  may  travel  to  the  eyes,  lachrymal  sacs,  antrum,  or 
ears.  Cervical  adenitis  is  frequent,  for  the  nasal  lymph  supply  is  most 
abundant  and,  as  Jacobi  pointed  out,  enlargement  of  the  angular  glands 
is  always  suspicious.  The  prognosis  is  nearly  always  grave,  and  con- 
valescence very  tardy.  In  contrast  with  this  severe  form,  usually  diph- 
theritic, though  sometimes  diphtheroid  (streptococcic),  there  is  a 
fibrinous  rhinitis  usually  subacute  or  chronic  and  generally  observed 
in  children,  which  is  due  to  the  Klebs-Loeffler  bacillus  (82  percent.), 
though  sometimes  to  the  streptococcus  (18  per  cent,  of  the  cases);  the 
membrane  is  abundant.  This  form  is  obviously  dangerous  to  other 
children,  since  the  remarkable  absence  of  constitutional  reaction  does 
not  prevent  play  or  school-going.  It  responds  readily  to  antiseptic 
douches. 

2.  Diphtheritic  Croup  (Diphtheritic  laryngo-tracheo- bronchitis). — 
Most  cases  (85  percent.)  of  croup  are  diphtheria,  though  some  are  due  to 
streptococcic  infection;  their  symptoms  are  identical.  Frequency: 
Diphtheria  involves  the  throat  in  84  percent,  and  the  larynx  in  16  per 
cent,  of  the  cases.  Forms:  (a)  Catarrhal  laryngitis,  due  to  the  diph- 
theria bacillus,  produces  symptoms  of  short  duration,  usually  two  or 
three  days;  they  may  be  severe  or  even  stenotic.  (6)  Diphtheritic 
laryngitis  (croup)  is  usually  descending  (97  per  cent,  of  cases) — i.e., 
secondary  to  throat  or  nasal  diphtheria,  but  may  on  rare  occasions  be 
primary  in  the  larynx;  even  in  these  cases  there  is  usually  some  pharyn- 
geal involvement.  The  ascending  form  is  most  exceptional.  The  child 
is  usually  hoarse  at  night  or  early  in  the  morning,  coughs  the  croupy 
cough,  and  then  after  twelve  to  twenty-four  hours  is  distinctly  dys- 
pnoeic.  The  accessory  muscles  of  respiration  come  into  play  and  there 
is  inspiratory  retraction  of  the  thorax  and  epigastrium,  especially  in 
rhachitic  children.  Excursion  of  the  larynx  up  and  down,  extreme 
restlessness,  and  temporary  improvement  after  expectorating  the  mem- 
brane, may  also  be  noted.  The  stenosis  is  due  to  membrane  in  the 
epiglottis,  true  cords,  trachea,  or  even  in  the  bronchi.  The  membrane 
is  less  adherent  than  when  it  is  in  the  pharynx,  and  sometimes  more 
pultaceous.  The  stenosis  is  accentuated  by  the  central  and  immovable 
position  of  the  vocal  cords,  by  swelling  in  the  subchordal  tissue,  and  by 
muscular  spasm.  Aphonia  is  common  but  not  invariable.  The  cough 
is  usually  rather  hoarse  than  metallic,  is  often  periodic,  is  increased  after 
tracheotomy,  or  intubation,  and  often  evacuates  both  the  membrane 
and  tube.  Cough  may  be  wholly  absent  because  of  decreased  reflex 
bronchial  excitability. 

Temperature  is  usually  absent  though  it  may  arise  from  compli- 
cations. Fever  after  tracheotomy  or  intubation  is  ominous.  The  pulse 
rate  increases  with  augmentation  of  the  stenosis  because  the  vessels 
contract  from  central  stimulation.  The  respite  following  the  raising 
of  the  membrane  is  usually  transient,  exacerbations  occur,  and  finally, 


166  THE  SPECIFIC  INFECTIONS 

dyspnoea  becomes  continuous  with  stagnation  of  secretion  in  the  tubes, 
absence  of  the  vesicular  murmur,  stridor,  extension  downward  of  the 
membrane  in  some  instances,  loss  of  strength,  increasing  rapidity  and 
weakness  of  the  pulse,  cold,  clammy  skin — in  short,  the  complete 
picture  of  carbon  dioxide  poisoning  and  total  asphyxia.  In  some 
instances,  perichondritis,  deep  necrosis,  or  gangrene  may  develop.  (In 
reading  older  medical  works  and  pathologies,  the  student  may  be  con- 
fused with  the  use  of  the  terms  "croup"  and  "diphtheria."  Anatomi- 
cally it  was  held  that  croupous  and  diphtheritic  membranes  differed 
chiefly  in  degree — croupous  being  more  superficial  and  benign,  diph- 
theritic being  more  deep  and  malign.  In  the  present  connection  w^e  use 
the  term  "croup"  as  synonymous  with  laryngeal  diphtheria.) 

3.  Diphtheria  of  Skin. — True  diphtheria  caused  by  the  diphtheria 
bacillus  may  produce  a  membrane  on  the  eye,  lips,  nose,  mouth,  navel, 
neck,  genitalia,  and  extremities.  It  is  usually  associated  with  the  more 
common  throat  localization.  The  skin  is  hard  and  infiltrated,  the 
secretion  is  corrosive,  the  contiguous  lymphatics  are  involved,  and  some- 
times cellulitis  or  phlegmon  may  result.  Other  cases  of  so-called 
"wound  diphtheria"  are  due  to  the  streptococcus,  which  is  the  most 
common  cause  of  skin  membranes.  In  tracheotomy,  the  membrane 
which  forms  in  the  wound  is  mostly  streptococcic. 

4.  Diphtheritic  Vulvo-vaginitis. — Genital  involvement  is  rare  (under 
1  per  cent.),  is  dangerous,  and  may  be  primary,  but  usually  follows 
severe  pharyngeal  diphtheria;  it  consists  of  diffuse  membrane,  pain- 
ful rhagades,  ulcers,  and  foul  secretion,  with  intumescence  of  the 
lymph  glands.  A  diphtheroid  (usually  streptococcic)  form  is  also 
encountered. 

5.  Diphtheritic  Ophthalmia. — This  localization  is  (a)  false  or  diph- 
theroid (due  to  pus  cocci)  or  (b)  genuine  or  diphtheritic.  It  may  here 
be  noted  that  the  old  division  into  croupous  (benign),  and  diphtheritic 
(malign)  forms  is  no  longer  valid.  Diphtheritic  ophthalmia,  chiefly  in 
young  children,  occurs  in  3  per  cent,  of  cases.  It  may  be  primary  in  the 
eye,  or  secondary  to  nasopharyngeal  diphtheria. 

6.  Diphtheritic  Otitis. — This  does  not  occur  in  over  5  or  6  per  cent,  of 
the  cases  (as  against  33  per  cent,  of  otitis  in  scarlatina  and  nearly  100 
per  cent,  in  measles).  The  orifice  of  the  Eustachian  tube  or  the  middle 
ear  may  be  reached  by  the  diphtheria  bacillus  which  usually  travels 
from  the  throat. 

Complications  and  Sequels. — The  most  important  are  diphtheritic 
paralysis,  heart  paralysis,  and  nephritis. 

1.  Diphtheritic  Paralysis. — The  paralyses  result  clinically  and 
experimentally  from  toxaemia,  and  occur  in  3  to  10  per  cent,  (even  20 
per  cent.)  of  cases.  The  percentage,  apparently,  has  not  been  reduced 
by  the  use  of  antitoxin  (v.  %.).  The  frequency  and  intensity  of  the 
paralysis  is  usually  directly  proportional  to  the  intensity  of  the  diph- 
theria but  there  is  no  invariable  relation  between  the  palsy  and  the 
severity  of  the  infection.  Indeed  the  causal  diphtheria,  in  some  cases, 
has  apparently  escaped  detection. 


DIPHTHERIA  167 

(a)  Early  Diphtheritic  Paralysis. — This  occurs  in  septic  cases  at  the 
acme.  Dysphagia  is  its  most  common  form.  There  is  danger  of  in- 
halation pneumonia,  especially  in  stupid  cases.  Other  changes  may 
occur,  such  as  the  disappearance  of  the  patellar  reflexes,  and  changes  in 
sensation.    Most  cases  die. 

(b)  Post-diphtheritic  Paralysis.— This  variety  occurs  after  two  or 
three  weeks  and  usually  follows  throat  lesions  since  laryngeal  cases  are 
likely  to  die  early;  Baginsky  saw  it  principally  in  adults  and  RoUeston 
mostly  between  the  ages  of  three  and  six  years.  Gowers  claims  that  all 
throat  troubles  leading  to  paralysis  are  diphtheritic,  though  Bourges 
and  others  cite  cases  of  paralysis  after  simple  angina.  The  most  com- 
mon paralysis  is  that  of  the  palate,  which  causes  dysphagia,  anaesthesia 
of  the  throat,  and  nasal  speech.  From  central  or  peripheral  change  the 
pupils  become  wide  and  react  to  light  but  not  to  accommodation 
(Donders).  The  arms  may  be  affected,  but  frequently  escape.  Ataxia 
may  be  the  first  symptom.  Heart  or  central  nervous  symptoms  may 
appear  {v.  i.).  The  reflexes  disappear  early  whether  actual  paralysis  is 
reached  or  not,  the  muscles  react  slowly,  if  at  all,  to  the  faradic  current, 
although  the  reaction  of  degeneration  runs  by  no  means  parallel  to  the 
degree  of  loss  of  voluntary  motion.  The  muscles  waste  considerably. 
The  sensory  nerves  suffer  less,  sensation  being  largely  retained  above 
the  knees.  The  palsied  limbs  are  sometimes  painful  and  the  muscles 
and  nerve  trunks  are  often  tender.  Sensory  disturbance  may  be  noted 
in  the  rectal,  genital,  and  vesical  twigs.  The  trunk,  bladder,  and  rectum 
are  more  commonly  involved  than  is  usually  admitted.  The  cranial 
nerves  (strabismus,  ptosis,  diplopia),  the  phrenic  nerves  and  the  vagus 
(recurrent  paralysis,  superior  laryngeal,  cardiac  branches),  may  be 
involved;  fearful  abdominal  pains  with  threatening  collapse  attribut- 
able to  sympathetic  involvement,  and  sometimes  psychical  disturbance 
may  be  noted.  Anatomically,  disintegration  of  the  medullary  substance, 
multiplication  of  nuclei  in  Schwann's  sheath,  granular  degeneration, 
and  even  total  loss  of  the  axis  cylinder  and  sometimes  foci  of  hemor- 
rhage, are  present,  the  changes  being  almost  totally  parenchymatous. 
Diphtheritic  neuritis  (actual  nerve  inflammation)  is  seen  almost 
wholly  in  the  palate  and  is  due  to  local  invasion  from  the  inflamed 
throat.  The  patient  recovers  in  two  to  three  weeks  if  the  pharynx  alone 
is  involved,  and  in  three  to  four  (even  six  to  eight)  months  if  the  limbs 
are  affected.  Death  results  in  18  per  cent,  of  the  cases,  chiefly  from 
vagus  involvement. 

(c)  Organic  Central  Changes. — The  brain  is  slightly  congested  and 
oedematous.  Degenerated  areas  may  occur  in  the  crura,  medulla,  pons 
or  the  motor  nerves,  and  are  less  marked  in  the  sensory  nerves.  Acci- 
dental findings  are  cerebral  hemorrhage,  embolism  from  heart  thrombi, 
and  acute  encephalitis  (possibly  terminating  in  focal  sclerosis).  In  the 
spine,  hemorrhage,  exudation  into  the  nerve  roots,  meningitis,  and 
degeneration  of  the  motor  cells,  with  disintegration  of  their  roots,  have 
been  noted.  The  degenerative  cerebrospinal  lesions  occur  not  infre- 
quently with  multiple  neuritis. 


168  THE  SPECIFIC  INFECTIONS 

II.  Cardiac  Complications  (Diphtheritic  Heart  Paralysis). — Anatomi- 
cally, the  heart  muscle  is  the  seat  of  early  changes.  It  is  soft,  thin, 
friable,  light  brown  or  yellow  in  color,  and  fatty;  it  is  the  occasional  seat 
of  endocardial  and  myocardial  hemorrhages,  acute  interstitial  myo- 
carditis and  fragmentation  or  myolysis,  which  Eppinger,  in  describing 
eighteen  cases  of  sudden  death,  considers  the  usual  cause  of  death. 
Pericarditis,  with  septic  or  hemorrhagic  effusions,  is  not  frequent. 
Permanent  changes  due  to  endocarditis  (in  2  per  cent,  of  fatal  cases) 
or  to  myocarditis  are  uncommon. 

Clinically,  the  tones  are  muffled.  The  first  tone  is  impure  or 
obscured  by  a  systolic  murmur  (90  per  cent,  of  cases);  the  second 
pulmonic  is  accentuated,  the  rhythm  is  disturbed  (60  per  cent.) 
and  sometimes  there  is  gallop-rhythm  and  embryocardia.  The 
pulse  is  soft,  dicrotic,  increased  from  80  to  120,  or  up  to  150  if  there 
is  fever,  but  it  may  be  slow.  The  heart-failure  is  more  frequent  than 
it  is  in  any  other  acute  infection,  not  even  excepting  pneumonia. 
Syncope  on  sitting  up  is  fairly  common.  Diphtheritic  heart  paralysis 
occurs  (1)  early  in  severe  or  gangrenous  types,  or  (2)  late  (in  10  to  20 
per  cent,  of  diphtheria  cases)  after  three  to  four  or  six  weeks,  when 
convalescence  is  apparently  established.  It  is  marked  by  copious  vomit- 
ing, pain  in  the  chest  and  epigastrium,  insufficient  heart  action,  cardiac 
dilatation,  cold  extremities,  pallor,  dyspnoea,  cyanosis  and  convulsions. 
The  pulse  is  often  irregular,  fast,  or  with  equally  ominous  significance, 
slow.  Heart  failure  is  explained  in  various  ways  (1)  acute  interstitial 
myocarditis  (Rhomberg) ;  (2)  myolysis  (Eppinger) ;  (3)  sudden  centric 
vasomotor  paralysis  (Hasse);  (4)  neuritis  of  the  cardiac  plexus  or  of 
the  vagus  or  phrenic  nerves;  (5)  cardiac  thrombosis  causing  cerebral 
or  pulmonary  embolism;   33  per  cent.  die. 

III.  Diphtheritic  Nephritis. —  (a)  Albuminuria,  resulting  from  renal 
degeneration,  occurs  in  50  per  cent,  of  all  cases  and  in  100  per  cent,  of 
severe  cases,  (b)  In  light  forms  of  nephritis  there  is  some  albumin; 
the  specific  gravity  and  quantity  of  the  urine  are  about  normal,  and  there 
are  leukocytes  or  epithelial  cells  with  indistinct  nuclei,  the  cells  being 
highty  refractile  and  coarsely  granular.  Blood  is  rarely  found.  There 
are  some  hyaline  and  granular  casts.  These  findings  are  caused  by  the 
toxins  and  correspond  in  time  and  degree  to  the  diphtheritic  local  pro- 
cess in  the  pharynx,  (c)  The  severe  forms  of  nephritis  almost  always 
occur  in  the  severe  general  infection  or  in  septic  types  and  are  character- 
ized anatomically  by  diffuse  parenchymatous  changes,  necrosis, 
hemorrhage,  and  exudation.  Albumin,  cells,  casts,  and  cylindroids,  are 
abundant.  Haematuria  is  rare,  although  hemorrhage  into  the  kidney 
substance  is  frequent  anatomically.  Although  nephritis  influences  the 
prognosis,  diphtheritic  nephritis  rarely  produces  hydrops  or  uraemia  and 
"is  not  an  independent  factor  as  in  scarlatina."  It  very  rarely  becomes 
chronic. 

IV.  Respiratory  Complications. — The  bronchi  and  trachea  may 
remain  free.  There  may  be  membrane  formation  (in  50  per  cent,  of 
fatal   cases)  or  purulent   secretion.      Lobar  pneumonia  is  a  genuine 


DIPHTHERIA  169 

complication,  though  bronchopneumonia  is  present  in  50  to  80  per  cent, 
of  the  fatal  cases  and  is  caused  by  the  Klebs-Loeffler  bacillus  alone,  or 
by  the  pus  or  pneumonia  cocci,  by  the  colon,  proteus  or  pyocyaneus 
bacilli.  Anatomically,  some  cases  are  due  to  downward  extension  of 
the  bronchitis;  some  cases  are  haematogenous  infarcts  or  abscesses; 
others  are  due  to  inhalation,  and  still  others,  seen  after  intubation  or 
tracheotomy,  rather  resemble  lobar  pneumonia  and  are  elevated  and 
granular  in  appearance.  Increase  of  pulse  and  respiration-rate,  local 
consolidation,  and  accession  of  fever  are  observed.  Pleurisy  (serous, 
hemorrhagic  or  purulent)  is  not  often  observed. 

V.  Alimentary  Tract. — Mouth. — Fissures,  sordes,  membrane  or 
ulcers  on  the  lips,  suppuration  in  the  tonsils  and  in  the  retropharyngeal 
space,  gangrene,  and  deforming  cicatrices,  sometimes  occur.  The 
oesophagus  is  usually  intact,  but  the  diphtheritic  process,  in  septic  cases, 
may  reach  downward  and  produce  stenosis. 

Stomach. — Such  symptoms  as  epigastric  pain  and  vomiting  are  most 
often  cardiac ;  such  rare  organic  changes  as  hemorrhage  and  membrane 
formation  usually  escape  clinical  recognition. 

Intestines. — Constipation  is  usual ;  in  septic  forms,  thick,  foul  or  even 
dysenteric  evacuations  may  be  exceptionally  observed.  Anatomically, 
there  may  be  membrane  formation  and  swelling  of  Peyer's  patches.  The 
liver  is  swollen  from  fatty  or  cloudy  degeneration  or  from  congestion,  in 
which  latter  case  it  also  becomes  painful.  Icterus  is  rare.  Splenic 
tumor  is  found  in  septic  types  especially. 

VI.  The  Skin. — The  skin  is  usually  normal,  except  for  the  febrile 
hypersemia,  cardiac  pallor,  or  croup -cyanosis.  The  following  altera- 
tions may  be  observed:  Herpes,  profuse  sweats,  petechise  and  the 
gray-blue  color  in  septic  types,  symmetrical  gangrene  and  dermato- 
myositis  due  to  septicopysemia;  they  usually  occur  with  adenitis, 
nephritis,  pneumonia,  ulcerative  endocarditis  and  scarlatiniform  or 
morbilliform  erythemata.  Scarlatina  or  measles  may  actually  com- 
plicate diphtheria. 

VII.  The  Glands. — The  anterior  cervical  glands  are  swollen,  ten- 
der and  painful.  In  the  most  severe  forms  periadenitis  follows  with 
diffuse  involvement  of  the  cellular  tissue  (angina  Ludovici),  section  of 
which  evacuates  serum,  though  seldom  pus.  Glandular  and  articular 
changes  are  less  frequent  than  in  scarlatina.  Muscular  degeneration, 
interstitial  infiltration,  and  tendency  to  separation  of  the  muscle-fibers, 
are  observed  in  the  heart  (myolysis  or  fragmentation)  or  even  more 
clearly  in  the  diaphragm. 

Diagnosis. — To  the  naked  eye  a  thick,  adherent  membrane,  which 
is  not  removable  without  hemorrhage  and  which  leaves  ulceration 
(Bretonneau),  is  sufficiently  characteristic.  The  enlarged  glands  are 
of  diagnostic  value.  A  positive  bacteriological  diagnosis  is  important,  in 
such  cases  as  have  actual  membrane,  diffuse  reddening,  and  tonsillitis; 
but  three  or  four  negative  examinations  are  necessary  before  negative 
conclusions  can  certainly  be  drawn.  The  statistics  of  Heubner  and 
of  Baginsky  show  positive  findings  in  from  92  to  98  per  cent,  of  cases 


170  ,  THE  SPECIFIC  INFECTIONS 

in  which  the  clinical  diagnosis  of  diphtheria  has  been  made.  These 
figures  are  probably  most  nearly  correct,  although  others  find  the  diph- 
theria bacillus  in  a  notably  lower  percentage.  The  nose,  nasopharynx 
and  pharynx  must  always  be  examined  in  sick  children  and  also  in 
adults.  In  suspicious  cases,  particularly  when  cultures  cause  consider- 
able delay,  antitoxin  should  be  given  at  once. 

The  health  departments  in  our  large  cities  provide  apparatus  for 
growing  cultures,  stations  at  which  cultures  and  antitoxin  may  be 
obtained,  and  central  and  subsidiary  laboratories  for  diagnosis.  The 
Chicago  Health  Department  has  also  a  most  able  corps  of  physicians 
for  free  treatment,  consultation  and  intubation.  It  is  easy  to  obtain 
on  sterile  cotton  on  a  probe  a  smear  from  the  membrane  or  suspicious 
focus,  to  rub  it  on  the  serum  without  breaking  its  surface,  and  to  put 
the  tin  box  containing  it  in  the  incubator  or-  under  the  axilla  until  the 
brood  oven  can  be  reached.  In  half  a  day  characteristic  cultures  are 
obtained.  Direct  smears  from  the  throat  on  a  slide  very  often  show 
the  bacillus.  In  small  places  communal  laboratories  can  easily  be 
maintained,  and  competent  young  practitioners  found  to  do  this,  and 
other  clinical  microscopy.  In  laryngeal  diphtheria  the  bacillus  is 
usually  found  on  the  pharynx,  but  not  on  the  tonsils.  Repeatedly 
negative  findings  are  of  value  in  the  fseiidodiphtheritic  or  diphtheroid 
pharyngitis,  rhinitis,  laryngitis,  and  bronchitis, — e.  g.,  membranes  due 
to  strepto-,  staphylo-,  and  pneumococci,  aphthous  growth,  sj'philis, 
and  the  colon  bacillus.  The  scarlatinal  membrane  has  been  consid- 
ered. In  Vmcent's  angina  (q.  v.),  angina  diphtheroides  or  angina 
ulceromembranosa,  described  by  Vincent  (1898),  there  is  a  whitish- 
yellow  to  grayish-brown  membrane  which  may  be  confused  with 
diphtheria  and  syphilis  and  which  is  caused  by  the  symbiosis  of  two 
otherwise  innocuous  parasites;  first  the  bacillus  fusiformis  (6  to  12  ft 
and  staining  readily  with  methylene  blue  and  fuchsin),  and  the  spiro- 
c-hseta  darticola  (twice  as  large,  and  not  growing  in  cultures).  The 
infection  is  usually  mild  and  the  ulcers  heal  slowly  under  chlorat. 
potash  gargles  or  painting  with  pure  iodine. 

Course  and  Prognosis. — Aside  from  complications,  the  average 
course  is  one  week,  or  possibly  two.  It  is  more  favorable  in  diph- 
theria of  the  tonsils  and  skin  than  in  that  of  the  nose.  The  prognosis 
must  always  be  guarded,  (a)  Without  serotherapy  the  danger  is 
always  great,  since  light  cases  may  become  severe  or  extend  to  the 
larynx,  (b)  Epidemics  vary  in  virulence,  30  to  50  per  cent,  mortality 
having  been  observed  twelve  to  fifteen  years  ago.  (c)  According  to 
Glaeser,  in  the  first  year  the  mortality  is  77  per  cent.,  and  sinks  with 
each  year  until  it  is,  at  ten  years,  20  to  25  per  cent. ;  after  ten,  2  to  5^ 
per  cent. ;  after  thirty  and  forty,  1  to  3  per  cent,  (d)  Other  factors  are 
debility,  wide  extension  of  the  infection  from  part  to  part,  adenitis, 
and  croup;  the  general  diphtheritic  infection  or  septic  forms  with 
hemorrhage  or  gangrene;  heart  and  renal  complications;  rapid  and 
weak  or  slow  pulse;  involvement  of  the  brain  or  nerves,  (e)  In  946 
fatalities  studied  by  White  and  Smith,  about  50  per  cent,  died  of 


DIPHTHERIA  171 

bronchopneumonia,  usually  after  intubation  or  tracheotomy;  25  per 
cent,  died  of  cardiac  complications,  and  25  per  cent,  of  early  severe 
toxaemia,  though  some  succumbed  to  asphyxia  or  late  paralysis.  (/) 
Coincidence'with  other  acute  infections  is  ominous,  such  as  measles,  in 
which  the  exanthem  may  become  hemorrhagic,  and  respiratory  catarrh, 
may  result  in  a  wide  Klebs-Loeffler  infection,  the  combination  being 
usually  fatal;  coincidence  with  typhoid,  frequently  with  gangrene  or 
laryngeal  stenosis;  and  with  scarlatina,  summer  diarrhoea,  and  tubercu- 
losis. The  disease  is  less  severe  in  conjunction  with  varicella  and 
pertussis.  Diphtheria  belongs  to  the  class  of  infections  which  are 
likely  to  recur. 

Treatment. — First  Indication — Prophylaxis. — For  the  physician, 
this  begins  with  the  case  in  hand.  Isolation  must  be  absolute.  In 
needy  families  the  isolation  hospital  offers  the  best  solution.  In  Bos- 
ton it  has  reduced  the  mortality  of  diphtheria  to  one-third  or  one- 
sixth  of  its  former  rate.  All  suspicious  throat  cases  should  be  isolated 
pending  their  immediate  clinical  and  cultural  evolution.  Not  only 
should  a  sick  child  be  isolated,  but  other  children  in  the  family  should 
be  kept  from  school  and  away  from  playmates.  Of  course,  the  sick 
one  must  be  isolated  until  its  throat  gives  negative  cultures.  The 
physician  may  protect  himself  by  examining  the  throat  through  a 
piece  of  glass,  and  may  avoid  carrying  the  germs  by  slipping  on  a 
surgical  gown  and  washing  both  face  and  hands  with  bichloride  of 
mercury  or  similar  solution.  In  fatal  cases  the  body  should  be  wrapped 
in  a  sheet  saturated  with  bichloride,  and  buried  privately  in  a  tightly 
closed  casket.  Those  exposed  to  the  infection  may  receive  antitoxin, 
and  should  gargle  the  throat  once  with  \  of  1-per-cent.  solution  of  silver 
nitrate,  or  often,  with  bichloride  of  mercury  (5000).  The  clothing, 
blankets,  rugs,  etc.,  must  be  steamed.  After  convalescence,  the  walls 
of  the  room  should  be  rubbed  with  bread  w^hich  is  then  burned,  the 
woodwork  should  be  washed  with  2-per-cent.  lysol  solution  or  1-per- 
cent, bichloride  of  mercury  and  the  room  should  be  fumigated  with 
formaldehyde.  Under  prophylaxis  may  be  included  the  building  up 
of  the  general  physiological  resistance  and  the  treatment  of  chronic 
catarrh  of  the  nose,  throat,  and  bronchi. 

Second  Indication — Local  Treatment. — Though  local  treatment  of 
the  throat  is  less  important  than  before  the  days  of  serotherapy,  the 
antitoxin  does  not  always  kill  the  bacilli,  and  does  not  affect  the  asso- 
ciated streptococci.  Caustics  are  never  necessary.  In  children  such 
mild  antiseptics  as  3-per-cent.  boric  solution  and  3  to  10-per-cent. 
potassium  permanganate  solution,  should  be  used  lest  they  be  swal- 
lowed. The  child  is  held  in  the  nurse's  arms  with  its  arms  and  body 
firmly  wrapped  in  a  sheet.  The  mouth  is  made  to  open  by  closing 
the  nostrils,  and  a  piece  of  wood  or  cork  is  inserted  between  the  teeth. 
The  throat  is  then  swabbed.  It  is  a  harsh  procedure  and  the  effects 
are  apparently  more  than  offset  by  the  resultant  exhaustion.  In  adults 
1  to  1000  bichloride,  25-per-cent.  hydrogen  peroxide,  or  1-per-cent. 
carbolic  solutions,  5-per-cent.  ammonium  sulphocarbolate,  5-per-cent. 


172  THE  SPECIFIC  INFECTIONS 

ferric  chloride  or  iodoform  salve,  may  be  used,  or  Loeffier's  solution, 
which  is  as  follows: 

Menthol 10  parts. 

Toluol 30  parts. 

Tr.  ferri  sesquichloridi 4  parts. 

Alcohol  absoluti 60  parts. 

Loeffler's  solution  should  be  kept  well  corked  in  a  dark  bottle.  Local 
injury,  such  as  opening  up  new  wound  surfaces  for  infection,  must  be 
avoided.  In  nasal  irrigation  the  tube  is  held  horizontally,  so  that 
fluid  may  return  by  the  other  nostril.  A  kettle  containing  a  very 
weak  carbolic  solution  should  be  kept  steaming  in  the  room. 

Third  Indication — Serotherapy. —  Gscheidlen  and  Traube  showed 
that  the  blood  possessed  antibacterial  action,  both  within  and  with- 
out the  body,  and  immunity  was  produced  by  Behring  against  anthrax 
and  by  Bouchard  against  the  Bacillus  pyocyaneus.  Behring  demon- 
strated also  that  the  serum  in  diphtheria  and  tetanus  could  overcome 
bacteria  without  destroying  them.  In  1888,  Richet  and  Hericourt 
made  animals  immune  to  the  streptococcus,  and  Behring  and  Kitasato 
produced  immunity  to  tetanus.  Behring  (1890)  borrowed  Ehrlich's 
results  with  ricin  and  abrin  to  establish  the  units  of  immunization, 
and  (1893)  used  the  diphtheria  antitoxin  on  diphtheria  patients.  The 
method  of  action  of  an  antitoxin  is  vital  or  active  (Buchner,  Roux, 
Martin)  though  some,  (Behring  and  Kitasato)  consider  that  it  is 
chemical  or  passive. 

1.  Technique. — A  syringe  with  an  asbestos  plunger  should  be 
used.  The  syringe  need  not  be  boiled  each  time,  but  should  be  cleaned 
after  each  injection  with  water  until  the  serum  is  washed  out;  it 
should  then  be  washed  with  carbolic  acid  or  alcohol,  which  should 
be  thoroughly  removed  each  time  lest  it  coagulate  the  antitoxin  at 
the  next  injection.  The  needle  must  be  boiled  each  time.  With  ordi- 
nary surgical  antisepsis,  inject  the  antitoxin  into  the  subcutaneous 
tissue  of  the  thigh  in  adults,  and  into  the  interscapular  region  in  chil- 
dren. In  very  severe  infections,  intravenous  injections  should  be  em- 
ployed as  results  may  be  thus  obtained  eight  hours  earlier.  The  unit 
is  1  c.c,  which  counteracts  ten  times  the  minimum  dose  of  diphtheria 
poison  fatal  to  a  300  gm.  guinea-pig. 

2.  The  dosage  is  rather  empirical,  depending  on  the  localization, 
age,  and  severity  of  the  disease  and  the  effects  produced.  The  usual 
classification  is  as  follows:  (a)  Single:  600  units,  used  in  cases  under 
two  years,  without  croup;  for  immunization,  a  somewhat  smaller 
dose  "is  required  than  for  cure  (200  to  500  c.c.).>  (6)  Double:  1,000 
units,  in  children  under  two  years  when  croup,  fetor  or  necrosis  occur; 
in  older  children  with  simple  symptoms,  (c)  Triple:  1,500  units,  in 
severer  cases.  On  the  whole,  dosage  is  governed  by  results  {v.  i.). 
After  administration  the  discharge  should  lessen,  the  membrane  should 
exfoliate,  the  fever  should  fall,  and  toxaemia  decrease.  At  least  twice 
as  much  antitoxin  is  necessary  for  cure  as  for  immunization.     After 


DIPHTHERIA  173 

eight  hours,  three  times  as  much  is  necessary  as  at  the  beginning; 
after  twenty-four  to  thirty-six  hours,  eight  times  as  much.  As  we 
cannot  measure  the  toxins,  so  we  cannot  exactly  specify  regarding  the 
antitoxin  dOse.  Personally,  the  author  prefers  an  initial  dosage  of 
3,000  to  5,000  units  to  insure  results  and  to  avoid  delay  and  frequent 
repetition.  The  decreased  bulk  of  present  preparations  also'  allows 
a  larger  dosage.  In  severe  cases,  twice  the  above  amount  should  be 
given.  McCallum,  above  all  others,  has  emphasized  the  importance 
of  full  doses,  and  he  speaks,  and  with  reason,  of  doses  of  10,000,  30,000, 
or  even  50,000  units  in  desperate  cases,  because  results  must  be  pro- 
duced. In  a  recent  article,  H.  A.  Hare  states  that  antitoxin  dosage 
is  not  measured  by  units  and  that  children  require  as  large  doses  as 
adults.  He  cites  Sutherlin  as  giving  a  total  of  498,000  units  in  one  case! 
3.  Effects. — (a)  The  local  changes  are  lessened,  the  mucosa  becomes 
redder,  and  the  membrane  more  yellow  and  it  exfoliates  in  from  one- 
half  to  two  or  three  days,  with  decrease  in  glandular  swelling.  Exten- 
sion afterward  is  rare,  (b)  The  fever  falls  by  crisis  or  by  lysis,  unless 
there  are  complications.  A  temporary  rise  in  temperature  sometimes 
occurs.  Antitoxin  is  given  until  the  fever  falls,  (c)  The  pulse  is  les- 
sened, and  hyperleukocytosis  is  decreased.  Light  cases  rarely  become 
severe,  and  nonseptic  rarely  become  septic,  unless  there  is  coexisting 
tuberculosis,  syphilis,  etc.  The  kidneys  are  never  injured.  The  author 
believes  that  paralysis  and  heart  failure  are  less  frequent  when  the 
administration  of  the  antitoxin  is  prompt.  Both  of  these  complica- 
tions are  thought  to  occur  in  the  same  proportion  as  in  pre-serum 
days.  But  even  if  their  percentage  is  not  absolutely  reduced,  many 
patients  now  live  who  would  previously  have  died  before  developing 
paralysis,  (d)  The  mortality  is  reduced  from  41  (or  43  to  46  per  cent.) 
to  15  percent.  (Siegert's  collection  42,000  cases) ;  10  per  cent.  (Wenner, 
9.8  per  cent.,  132,500  cases,  American  cities) ;  or  6.7  per  cent.  (Chicago 
Health  Department  Report).  London  statistics  give  a  reduction  of 
one-third  in  the  general  morality  and  one-half  in  tracheotomy  (60 
per  cent,  morality  reduced  to  32  or  25  per  cent.).  The  fatal  cases 
and  severe  complications  are  lessened  in  direct  ratio  as  the  antitoxin 
is  given  early;  if  on  first  day  of  disease,  0;  second  day,  2  per  cent.; 
third  day,  8  to  10  per  cent.;  fourth  day,  14  per  cent.  Failure  to  use 
antitoxin  is  criminal  neglect;  50  per  cent,  of  croup  cases  regress  with 
the  use  of  antitoxin,  and  heart  lesions  are  reduced  50  per  cent,  in  fatal 
cases.  (5)  Antitoxin  is  a  prophylactic,  and  should  be  given  in  special 
instances;  e.  g.,  to  weak  or  very  young  children  (in  smaller  doses). 
It  protects  for  two  or  three  weeks  in  all  but  0.7  per  cent,  of  1,000  cases 
(Zuppinger).  (6)  The  sequels  are:  (i)  Abscess  formation;  (ii)  exan- 
themata, which  are  local  (on  the  fourth  or  fifth  day)  or  general  (in  one 
to  two  weeks),  are  due  to  individual  peculiarity  or  some  unknown 
element  in  the  antitoxin,  and  appear  as  urticaria,  morbilliform,  scar- 
latiniform,  or  petechial  eruptions;  antitoxin  rashes  occur  in  33  per 
cent,  of  the  cases;  and  are  said  to  be  decreased  by  the  administration 
of   potassium   acetate   (gr.  x  to  xxx),  combined  with   free    catharsis 


174  THE  SPECIFIC  INFECTIONS 

(Roehr) ;  (iii)  nephritis,  which  is  always  due  to  the  diphtheria  itself; 
(iv)  sudden  death  which  results  from  vomiting  into  the  larynx, 
shock,  lymphatic  diathesis,  and  from  other  disease;  sudden  death  is 
exceedingly  rare;  (v)  tetanus  has  been  inoculated.  In  a  few  cases 
where  antitoxin  was  injected  for  prophylaxis,  the  author  has  seen  ex- 
tremely severe  symptoms;  pallor  alternating  with  flushing,  chills, 
fever,  renal  suppression,  oedema  of  the  skin  and  pharynx  and  very 
severe  cardiac  weakness;  these  cases  to  a  certainty  had  no  diphtheria, 
for  throat  cultures  were  first  taken;  the  statement,  therefore,  that 
antitoxin  never  injures  does  not  hold  for  all  prophylactic  doses. 

Fourth  Indication. — General  and  Symptomatic  Treatment. — A  rich 
fluid  diet  of  milk,  eggs,  peptonoids,  with  tonics,  cinchona,  wine,  etc. 
is  given.  In  marked  dysphagia  rectal  feeding  is  indicated.  Forced 
feeding  by  the  stomach  tube  or  nasal  catheter  is  dangerous  because 
injury  to  the  throat  is  likely. 

Sepsis. — Concentrated  diet  by  mouth  and  rectum,  alcohol  ad  lib- 
itum, oxygen,  saline  infusions  or  enemata,  strychnine  and  iron,  and 
Marmoreck's  antistreptococcic  serum  should  be  given;  but  all  meas- 
ures are  usually  of  no  avail  if  4,000  units  (Baginsky)  or  tens  of 
thousands  of  units  do  not  give  relief.  Crede's  collargol  is  given  intra- 
venously in  severe  cases;  Netter,  in  586  cases,  found  that  it  reduced 
the  death  rate  by  8  to  20  per  cent. 

Paralyses. — General  stimulation  and  alimentation  are  indicated; 
electricity  is  of  little  or  no  avail;  massage,  baths  and  strychnine  are 
useful  in  the  later  stages. 

Heart  Failure. — The  ice-bag  is  indicated  for  stormy  heart  action; 
ether,  iron,  valeriaa,  oxygen,  alcohol,  digitalis,  strophanthus,  coffee, 
aromatic  wines,  camphor  and  strychnine  should  be  given.  For  severe 
abdominal  pain  and  vomiting,  usually  an  evidence  of  cardiac  failure, 
the  above  remedies,  and  champagne  with  menthol  and  carbolic  acid, 
are  indicated.  The  heart  must  be  watched  far  into  apparently  com- 
plete convalescence. 

Nephritis. — Nephritis  cannot  be  prevented.  Alcohol,  tincture  of 
ferric  chloride,  beef  tea  and  eggs  are  to  be  avoided ;  vichy,  cardiants, 
milk  diet,  baths,  laxatives,  and  care  of  the  skin  are  advisable. 

Local  Diphtheria. — Two  per  cent,  nitrate  of  silver  in  balsam  of 
Peru  affords  relief  in  vaginitis;  ice  applications,  atropia,  and  silver 
in  ophthalmia;  over  inflamed  glands,  a  10  per  cent,  ichthyol  salve 
may  be  applied;  local  diphtheria  necessitates  antitoxin,  independently 
of  its  location. 

Croup. — Mercurial  inunctions  are  given,  together  with  steam  sprays 
or  tents  and  ice  locally  applied;  for  emergencies,  the  hot  water  may 
be  turned  on  in  the  bath-room,  after  closing  the  door  (Jacobi);  or 
the  child  may  be  held  over  a  pail  of  water  into  which  live  coals  are 
thrown;  emetics  may  be  administered,  with  which  wine  (Strieker)  is 
given  because  emetics  often  fail  in  carbon-dioxide  narcosis;  retrac- 
tion of  the  chest  walls,  suffocation,  cyanosis,  and  cold  extremities, 
necessitate  intubation  or  tracheotomy. 


INFLUENZA   {LA   GRIPPE)  175 

O'Dwyer's  Intubation. — Advantages. — It  is  bloodless,  is  shorter, 
easier,  and  quicker  than  tracheotomy;  there  is  less  wound  infection, 
and  it  is  less  objectionable  to  the  family. 

Disadvantages. — Membrane  may  rise  beneath  the  tube,  and  trach- 
eotomy may  therefore  be  necessary  after  intubation.  The  tube  may 
sometimes  produce  trauma,  false  passages,  necrosis,  ulcers,  perichon- 
dritis and  stricture.  The  tube  is  usually  replaced  two,  three,  or  four 
times,  and  rarely  need  remain  more  than  five  or  six  days  when  the 
serum  is  used.  It  is  removed  by  the  extubator,  by  pressure,  or  by  a 
string,-  which  is  necessary  in  private  practice.  Size  of  the  tube:  5  to  6 
millimeters,  one  to  two  years;  6  to  7  millimeters,  two  to  four  years;  7 
to  8  millimeters,  four  to  six  years;  8  to  9  millimeters,  six  to  eight  years. 

Tracheotomy. — Tracheotomy  is  indicated  when  the  heart  is  weak 
or  when  great  asphyxia,  much  secretion,  or  gangrenous,  diffuse,  or 
septic  infiltration  or  oedema  of  the  lungs  exist.  In  the  after-treatment, 
the  patient  requires  a  moist  atmosphere,  and  cleaning  of  the  tracheo- 
tomy tube  every  second  day,  is  important.  The  tube  should  not  be 
permanently  removed  until  all  stenotic  symptoms  and  all  plaques 
disappear.  In  cases  treated  by  serotherapy,  this  may  be  done  on  the 
fourth  day  as  against  the  sixth  or  seventh  in  cases  treated  before  anti- 
toxin was  introduced.  The  prognosis  of  tracheotomy  depends  upon 
possible  coincident  wound-infection  with  erysipelas  or  diphtheria, 
phlegmon,  thrombophlebitis,  mediastinal  suppuration,  ulceration  of 
trachea,  inhalation  pneumonia,  cardiac  collapse,  and  nephritis.  Rapid 
rise  of  temperature  is  ominous.  Antitoxin  has  reduced  the  mortality 
from  66  per  cent,  to  35  per  cent,  (or  25  per  cent.). 

CEREBROSPINAL  FEVER. 

Cerebrospinal  fever  (epidemic  meningitis),  is  an  independent  in- 
fection, but  will  be  considered  under  diseases  of  the  meninges,  with 
the  tuberculous  and  suppurative  forms. 

INFLUENZA    (LA  GRIPPE). 

Definition. — A  specific  infective  disease,  caused  by  the  Bacillus 
influenzae,  propagated  by  direct  human  intercourse  but  also  by  means 
of  fomites;  endemic  over  the  entire  world  and  almost  yearly  epidemic 
somewhere,  characterized  by  its  unparalleled  rapidity  in  extension, 
the  large  number  of  people  attacked,  its  protean  symptomatology 
and  its  particular  aflfinity  for  the  respiratory  tract. 

Varieties. — (1)  Influenza  vera,  (a)  pandemic;  (b)  endemic  or  epi- 
demic, due  to  Pfeiffer's  bacillus.  (2)  Influenza  notha  s.  nostras, 
pseudogrippe,  catarrhal  fever  of  unknown  bacteriology. 

Pandemics  originate  in  Asiatic  Russia.  No  other  pandemic  has 
ever  been  so  widely  distributed  as  influenza,  which  spreads  very 
rapidly  but  not  faster  than  the  fastest  trains  and  steamers.     The 


176  THE  SPECIFIC  INFECTIONS 

rapidity  of  its  dissemination  is  due  (1)  to  the  enormous  virulence 
of  the  virus;  (2)  to  the  ease  with  which  the  germ  is  spread;  (3)  to 
the  universal  susceptibility;  (4)  to  the  short  incubation  period  (one 
to  three  days),  and  (5)  to  the  fact  that  a  great  number  of  mod- 
erately sick  individuals  frequent  cars,  conveyances,  churches,  schools, 
and  places  of  business.  Epidemics  develop  gradually,  usually  follow- 
ing pandemics;  they  occur  every  few  years  (pandemics  are  separated 
by  decades),  last  one  to  two  months,  are  less  severe  because  of  les- 
sened virulence  of  the  virus  and  increasing  immunity.  According  to 
Hirsch,  the  first  epidemic  occurred  in  1173.  The  first  pandemic 
seems  to  have  been  in  1510. 

Etiology. — Though  no  age  confers  immunity,  most  cases  occur  be- 
tween the  twentieth  and  fortieth  years  and  especially  in  robust  indi- 
viduals. Physicians  are  very  often  attacked.  The  immunity  usually 
conferred  by  one  attack  is  less  enduring  and  absolute  than  in  small- 
pox, and  other  infectious  diseases. 

Bacteriology. — The  organism  discovered  by  Pfeiffer  (1891-2)  is  the 
smallest  bacillus  which  has  been  cultivated.  Its  ends  are  rounded 
and  it  resembles  a  diplococcus  when  two  bacilli  lie  end  to  end.  It 
has  no  capsule,  is  non-motile,  it  lies  free  in  the  sputum  in  the  early 
stages  and  later  is  found  in  the  leukocytes,  but  often  disappears  early 
from  the  sputum.  The  bacilli  lie  in  lines  "like  schools  of  fish"  (Finck- 
ler).  Ten  minutes  are  necessary  for  staining  with  carbol  fuchsin. 
The  bacillus  is  aerobic,  short-lived,  and  very  susceptible  to  drying. 
Culturally  it  grows  characteristically  on  blood-serum  as  closely  com- 
pressed yet  discrete  colonies,  clear  as  water,  and  almost  microscopic 
in  size;  it  grows  at  body  temperature  and  is  easily  overgrown  by 
saprophytes.  The  germ  has  also  been  found  in  rare  instances  in  the 
blood,  in  pneumonic  and  encephalitic  foci,  in  the  peritoneum,  spinal 
fluid,  gall-bladder,  heart,  spleen  and  kidney,  and  possesses  rather 
marked  pyogenic  characters;  it  is  often  associated  with  the  pneumo- 
coccus  and  streptococcus.  Its  atrium  is  probably  through  the  upper 
respiratory  tract  although  there  are  instances  of  primary  pneumonia. 
The  nervous  and  alimentary  types  are  probably  likewise  explained. 

Sjrmptoms. — It  is  sometimes  said  that  there  is  no  uniform  clinical 
picture  of  influenza  and  certainly  there  is  scarcely  an  acute  infection 
with  such  varied  grouping  of  symptoms  and  such  varied  sequels  and 
complications. 

After  a  short  incubation,  which  never  exceeds  one  to  three  days, 
the  grippe  begins  suddenly  with  chill  and  fever,  headache,  usually 
frontal,  great  anorexia  and  depression,  pains  in  the  back  and  legs, 
respiratory  catarrh,  which  is  frequently  followed  by  capillary  bron- 
chitis or  pneumonia  in  children  or  the  aged,  and  intense  nervous  and 
sometimes  digestive  symptoms.  Lichtenstern  classifies  influenza  as 
follows : 

(A).  Purely  Toxic  Type. — (1)  Simple  influenzal  fever;  fever  with 
its  symptoms,  headache,  etc.  (2)  Nervous  form ;  fever,  pains  in  the 
back,  legs  and  head,  neuralgias,  and  prostration. 


INFLUENZA    {LA  GRIPPE)  177 

(B).  Toxic  Inflammatory  Type. —  (1)  Respiratory  catarrh  of  the 
nose,  throat,  larynx,  trachea  and  bronchi.  Respiratory  symptoms 
are  absent  only  in  25  per  cent,  of  cases,  a  fact  not  recognized  before 
1889-1890.  ^  (2)  Gastro-intestinal  catarrh,  coated  tongue,  anorexia, 
vomiting  and  diarrhoea. 

The  duration  is  short  (one  to  three  days)  and  the  diagnosis  is  usually 
easy  without  the  detection  of  the  bacillus.  Recurrences  are  frequent. 
Nervous  symptoms  in  the  primary  attack  may  be  followed  by  respir- 
atory complications  in  the  recurrence,  or,  more  frequently,  an  initial 
respiratory  catarrh  is  seen  with  nervous  manifestations  in  the  recrudes- 
cence. In  rare  instances  influenza  may  cause  chronic  symptoms, 
chiefly  respiratory.  Convalescence  is  marked  by  great  nervous  de- 
pression, neuralgias,  and  tardy  return  of  vigor. 

Special  Symptoms. — 1.  Fever. — The  rise  is  usually  sudden  to 
103°  or  104°;  but  on  exceptional  occasions  it  rises  gradually.  It  is 
entirely  atypical.  Remittent  fever  is  more  common  than  continuous 
fever,  which  may  suggest  typhoid.  It  is  occasionally  intermittent, 
resembling  malaria.  Hyperpyrexia  is  observed  particularly  in  en- 
cephalitis grippalis,  but  again  some  of  these  cases  and  certain  nervous 
forms  are  afebrile  (Eichhorst).  The  typus  inversus  has  been  noted 
(Pribram).  The  fever  lasts  from  one  to  three  or  four  days,  it  is  often 
shorter  than  the  other  symptoms  and  rarely  lasts  a  week.  Some- 
times the  fever  returns  after  two  or  three  days,  constituting  a  recur- 
rence or  relapse.  Fever  may  last  longer  as  a  result  of  complications. 
Often  there  is  a  remarkable  loss  in  weight. 

2.  Nervous  System. — The  nervous  system  is  almost  always  in- 
volved and  is  second  in  importance  only  to  the  respiratory  tract.  The 
most  frequent  disturbances  are  functional  and  psychical,  but  gross 
anatomical  lesions  are  sometimes  found.  Headache  is  observed  in 
nearly  100  per  cent,  of  the  cases.  It  is  especially  frontal  and  often 
very  severe.  Influenza  comatosa  results  from  very  acute  intoxication, 
which  may  cause  epileptiform  seizures,  tremors,  or  severe  delirium. 
The  post-influenzal  psychoses,  acute  and  chronic,  are  due  to  cerebral 
toxaemia  or  exhaustion  and  are  observed  five  to  eight  times  as  fre- 
quently as  in  any  other  acute  disease.  An  hereditary  tendency  is 
observed  in  62  per  cent.,  and  most  cases  are  seen  in  the  young.  They 
may  occur  from  the  initial  intoxication  but  usually  follow  the  attack. 
The  majority  are  of  the  hypochondriacal  type  (exhaustion  psychoses), 
but  mania  is  sometimes  seen.  Suicides  were  increased  25  per  cent, 
in  Paris  during  the  last  pandemic.  In  encephalitis  grippalis,  of  which 
twelve  cases  are  recorded,  there  are  acute  hemorrhagic  foci  of  inflam- 
mation (Virchow,  Senator,  Furbringer,  Konigsdorf,  Schmidt,  Oppen- 
heim),  which  are  usually  discrete  (sometimes  confluent)  and  multiple; 
they  almost  always  occur  in  the  gray  substance  of  the  cortex  or  ganglia 
and  vary  in  size  from  the  "flea-bite"  spots  of  inflammatory  hemor- 
rhage with  surrounding  softening  to  the  size  of  a  cherry  or  pigeon's 
egg.  The  inflammation  is  due  to  embolism  by  the  Bacillus  influenzte 
(Pfuhl  and  Nauwerk)  or  to  encephalitis  suppurativa,  which  in  turn  is 

12 


178  THE  SPECIFIC  INFECTIONS 

either  primary  or  secondary  to  foci  in  the  nose,  ear,  and  lung.  Some- 
times concomitant  venous  thrombosis,  hemorrhage,  pachy-  or  lepto- 
meningitis occur.  Cortical  focal  symptoms  (mono-  and  hemiplegia) 
or  a  sudden  apoplectiform  onset  may  mark  the  process,  or  there  may 
be  diffuse  cerebral  symptoms  at  the  beginning  or  acme  of  the  disease, 
without  definite  focal  localization.  Encephalitis  is  usually  fatal  but 
recovery  is  recorded.  Meningitis  grippalis  generally  develops  early. 
The  virus  reaches  the  brain  by  the  blood  stream  or  by  contiguity 
through  the  basis  cranii.  In  localization  it  is  basal  or  cortical.  Lum- 
bar puncture  may  show  the  grippal  bacillus,  which  may  distinguish 
this  from  other  forms  of  meningitis  and  from  toxaemia  (pseudomenin- 
gitis  or  meningismus).  Mya  (1904)  reported  three  cases  of  suppura- 
tive meningitis  in  which  recovery  occurred;  the  bacillus  was  found 
by  lumbar  puncture.  Spinal  complications ,  such  as  transverse  mye- 
litis, hemorrhagic  disseminated  myelitis,  Landry's  paralysis,  and  acute 
poliomyelitis,  have  been  observed  clinically  though  investigated  but 
little  pathologically.  Neuritis,  local  or  general,  is  usually  post-influ- 
enzal;  nuclear  (spinal)  changes  are  sometimes  suggested.  Pains  are 
frequent  in  the  back,  legs  and  joints;  neuralgia  may  affect  any 
nerve,  but  most  often  the  fifth,  sciatic,  and  intercostals;  neurasthenia, 
which  is  often  hypochondriacal,  and  hysteria  may  be  observed  as 
sequels. 

3.  The  Respiratory  Tract. — This  is  the  entrance  for  the  bacillus 
and  is  involved  in  75  per  cent,  of  cases,  either  entirely  or  in  one  part, 
as  is  the  case  in  such  inflammations  as  coryza  and  bronchitis. 

Epistaxis  is  quite  uncommon,  though  coryza,  with  reddening  of 
the  eyes,  is  seen  in  70  per  cent,  of  cases,  and  may  possibly  be  accom- 
panied by  involvement  of  the  frontal  or  other  sinuses,  or  even  em- 
pyema or  neuralgia  of  the  same.  The  bacillus  may  be  found  in  the 
conjunctiva. 

Angina  is  seen  in  33  per  cent,  and  tonsillitis  in  60  per  cent,  of  cases. 

Laryngitis  (6  to  16  per  cent.)  occurs  with  hoarseness.  Fibrinous 
-deposit  or  submucous  abscess  has  occurred. 

Tracheitis  (50  to  80  per  cent.)  causes  pain,  tenderness  and  severe 
paroxysmal  cough,  induced  by  irritation  at  the  bifurcation. 

Bronchitis  is  either  diffuse,  developing  anteriorly  as  well  as  poste- 
riorly (Kundrat),  or  more  characteristically,  occurs  over  one  lung  or 
■one  lobe.  At  autopsy  are  found  great  congestion  (which  is  the  prime 
lesion  according  to  Klebs),  a  tendency  to  extension,  hemorrhage, 
round-cell  infiltration  into  the  mucosa,  and  exudation  and  throm- 
bosis in  the  smaller  vessels,  which  causes  necrosis  of  the  mucosa. 
The  sputum,  according  to  Pfeiifer,  is  characteristically  nummular  and 
greenish-yellow.  It  is  often  blood-stained,  contains  the  bacillus,  is 
viscid  and  is  often  abundant.  Rales  are  most  often  found  above  the 
liver  and  near  the  lingual  lobe.  We  also  may  observe  dyspnoea,  which 
is  nervous  (Graves)  or  congestive  (Biermer)  in  origin,  without  appro- 
priate physical  findings.  Cyanosis  may  develop,  and  is  particularly 
dangerous  in  the  young,  aged  and  decrepit. 


INFLUENZA    {LA  GRIPPE)  179 

Acute  bronchiectasis  is  not  uncommon,  but  usually  escapes  clin- 
ical recognition. 

Influenzal  'pneumonia  occurs  in  from  5  to  8  per  cent,  of  the  cases 
and  is  the  most  important  complication.  Pfeiffer's  bacillus  is 
its  most  frequent  cause,  according  to  Leichenstern  and  Wasser- 
mann.  The  pneumococcus,  streptococcus,  and  staphylococcus,  alone 
or  combined  with  the  Bacillus  influenzse,  are  the  cause  of  some 
cases. 

Genuine  lobar  pneumonia  undoubtedly  occurs,  and  a  grippe  epi- 
demic may  double  the  number  of  lobar  pneumonia  cases.  When  it 
complicates  grippe  it  is  said  to  be  less  completely  lobar  and  less 
clearly  granular. 

Influenzal  pneumonia,  strictly  speaking,  is  exclusively  catarrhal 
(Pfeiffer,  Back,  Wassermann),  and  shows  no  fibrinous  exudation  or 
granulations,'  but  merely  infiltration  of  cells,  which  commences  about 
the  bronchi  as  multiple  distinct  foci  with  normal  lung  between  them; 
(the  lobular  foci  sometimes  fuse  into  secondary  lobar  pneumonia). 
It  often  causes  minute  abscesses.  There  is  another  type  like  the 
"acute  lobar  desquamative  pneumonia"  of  Buhl,  and  still  another, 
the  "acute  primary  streptococcus  pneumonia"  of  Finkler,  which  is 
lobular  and  catarrhal.  Uncertainty  as  to  the  exact  type  may  exist, 
but  as  Ziegler,  Sahli,  Kundrat  and  Weichselbaum  have  shown, 
mixed  infection  is  of  great  importance.  Clinically,  the  pneumonia 
is  usually  atypical  and  begins  insidiously  without  a  chill,  but  with 
increase  of  the  prior  cough  and  dyspnoea.  It  develops  during  or  after 
the  influenzal  attack,  although  pneumonia  may  be  the  first  sign  of 
influenzal  infection.  Its  symptoms  are  more  pronounced  than  its 
physical  signs,  and  the  disproportionate  cyanosis  and  dyspnoea  some- 
times suggest  miliary  tuberculosis.  Foci  of  dulness  may  be  found 
but  distinct  bronchial  breathing  is  rare;  bronchophony  is  a  much 
more  reliable  symptom.  The  heart  is  often  weak  and  a  peculiar 
redness  of  the, face  and  head,  profuse  sweats  at  the  beginning,  and 
characteristic  paroxysmal  coughing  are  symptoms  not  seen  in  ordi- 
nary pneumonia.  The  foci  may  be  bilateral  or  multiple  (60  per  cent, 
of  the  cases)  and  the  apices  are  involved  very  frequently.  The  symp- 
toms and  signs  may  recur  or  intermit  as  the  consolidation  wanders 
from  place  to  place.  The  sputum  is  purulent  or  bloody,  but  the  type 
of  pneumonia  is  not  determined  either  from  the  sputum  or  from  its 
bacteriology.  Influenzal  pneumonia  may  result:  (1)  In  solution  by 
lysis;  (2)  in  death  in  the  first  stage  of  congestion  from  oedema  pul- 
monum;  the  patient  may  die  later,  gray  hepatization  having  set  in 
within  three  days;  the  mortality  is  20  to  30  per  cent.;  (3)  in  chronic 
influenza  pneumonia,  with  hectic  fever  and  suppuration;  e.g.,  in  an 
upper  lobe  (Graves,  1837);  it  may  simulate  tuberculosis;  during  a 
grippal  epidemic,  an  increased  mortality  from  tuberculosis  is  noticed; 
(4)  in  abscess  or  gangrene  of  lung  . 

Pleurisy  may  follow  pulmonary  lesions  or  even  the  bronchitis 
(Kundrat).     Primary  pleurisy  occurs  in  27  per  cent.   (12  to  33  per 


180  THE  SPECIFIC  INFECTIONS 

cent.)  of  tlie  fatal  cases  of  influenza.    It  may  begin  early  and  its  symp- 
toms are  frequently  severe  and  protracted. 

4.  Circulation. — The  heart-muscle  is  directly  injured,  especially 
in  its  nervous  apparatus.  The  lesser  circulation  is  most  involved. 
Weakness  of  contraction,  syncope,  even  death,  may  occur  during 
convalescence,  especially  when  there  are  preexisting  fatty,  valvular, 
or  arteriosclerotic  changes.  The  pulse  is  labile,  often  arrhythmic  or 
dicrotic  (Pribram);  it  may  be  rapid,  and  out  of  proportion  to 
the  fever;  cyanosis,  dyspnoea  and  bronchiolitis  are  frequent  in  such 
cases.  A  slow  pulse  is  very  frequent  (45  to  50  per  cent.)  in  severer 
types  and  is  caused  by  toxsemic  stimulation  of  the  vagus.  Acute  endo- 
carditis resulting  from  mixed  infection  sometimes  follows  suppurat- 
ing foci  in  the  lungs;  three  cases  are  recorded  in  which  the  influenza 
bacillus  was  found.  Pericarditis  is  a  sequence  of  other  lung  or  heart 
disease.  Acute  phlebitis  is  seen  mostly  in  severe  cases,  when  the 
heart  is  weak  (cardiac  type),  and  occurs  most  frequently  in  the  upper 
extremities.  Arteritis  is  rare,  is  embolic  or  primary,  occurs  mostly 
in  the  popliteal  vessels,  and  may  end  in  gangrene.  The  existence  of 
leukocytosis  is  denied  by  some  writers;  it  occurs  in  not  more  than  a 
third  of  the  cases.  Blood  disintegration  and  hemorrhages  into  the 
skin,  serous  and  mucous  membranes,  usually  indicate  severe  intoxica- 
tion. 

5.  Alimentary  Tract. — Digestive  symptoms  are  not  especially  im- 
portant. The  tongue  is  coated  but  rarely  dry  or  typhoidal.  Fetor 
ex  ore  and  vomiting  (.34  per  cent.)  which  is  sometimes  bilious  and 
persistent,  and  grippal  hypersesthesia  of  the  stomach  may  be  observed. 
Constipation  is  more  frequent  than  diarrhoea.  Typhoidal  symptoms 
may  occur  (see  Differextiatiox).  There  are  the  usual  febrile  degen- 
erative changes  in  the  liver.  Icterus  is  rare  (2  per  cent.).  The  spleen 
is  enlarged  clinically  in  but  15  per  cent,  of  cases. 

6.  Genito-TJrinary  Tract. — Albuminuria  (under  10  per  cent.)  may 
result  from  toxtemia  or  stasis.  Altered  red  blood-cells  in  the  urine 
are  rather  frequent,  xicute  glomerulonephritis  occurs  in  1  per  cent, 
of  cases.  Diabetes  mellitus  is  said  to  have  followed  influenza;  if 
influenza  complicates  an  old  diabetes,  the  prognosis  is  doubtful  or 
unfavorable.  Hayem  found  urobilinuria  almost  constantly.  Senator 
noted  the  frequent  occurrence  of  the  diazo  reaction  and  of  indicanuria. 
Cystitis,  hsematuria,  menorrhagia,  abortion  and  orchitis  are  but  oc- 
casional complications. 

7.  Skin,  Muscles,  Joints. — Urticaria,  herpes  (5  to  25  per  cent,  of 
cases),  redness  and  hyperidrosis  (vasomotor  paresis),  miliaria,  ery- 
thema nodosum  or  multiforme,  scarlatiniform  or  morbilliform  erup- 
tions on  the  face  or  chest,  purpura,  erysipelas,  and  pemphigus  may 
be  noted.  Skin  eruptions  occur  in  16  per  cent,  of  the  cases.  Poly- 
synovitis  (rheumatoid  form  7  per  cent.),  pyarthrosis  or  myositis  are 
not  common;  bone  troubles  are  not  important  and  are  infrequent. 

Eye  involvement  (7  percent.),  conjunctivitis,  keratitis,  herpes,  pain 
in  the  eye-ball,  swelling  of  the  lids,  and  otitis  media   (30  to  40  per 


INFLUENZA   {LA  GRIPPE)  181 

cent.),  which  is  usually  purulent,  and  often  hemorrhagic,  are  due  to 
the  pyogenic  cocci,  pneumococci  and  the  influenza  bacillus. 

Diagnosis. — At  the  time  of  an  epidemic  the  diagnosis  is  usually 
easy.  Respli-atory  catarrh,  headache,  pains  in  the  joints  and  back, 
nervous  depression  and  tardy  convalescence  are  significant.  The 
diagnosis  of  the  toxic,  nervous  and  alimentary  forms  is  more  difficult 
and  many  errors  may  be  made.  The  importance  of  bacteriological 
diagnosis  has  been  over-rated,  but  positive  results  are  decisive. 

Differentiation. — Typhoid  Fever. — The  diseases  may  be  confused 
when  atypical  severe  influenza  begins  with  gradual,  step-like  rise  of 
the  fever  and  typhoid  symptoms,  such  as  tympany,  enteritis,  colic, 
peritoneal  manifestations,  intestinal  hemorrhage,  swelling  of  the  spleen, 
and  roseolse.  At  autopsy,  swelling  and  even  ulceration  of  the  stomach 
mucosa  and  Peyer's  patches  occur  (Jiirgens).  However,  coryza,  con- 
junctivitis, the  existence  of  an  epidemic  and  early  catarrhal  symptoms, 
indicate  influenza,  and  the  serum  test  and  other  cardinal  typhoid  find- 
ings iq.v.)  decide  the  diagnosis. 

Simple  Coryza,  Bronchitis,  etc. — These  are  distinguished  from  true 
influenza  by  the  sudden  rise  of  fever  in  influenza,  its  nervous  mani- 
festations, pains  in  the  head,  bacteriology,  spleen  and  exanthems. 
Ivord  found  the  bacillus  of  Pfeiffer  in  30  per  cent,  of  bronchitis  cases 
in  Boston,  in  which  there  was  no  suspicion  of  influenza. 

Measles. — The  early  diffuse  respiratory  catarrh  in  each  disease  may 
cause  confusion,  and  doubts  may  be  increased  by  measles-like  erup- 
tions in  influenza,  but  the  typical  measles  fever  curve  (the  fever  rising 
again,  after  the  prodromes,  with  the  exanthem),  and  Koplik's  spots, 
determine  the  diagnosis  on  the  third  or  fourth  day. 

Miliary  Tuberculosis. — This  is  suggested  only  in  severe  respiratory 
types;   the  history  is  usually  distinctive. 

Meningitis.— Influenza  may  masquerade  as  a  pseudomeningitis,  but 
focal  signs  are  usually  absent  and  doubts  are  settled  by  continued 
watching  and  lumbar  puncture. 

Apoplexy,  the  acute  psychoses  and  acute  poisoning  are  rarely  simu- 
lated by  influenza. 

Prognosis. — (1)  The  morbidity  is  enormous,  reaching  50  or  even 
75  per  cent,  of  the  population  (pandemic  of  1889-1890).  (2)  The  mor- 
tality is  i*r,  to  1  per  cent.,  but  statistics  are  unreliable  since  the  diag- 
nosis of  influenza  is  often  carelessly  made.  It  is  certain  that  influenza 
increases  the  total  number  of  deaths  from  pneumonia  and  tuberculosis, 
especially  in  the  weak  and  aged.  In  some  cases  the  course  is  chronic, 
the  bacillus  being  found  in  the  sputum  for  weeks  or  months,  especially 
in  tuberculous  subjects,  who  are  remarkably  susceptible. 

Treatment. — There  is  scarcely  any  prophylaxis  except  that  persons 
should  avoid  crowds.  Isolation  should  be  practised  in  asylums,  hos- 
pitals and  prisons.  Quinine  is  thought  valuable,  but  is  very  uncertain. 
Gargles  and  nasal  douches  may  possibly  prevent  infection  and  are 
distinctly  indicated  in  grippal  patients.  There  is  no  specific  treatment 
and  symptoms  must  be  met  as  they  arise.     In  every  case,  influenza 


182  THE  SPECIFIC  INFECTIONS 

should  be  treated  as  a  serious  disease  and  complications  should  be 
avoided  by  means  of  rest  in  bed  and  restricted  diet.  The  treatment 
is  much  like  that  of  a  severe  cold. 

1.  Pain. — At  the  onset,  Dover's  powder  and  antipyrin  aa  grains 
X,  at  once,  are  given  for  pain.  Antipyrin  has  been  used  to  excess,  but 
is  superior  to  acetanilid  and  phenacetin.  If  these  measures  do  not 
relieve  the  pain,  the  salicylates  should  be  used  as  they  are  in  rheu- 
matism.   Cold  baths  for  high  fever  are  poorly  tolerated  by  the  patient. 

2.  Catarrhal  Symptoms. — In  conjunctivitis,  boric  acid  solution  is 
excellent;  in  coryza,  douches  with  Dobelle's  solution,  tincture  of 
belladonna  and  of  aconite  in  two-  and  one-drop  doses,  respectively, 
should  be  used  every  half  hour  for  about  three  hours,  and  the  alkaloid 
cocaine  gr.  j  to  albolene  §j  should  be  used  locally;  in  pharyngitis, 
silver  nitrate  (20  per  cent.)  should  be  applied  once  or  twice;  in  ton- 
sillitis, nitrate  of  silver  should  be  introduced  into  the  follicles  which 
are  first  opened  and  touched  with  Dobelle's  solution;  for  bronchitis 
(q.  v.),  codeine  or  morphine  is  indicated;  for  enteritis,  bismuth  and 
paregoric  aa  5j  should  be  given  after  each  bowel  movement. 

3.  Severe  Nervous  Symptoms. — These  are  somewhat  relieved  by 
warm  baths.  Neuralgia  necessitates  the  use  of  antipyrin,  gelsemium, 
quinine,  camphor,  iron  and  arsenic.  Headache  is  treated  as  it  is  in 
typhoid;  it  is  increased  by  alcohol. 

4.  Heart. — The  heart  may  require  strychnine. 

5.  Convalescence. — Care  in  convalescence  is  important;  cases  of 
chronic  tuberculosis  or  bronchitis  require  high  altitudes. 


PERTUSSIS   (WHOOPING-COUGH). 

Definition. — A  specific,  frequently  epidemic,  infection  of  the  upper 
air-passages,  occurring  chiefly  in  children,  and  characterized  by  a 
cyclic  course  and  a  severe  convulsive  cough,  which  ends  in  a  long- 
drawn,  spasmodic  inspiration  or  whoop. 

History. — Pertussis  was  described  by  Ballonius  (157.8)  and  Willis 
(1674). 

Etiology. — (a)  Age. — It  usually  occurs  in  children  and  is  most 
frequent  at  the  fourth  year  (seven  months  to  seven  years).  It  is  ex- 
tremely infrequent  after  the  twentieth  year,  though  cases  do  occur  in 
middle  and  advanced  life. 

(6)  Sex. — Sixty-six  per  cent,  of  cases  occur  in  girls,  females  being 
more  inclined  to  spasmodic  diseases,  (c)  Anaemia  and  respiratory 
catarrh  are  predisposing  factors,  {d)  Most  cases  occur  in  March  and 
April. 

Pertussis  is  clearly  an  infection,  since  (1)  the  disease  is  directly 
infective  in  all  stages;  (2)  Koplik,  Affanassiew  and  Hensel  have  de- 
scribed a  facultatively  aerobic  bacillus  which  has  small  rounded  ends, 
is  but  little  larger  than  the  influenza  bacillus,  and  which  occurs  in 
clumps;    (3)  the  disease  may  occur  in  epidemics,  which  develop  from 


PERTUSSIS   {WHOOPING  COUGH)  183 

sporadic  cases;     (4)  one  attack  confers  almost  absolute  immunity. 
Incubation  lasts  from  two  to  five  to  eight  days. 

Symptoms. — 1.  Stage  of  Prodromes. — The  stadium  frodromorum 
s.  catarrhale  is  characterized  by  headache,  backache,  photophobia, 
conjunctivitis,  coryza,  sneezing,  angina,  and  by  a  cough  which  becomes 
dryer  and  harder  toward  the  end  of  this  stage.  In  a  few  cases  there 
is  moderate  fever.  The  digestive  tract  is  usually  intact.  This  stage 
averages  one  week  (one-half  to  two  weeks),  but  is  often  shorter  when 
marked  epidemics  prevail. 

2.  Convulsive  Stage. — The  stadiwn  convulsivum  s.  sfasmodicum 
dates  from  the  first  "whoop."  The  fever  (aside  from  complications) 
ceases  with  the  onset  of  this  stage.  The  seizures  are  paroxysmal,  con- 
vulsive, and  are  accompanied  by  dyspnoea  and  vomiting.  As  a  rule 
the  child  is  well  except  for  the  paroxysm,  which  has  for  an  aura,  tick- 
ling in  the  larynx  or  back  of  the  sternum,  thoracic  constriction,  vertigo, 
or  a  creeping  sensation,  when  the  child  braces  himself,  and  terrified, 
runs  for  support.  Then  the  explosion  comes  in  the  form  of  three  to  ten 
or  more  short  expiratory  coughs  following  in  rapid  succession  until 
the  breath  is  lost,  when  the  "whoop"  is  heard  as  a  long,  rapid,  deep, 
sharp,  singing  or  whistling  inspiration.  Then  a  thin,  tenacious  and 
sometimes  blood-tinged  mucus  is  expectorated  and  vomiting  consti- 
tutes the  crisis  of  the  paroxysm.  There  may  be  apnoea,  great  cyanosis, 
and  usually  diminution  or  suppression  of  the  vesicular  murmur. 
One  to  two  minutes  elapse  between  expiration  and  inspiration,  and 
inspiratory  and  expiratory  spasms  or  generalized  convulsions  may 
develop.  The  eyes  are  injected,  the  nose  runs,  the  face  is  like  that  of 
an  epileptic,  the  jugular  veins  are  large  and  the  skin  is  clammy.  In- 
voluntary evacuations  occur;  the  pulse  is  small ;  ecchymoses  sometimes 
occur  in  the  conjunctivae,  sclerse,  neck  or  face.  After  the  attack,  con- 
sciousness returns,  respiration  is  fast,  and  there  is  fatigue,  stupor, 
sweating,  and  pain  in  the  abdominal  or  other  muscles  from  the  strain 
of  coughing  or  occasionally  from  actual  muscle  rupture.  The  attacks 
occur  largely  at  night,  but  especially  toward  morning.  In  the  free 
interval  there  may  be  euphoria  or  great  depression,  stomach  disturb- 
ance, anorexia,  inanition,  or  diarrhoea.  The  urine  has  a  gravity  of 
1,022  to  1,032,  and  may  be  pale  and  contain  much  uric  acid.  The 
laryngoscope  sometimes  reveals  laryngeal  or  tracheal  catarrh.  Leuko- 
cytosis is  observed  early  in  the  disease,  is  unusually  marked,  and  the 
increase  is  chiefly  in  the  lymphocytes  (Meunier) ;  Frank  S.  Churchill 
states  that  lymphocytosis  occurs  in  85  per  cent,  of  cases,  and  in  90  per 
cent,  during  the  catarrhal  stage;  it  also  occurs  in  those  diseases  which 
require  differentiation  from  pertussis.  The  number  of  the  attacks 
averages  about  twenty;  this  may  be  increased  by  excessive  or 
rapid  eating  and  drinking,  by  nasal  or  psychical  irritation,  and  by 
respiratory  efforts,  such  as  weeping.  The  average  is  lower  in  a  warm 
climate. 

3.  Stage  of  Decline. — The  stadium,  decrementi  usually  comes  after 
three  or  four  weeks,  but  may  require  months.     The  attacks  become 


184  THE  SPECIFIC  INFECTIONS 

less  frequent,  and  the  appetite  returns.  This  stage  is  longer  in  propor- 
tion as  the  case  is  mild.  Its  complications  make  it  the  most  dangerous 
stage. 

Course. — The  course  lasts  one  week  for  the  incubation,  one  to  two 
weeks  for  the  catarrhal  stage,  three  to  six  weeks  for  the  spasmodic, 
and  three  weeks  for  the  decline.  It  is  modified  by  the  following  com- 
plications: 

Complications. — 1.  Increase  or  Extension  of  the  Usual  Symptoms. 
— Catarrhal  inflammation  is  common  in  the  initial  stage, — stomatitis, 
laryngitis,  catarrhal  diarrhoea  (10  per  cent.),  and  otitis  media  (10  per 
cent.).  Bronchitis  (bronchiolitis)  is  not  common  in  the  spasmodic 
stage.  It  may  occur  with  fever,  a  pulse  of  120  to  150,  respirations  of 
30  to  50,  irregularity  of  breathing,  many  rales,  cyanosis  and  atelec- 
tasis. Bro7ichopneumonia  is  the  most  frequent  and  severe  complica- 
tion, occurring  particularly  in  rhachitic  children  between  the  third 
and  fifth  years  and  is  most  ominous  in  younger  subjects,  especially 
those  under  the  third  year.  It  occurs  most  often  in  the  convulsive 
period.  The  mortality  is  great,  sometimes  20  to  25  per  cent,  of  cases. 
The  onset  is  gradual  with  fever  of  100°  to  102°,  a  pulse  of  130  to  160, 
respirations  of  30  to  80,  with  cyanosis  and  dyspnoea.  An  almost  abso- 
lutely bad  prognosis  must  be  given  in  the  very  young.  Sometimes 
the  pneumonia  greatly  lessens  or  entirely  prevents  the  spasms  (Trous- 
seau). Lobar  pneuinonia  is  much  rarer.  Exudative  pleurisy  is  a  rare 
but  very  severe  complication,  and  is  seen  almost  exclusively  in  older 
children  or  adults.  Endocarditis,  pericarditis,  meningitis  and  nephritis 
are  very  infrequent.  Spasm  of  the  glottis  rarely  occurs  in  children  be- 
fore the  fourth  year  and  is  mostly  seen  in  those  who  are  nervous  or 
scrofulous.  Its  incidence  is  largely  nocturnal,  and  it  may  cause  death 
from  asphyxia  even  in  the  lightest  cases.  Convulsions,  especially  in 
nervous  and  hydrocephalic  children,  may  occur  at  any  time,  but  are 
most  frequent  at  the  height  of  the  apnoea,  at  the  time  of  first  teething, 
and  in  the  second  to  fifth  week  of  the  disease.  They  are  of  the  carpo- 
pedal  type.  The  eyes  are  rolled  upward  and  outward,  the  pupils  are 
dilated,  and  coma  follows  the  dyspnoea. 

II.  Mechanical  Complications. — Hemorrhages  may  occur  into  the 
skin,  conjunctivae,  nose  (relieving  the  cerebral  congestion  following 
the  cough),  ears  and  throat.  Hemorrhage  may  occur  in  the  brain, 
resulting  fatally,  or  causing  spastic  paraplegia.  Detachment  of  the 
retina,  because  of  hemorrhage,  and  extravasation  of  blood  into  the 
lungs,  stomach,  and  intestine,  are  rare.  There  may  be  wdema  of  the 
eye-lids,  anasarca,  rupture  of  the  tympanum,  or  rupture  of  the  frenu- 
lum of  the  tongue,  the  ulceration  of  which  is  almost  constant.  Vomit- 
ing occurs  at  the  end  of  the  paroxysm  as  a  mechanical  crisis  to  the 
attack  and  is  so  constant  that  the  disease  was  once  thought  to  origi- 
nate in  the  stomach.  The  development  of  chronic  gastro-intestinal 
catarrh  is  infrequently  promoted  by  stasis.  Other  mechanical  compli- 
cations are  cardiac  dilatation,  pulmonary  emphysema  (less  often 
interstitial  than  alveolar),  bronchiectasis,  pneumothorax,  involuntary 


PERTUSSIS   {WHOOPING  COUGH)  185 

evacuations,  prolapse  of  the  rectum  or  uterus,  aneurysm,  muscular 
ruptures,  hernias,  rib  fracture,  and  spinal  deformity. 

III.  Toxaemia. — IMarked  toxaemia  is  rare.  Parenchymatous  de- 
generations are  found  in  the  fatal  cases.     Nephritis  is  not  common. 

Sequels. — The  hysterical  coughing  and  spasm  which  sometimes  fol- 
low pertussis  may  very  closely  resemble  it;  rhachitis  is  sometimes  a 
sequel;  tuberculosis  may  involve  the  lungs  or  peritoneal  or  mediastinal 
lymph  glands,  and  this  sometimes  produces  retrosternal  dulness;  it 
occurs  especially  after  pertussis  with  measles,  both  of  which  infections 
predispose  to  tuberculosis.  Preexisting  tuberculosis  renders  the  prog- 
nosis of  whooping-cough  very  unfavorable.  It  develops  in  the  third 
stadium  and  in  most  cases  between  the  sixth  and  tenth  years  of  age. 
Landry's  ascending  paralysis  has  been  observed.  The  heart-muscle 
may  suffer  permanent  weakness. 

Diagnosis. — Diagnosis  is  easily  made  (1)  by  the  definite  stages  of 
the  disease;  (2)  by  the  presence  of  an  epidemic;  (3)  by  the  absolutely 
characteristic  convulsive  seizures;  (4)  by  stigmata,  such  as  sublin- 
gual ulceration,  swollen  upper  eye-lids,  oedema  of  the  face,  petechise, 
and  tender  areas  in  the  larynx;  (5)  pressing  the  tongue  down  and  back 
with  a  spoon  often  elicits  a  characteristic  attack  of  coughing.  The 
stridor  may  be  absent  in  nurslings  and  adults.  The  diagnosis  may  be 
difficult  in  intervals  between  paroxysms  in  the  early  or  late  stages. 
Intercurrent — especially  febrile — diseases,  like  pneumonia  or  measles, 
may  render  pertussis  atypical. 

Differentiation. — 1.  Laryngeal  diseases  with  spasm.  2.  Acute  glot- 
tis oedema.  3.  Croup.  In  the  latter  there  is  fever,  aphonia,  metallic 
inspiration,  lividity  and  constancy  of  the  symptoms;  i.  e.,  no  interval. 

4.  False  croup,  (laryngismus  stridulus)  beginning  with  acute 
catarrhal    laryngotracheitis,    occurs    at    night    in    healthy   children. 

5.  An  epidemic  cough  in  babies  {tusssi  jernia)  may  occur  epidemi- 
cally, but  has  no  "whoop."  6.  Spasmodic  cough  from  disease  in 
the  bronchial  glands.  7.  ''Ictus  laryngeus"  (vertigo  or  epilepsia 
laryngea),  occurs  in  asthma,  gout,  tabes  or  laryngeal  disease,  and 
is  recognized  by  burning  in  the  larynx,  vertigo  and  falling,  as 
in  apoplexy  (ictus).  8.  Spasmus  glottitis  occurs  in  nervous  children 
at  dentition,  in  cases  of  rhachitis  and  tetany;  it  is  a  sudden  spas- 
modic closure  of  the  glottis  without  prodromes,  but  with  dyspnoea, 
cyanosis  and  convulsions.  9.  Asthma  periodicum  (Millar's  asthma) 
may  develop  in  healthy  children  from  the  second  to  the  sixth  year, 
with  hoarseness,  moderate  fever,  dyspnoea  on  the  second  day,  with 
convulsions,  cyanosis,  and  repeated  seizures.  Recovery  occurs,  or 
death,  within  the  first  eight  days  of  the  disease.  10.  Hysterical  "after  "- 
pertussis  is  characterized  by  the  absence  of  catarrhal  symptoms,  fever, 
vomiting  and  the  stigmata  of  pertussis;  i.  e.,  sublingual  ulceration, 
darkly  colored  upper  eye-lids,  oedema  of  the  face,  petechise  and  the 
tender  point  in  the  larynx,  irritation  of  which  induces  an  attack.  Hys- 
terical imitation  is  associated  with  the  stigmata  of  hysteria  (q.v.),  the  in- 
fluence of  suggestion  and  a  longer  course  than  that  of  pertussis  proper. 


186  THE  SPECIFIC  INFECTIONS 

Prognosis. — Whooping-cough,  with  its  complications,  is  a  very  fatal 
disease,  and  ranks  third  in  the  English  vital  statistics  for  children. 
Hirsch  states  that,  in  Prussia,  85,000  deaths  occurred  from  pertussis 
from  1875  to  1880,  and  in  England,  from  1857  to  1867,  120,000  died 
from  the  disease.  The  mortality  averages  3  per  cent. ,  but  varies  with 
the  virulence  of  the  epidemic,  and  may  even  reach  15  per  cent.  The 
longer  the  time  of  development  of  the  convulsive  stage,  the  better 
is  the  prognosis,  and  the  clearer  are  the  intervals  between  paroxysms. 
The  outlook  is  more  unfavorable  in  girls,  in  the  poor,  in  nurslings 
and  in  children  under  five  years,  especially  in  colored  children.  The 
mortality  of  cases  in  the  first  year  is  about  27  per  cent.,  in  the  second 
year  14  per  cent. ;  from  the  second  to  the  fifth  year,  3  per  cent. ;  from 
the  fifth  to  fifteenth  year,  1.8  per  cent.  (Hagenbach);  Toplitz  found 
41.7  per  cent,  of  pertussis  deaths  in  children  under  one  year,  and  48 
per  cent,  in  children  between  one  and  two  years  of  age.  According 
to  Trousseau,  when  more  than  forty  attacks  occur  in  one  day,  a  grave 
prognosis  is  indicated  and  when  over  60  attacks  occur  a  fatal  outcome 
is  certain.  The  writer,  however,  has  seen  recovery  in  cases  with  over 
100  paroxysms  daily.  Coincident  measles,  pneumonia  or  bronchitis, 
especially  if  of  early  development,  weak  heart,  purpura,  continued 
emesis,  glottis  spasm,  eclampsia,  sinus  thrombosis,  skin  emphysema, 
encephalitis,  brain  hemorrhage,  asphyxia,  and  the  sequels  of  scrofula 
and  tuberculosis,  render  the  prognosis  very  uncertain. 

Treatment. — 1.  Prophylaxis. — Isolation  is  difficult,  but  is  indicated, 
particularly  in  tuberculous  children.  It  may  be  thought  best  to  expose 
a  child  to  a  mild  epidemic.  The  greatest  danger  exists  during  the 
catarrhal  stage,  although  the  coughing  period  is  not  devoid  of  it. 
The  sputum,  and  the  washing  of  clothes,  etc.,  are  cared  for  on  anti- 
septic principles.  It  was  thought  that  vaccination  mitigated  or  aborted 
pertussis  (Archer),  but  in  eleven  personal  cases,  which  had  never 
been  vaccinated,  vaccinia  had  no  prophylactic  effect. 

2.  Medication.  —  There  is  no  specific,  as  proved  by  the  much- 
vaunted  resolvents,  emetics,  demulcents,  expectorants,  antispasmodics, 
narcotics,  tonics,  and  antiseptics.  All  drugs  should  be  employed 
cautiously.  The  following  are  of  value :  Quinine,  the  foremost  remedy, 
was  first  introduced  by  Binz,  who  gave  1|  times  as  many  grains  'per 
diem  as  the  child  was  years  old;  to  children  under  two  years,  he 
gave  ^  grain  for  each  month.  Children  object  to  the  taste  of  quinine  less 
than  do  adults. 

Widerhofer's  formula  runs  as  follows : 

Extr.  belladonnse gr.  iss. 

Quininse  sulph gr.  viij. 

Sacchari  albi gr.  xxx. 

M.  et  divide  in  pulv.  no.  X. 

S. — One  powder  three  times  daily. 

Camphor,  recommended  by  Jacobi,  is  a  stimulant  and  may  be  indi- 
cated in   asthenia   and   in  increasing  bronchitis,  |  grain  at  a  dose. 


PERTUSSIS   {WHOOPING  COUGH)  187 

Anti'pyrin  sometimes  decreases  the  number  and  severity  of  the  at- 
tacks; ^  grain  for  each  month  or  a  decigram  (1.5  grains)  for  each 
year  is  given,  which  may  be  gradually  doubled.  Bromine  should  be 
administered  as  bromide  or  bromoform  (Stepp).  It  is  not  curative, 
but  moderates  the  course  of  the  disease.  Bromoform  should  be  kept 
bottled  in  the  dark  and  should  be  administered  fresh  from  the  stock 
solution  each  time:  one  to  five  minims  in  simple  syrup. 

The  catarrh  may  be  treated  with  expectorants  and  alkaline  drinks. 
A  steaming  kettle  will  somewhat  alleviate  bronchitis,  the  child  being 
kept  in  bed  and  a  tent  constructed  over  the  bed.  Intralaryngeal  in- 
sufflations of  resorcin  (1  per  cent,  with  starch)  are  recommended. 
Blenorrhoea  should  be  treated  with  benzoic  and  tannic  acids  (aa  gr. 
ij,  t.  i.  d.). 

For  the  paroxysm  there  is  no  specific.  Belladonna  is  given  by  Jacobi 
in  the  form  of  the  extract,  one-sixth  grain  to  a  child  of  six  to  eight 
months,  until  flushing  is  observed.  Symptomatically  it  is  also  useful 
for  the  clammy,  cool  skin  and  for  collapse  symptoms.  Though  child- 
ren tolerate  belladonna  well,  great  care  must  be  exercised  with  regard 
to  the  very  young.  The  same  caution  is  necessary  with  ipecac,  chloral 
and  Henoch's  combination  of  belladonna  and  opium. 

Chloroform  inhalations  are  dangerous.  Codeine  is  less  effective 
than  morphia.  Chloroform  (Schilling)  may  be  given  with  advantage 
in  dry  coughs,  and  twice  as  many  drops  may  be  administered  as  the 
child  is  years  old.  It  should  be  given  in  one  dram  of  warm  water.  It  is 
said  that  the  paroxysm  may  be  averted  by  pulling  the  lower  jaw  down- 
ward and  forward. 

Yeo  recommends  the  following  formulse: 

Morphinse  hydrochloridi .    .    .    gr.  J. 

Sodii  bromidi      5ss. 

Aquse  laurocerasi 5ij. 

Aquae  chloroformi ad   Sjss. 

Misce,  fiat  mistura. 

S. — One  to  three  teaspoonfuls  for  a  dose,  according  to  the  age  of  the  child. 

^^ 

Chloral  hydratis .    .    .   gr.  xvj . 

Sodii  bromidi      gr.  xxxij. 

Aquse  chloroformi ad  oij. 

Misce.  fiat  mistura. 

S. — One  to  four  teaspoonfuls  for  a  dose,  according  to  age. 

^        ..  . 

Sodii  benzoatis gr.  Ixxij. 

Sodii  bicarbonatis gr.  xlviij. 

Ammonii  chloridi gr.  xxiv. 

Aquse  chloroformi oj- 

Aquse  anisi ad  Siij- 

Misce,  fiat  mistura. 

S. — One  to  four  teaspoonfuls,  according  to  the  age  of  the  child,  in  a  little  hot 

milk,  every  four  hours. 

Digitalis  is  used  by  Koplik  and  Knight  for  right-heart  dilatation. 
O'Dwyer  recommends  intubation  for  the  spasm  of  the  glottis.     This 


188  THE  SPECIFIC  IXFECTIOXS 

is  open  to  the  criticism  that  ulceration  might  occur  from  the  long- 
continued  pressure  in  the  larynx.     Bronchopneumonia  (q.  v.). 

3.  Hygiene. — In  warm  climates  pertussis  is  rare  and  runs  a  mild 
course.  A  suitable  climate  is  likewise  prophylactic  against  tubercu- 
losis. The  attacks  are  often  lessened,  or  the  disease  quickly  ended, 
by  removal  to  the  country.  Moderate  exercise  is  indicated.  Such 
irritants  as  beef  tea  or  stimulants,  dry  bread,  cookies  (Vogel),  and 
overfeeding  or  drinking,  should  be  avoided,  because  they  provoke 
coughing  and  vomiting  in  the  convulsive  stage.  Food  should  be  given 
at  frequent  intervals  in  concentrated  form — gruels,  milk  with  lime- 
water,  zwieback  in  milk,  eggs,  malt,  meat-juice,  etc.  Older  patients 
can  tolerate  more  solid  foods.  Rectal  feeding  and  the  use  of  the  nasal 
catheter  are  sometimes  of  advantage. 


EPIDEMIC  PAROTITIS    (MUMPS). 

Definition. — An  acute  specific  infection,  contagious,  febrile,  often 
epidemic,  and  characterized  by  a  primary  inflammation  of  the  parotid 
glands. 

History. — Parotitis  epidemica  was  known  to  Hippocrates,  who  de- 
scribed every  essential  point,  but  later  it  was  confused  with  other 
swellings  of  the  parotids  and  other  diseases.  Its  distribution  is  world- 
wide. 

Etiology. — (a)  Its  precise  cause  is  unknown,  although  various 
micrococci  and  diplococci  have  been  described,  (b)  Most  cases  occur 
between  six  and  fifteen  years  of  age,  although  isolated  cases  are  seen 
in  adults  and  the  aged,  (c)  The  sexes  are  about  equally  involved. 
(d)  More  cases  occur  in  the  cold,  moist,  spring  months  than  in  the 
summer,  (e)  Contagion  is  more  frequently  direct  from  person  to 
person  than  indirect  by  a  third  party  or  by  fomites.  (/)  It  prevails 
largely  in  epidemics,  although  sporadic  cases  are  occasionally  seen. 
(g)  Immunity  is,  as  a  rule,  conferred  by  one  attack.  It  rarely  prevails 
with  scarlatina,  varicella,  measles  or  influenza. 

Symptoms. — After  an  incubation  of  two  and  a  half  to  three  weeks, 
the  disease  usually  begins  with  fever,  which  is  followed  in  a  few  days 
by  parotid  intumescence  and  pain.  In  some  cases  prodromes  (slight 
fever,  chilliness,  and  redness  of  the  throat)  may  exist  for  thirty-six 
to  forty-eight  hours  before  actual  fever  and  parotitis  develop.  In 
other  instances  the  severity  of  the  epidemic  determines  such  severe 
initial  symptoms  as  vomiting,  convulsions,  or  facial  spasm  in  children; 
or  delirium,  prostration,  diarrhoea,  or  a  severe  typhoidal  condition  in 
adults.  As  a  rule,  the  fever  rises  at  the  outset  to  101°  or  even  104°, 
the  pulse  averages  100,  and  in  two  days  the  characteristic  parotitis 
develops.  Its  signs  are  clearly  inflammatory  (swelling,  pain,  tempera- 
ture, and  often  interference  in  function).  The  parotitis  is  usually 
bilateral,  for  the  inflammation  of  one  gland  is  rapidly  followed  by 
parotitis  in  the  other.     Indeed,  Bouchoud  said:    "Mumps  have  no 


EPIDEMIC  PAROTITIS   {MUMPS)  189 

singular" ;  but  in  some  epidemics  the  parotitis  is  unilateral  (Laveran). 
Its  degree  varies  and  sometimes  there  is  partial  swelling.  Again  it 
may  be  diffuse  over  the  entire  gland,  or  even  beyond  it.  We  know 
little  of  its  pathology  beyond  what  Virchow  described — hyperaemia  of 
the  parenchyma,  interstitial  swelling,  catarrhal  secretion  in  the  ducts 
and  inflammation  of  the  contiguous  lymph-glands.  The  swelling 
about  the  gland  may  reach  the  eyelids,  forehead,  mastoid  region,  or 
even  the  lower  neck  and  clavicle,  making  the  features  unrecognizable. 
It  seems  that  the  swelling  is  due  less  to  periparotitis  than  to  pressure 
on  the  facial  and  other  veins.  It  is  soft  and  does  not  pit.  In  rare  in- 
stances stasis  and  oedema  may  be  noted  in  the  pharynx  or  even  in  the 
larynx  and  with  obvious  danger.  This  may  explain  the  occasional 
epistaxis.  Compression  by  the  swollen  glands  of  the  masticatory 
muscles  makes  chewing  or  opening  the  mouth  difficult;  chewing  also 
excites  pain  because  it  excites  salivary  secretion  which  often  cannot 
pass  the  turgid  ducts.  Compression  of  the  Eustachian  tube  or  external 
meatus  may  occasion  tinnitus.  In  the  early  unilateral  involvement, 
the  face  inclines  to  the  affected  side  in  order  to  relax  the  swollen 
tissues;  in  the  later  bilateral  parotitis,  the  head  is  often  bent  for- 
ward for  the  same  purpose.  The  salivary  secretion  may  be  normal, 
increased  or  decreased.  Suppuration  is  rare  and  is  probably  due  to 
mixed  infection.    Leukocytosis  is  usually  absent. 

In  severe  cases  the  submaxillary  and  sublingual  glands  participate 
in  the  inflammation  or  swelling  (even  in  50  per  cent,  of  some  epidemics 
recorded) ;  in  atypical  cases  they  may  be  the  sole  seat  of  the  disease, 
and  the  parotids  may  be  free  from  infection.  The  parotitic  swelling 
reaches  its  acme  in  three  or  four  days  and  an  equal  period  is  necessary 
for  its  subsidence.  The  course  then  is  one  week,  or  perhaps  two.  The 
fever  throughout  is  remittent  or  intermittent,  and  falls  by  lysis  in 
from  four  to  seven  days.  One  to  two  weeks  are  necessary  for  con- 
valescence. 

Complications  and  Sequels. — 1.  The  most  important  are  orchitis 
and  epididymitis,  which  were  described  by  Hippocrates.  On  the 
sixth  to  the  ninth  day  fever  returns  (102°  to  105°),  sometimes  with 
chills  and  local  redness.  Swelling  and  pain  in  one  testicle  develop, 
and  are  often  accompanied  by  general  symptoms.  Orchitis  usually 
follows  the  parotitis,  whence  it  was  formerly  considered  metastatic. 
This  view  is  untenable,  because,  in  some  epidemics,  orchitis  precedes 
or  even  occurs  without  parotitis.  We  must  then  explain  mumps  as 
a  general  infection,  the  blood  carrying  the  virus  first  and  most  com- 
monly to  the  parotid  glands  and  later  (and  even  before  or  alone)  to 
the  testicle.  A  urethritis  is  sometimes  observed,  analogous  to  the 
catarrh  of  the  parotid  duct.  It  is  sometimes  held  that  this  inflammation 
is  the  primary  and  atrial  one.  Testicular  localization  occurs  almost 
wholly  in  the  sexually  mature  and  active  testis  and  is  therefore  most 
rare  in  children  or  the  aged.  Orchitis  or  epididymitis  is  usually  uni- 
lateral. It  occurs  in  a  variable  percentage  and  depends  on  the  char- 
acter of  the  epidemic.     Comby  observed  it  in  30  per  cent,  of  cases  of 


190  THE  SPECIFIC  INFECTIONS 

mumps  among  French  soldiers.  Acute  hydrocele  is  due  to  the  epi- 
didymitis. The  fever  occasionally  resolves  by  lysis,  and  suppuration 
from  mixed  infection  is  very  exceptional.  Testicular  atrophy  occurs 
in  44  per  cent.  (Gramers)  to  63  per  cent,  of  the  cases  (Comby)  and  if 
bilateral  may  occasion  sterility.  In  women,  ovaritis  and  vulvovaginitis 
are  infrequent.  Mastitis  is  rather  more  frequent,  and  may  be  observed 
in  men  and  boys. 

2.  Other  glandular  organs  are  less  frequently  inflamed.  Of  these 
the  lachrymal  glands  are  most  often  affected,  then  the  thyroid,  with. 
symptoms  of  acute  Graves's  disease,  pancreas  (1.5  per  cent.,  Simonin), 
and  the  thymus.    The  spleen  is  seldom  swollen. 

3.  Other  complications  are  very  rare.  These  are  severe  delirium, 
meningitis,  encephalitis,  paralysis  of  the  facial  or  other  cranial  nerves; 
polyneuritis,  or  the  neuroses;  labyrinthine  or  middle-ear  disease,  eye 
inflammations,  optic  neuritis;  endocarditis;  synovitis;  albuminuria 
or  nephritis;  bronchitis  or  bronchopneumonia ;  necrosis,  suppuration, 
or  gangrene  of  the  parotid  or  testis. 

Diagnosis. — The  diagnosis  is  usually  easily  made.  Osteomyelitis  of 
the  jaw,  periostitis,  parulis,  lymphadenitis,  thrombo-phlebitis  of  the 
external  jugular,  and  furuncle  of  the  external  ear,  should  be  considered 
and  excluded.'  Epidemic  parotitis  must  not  be  confused  with  secon- 
dary parotitis,  which  results  from  trauma,  or  pus  burrowing  from  the 
middle  ear,  or  with  mercurial,  iodide  or  lead  parotitis,  and  puru- 
lent metastasis  in  typhoid,  pneumonia,  and  erysipelas,  in  which 
the  pyogenic  virus  enters  by  the  ducts  or  settles  from  the  blood- 
current.  In  post-operative  parotitis,  after  laparotomy,  the  saliva 
is  decreased;  ansesthesia  first  increases,  then  decreases  the  salivary 
flow;  trauma  to  the  gland,  from  holding  up  the  jaw,  may  promote 
infection. 

Prognosis. — The  prognosis  is  usually  good,  for  but  7  deaths  occurred 
in  58,331  cases.  The  course  is  lighter  in  children  than  in  adults. 
Atrophy  and  sterility  may  result  from  orchitis. 

Treatment. — The  patient  should  be  isolated.  The  fever  is  controlled 
as  in  other  fevers,  and  diet  and  hygiene  are  the  same.  Complications 
are  treated  symptomatically.  The  patient  should  be  kept  in  bed  for 
one  and  a  half  weeks.  Pain  often  necessitates  the  use  of  opiates. 
The  local  parotid  or  testicular  inflammation  is  self-limited,  and  re- 
sists all  attempts  at  abortion  or  mitigation.  Local  heat  is  soothing  and 
better  tolerated  than  the  ice-bag. 


ACUTE  ARTICULAR  RHEUMATISM  (RHEUMATIC  FEVER). 

Definition. — An  acute,  febrile,  non-contagious  disease,  with  multiple 
articular  involvement  and  with  a  tendency  to  heart  complications. 

Frequency. — McCrae's  statistics,  from  Johns  Hopkins  Hospital, 
show  that  rheumatism  constitutes  2  per  cent,  of  admissions,  as  against 
3.5  to  7  per  cent,  in  the  London  hospitals. 


ACUTE  ARTICULAR  RHEUMATISM   {RHEUMATIC  FEVER)    191 

Etiology. — Though  strict  proof  is  lacking  that  rheumatism  is  an 
acute  infection,  the  evidence  is  strongly  presumptive.  This  is  shown 
by  its  occasional  yet  undoubted  epidemiology;  its  clinical  picture; 
its  tendency  to  recur  like  pneumonia  and  erysipelas;  the  autopsy 
findings  of  exudation,  hemorrhage,  cloudy  swelling,  and  acute  splenic 
tumor;  the  frequency  with  which  a  suitable  atrium  may  be  observed, 
such  as  an  angina,  which  furthers  the  entrance  of  microorganisms 
into  the  system;  and  its  indubitable  close  affiliations  with  such  dis- 
eases as  endocarditis,  pericarditis,  and  meningitis,  whose  mycotic  origin 
is  clearly  established.  Guttmann  and  Sahli  found  staphylococci  in 
the  joints,  kidneys,  and  pericardium,  and  Leyden  discovered  a  diplo- 
coccus.  Sahli  early  questioned  the  unity  of  the  disease  and  is  now 
inclined  to  regard  it  as  a  modified  septicopya^mia.  Birsch-Hirschfeld, 
Triboulet,  Bouchard,  Charrin,  Singer,  Alchame,  and  many  others, 
have  found  bacteria  not  only  in  the  joints  but  in  the  blood  and  vis- 
cera. If  all  observers  found  the  same  bacteria,  conclusions  would 
be  more  easily  drawn,  but  the  finding  of  streptococci,  staphylococci, 
diplococci  and  bacilli  creates  confusion,  and  it  must  be  stated  that 
the  rlieumatisin  virus  is  unknown. 

Of  late  the  Micrococcus  rheumaticus,  described  by  Triboulet  (1898) 
and  Wassermann  (1899),  has  attracted  especial  attention.  It  is  claimed 
that  it  differs  from  the  ordinary  streptococcus  in  changing  the  color 
of  agar  serum  media  and  in  growing  on  filtered  media  in  which  the 
ordinary  streptococcus  has  already  grown  (Marmorek's  test);  in  grow- 
ing best  on  very  alkaline  media  and  quickly  secreting  much  acid. 
It  is  said  to  produce  in  the  urine  formic  acid  (which  we  find  in  rheu- 
matism) and  produces  hemolysis  (like  the  rheumatic  anaemia).  Singer 
likens  rheumatism  to  septicopyemia  in  that  common  symptoms 
occur  in  each — temperature,  anaemia,  articular  metastases,  endocar- 
ditis, leukocytosis,  and  peptonuria.  He  places  particular  stress  upon 
the  detection  of  pyogenic  organisms  in  the  rheumatic  joints,  in  the 
initial  angina,  in  endocarditis,  in  pneumonia,  in  erythema  multiforme, 
in  the  various  serous  membranes  involved,  and  in  the  urine.  Chvo- 
stek  and  Egger  explain  the  presence  of  these  organisms  by  bacterial 
invasion  of  the  tissues  during  the  death  agony,  "an  agonal  invasion," 
since  bacteria  could  not  be  obtained  from  aspiration  of  the  joints 
during  life.  The  rheumatic  arthritis  is  sometimes  explained  by  tox- 
aemia rather  than  by  bacterisemia,  analogous  to  the  toxic  pericarditis 
of  uraemia,  or  the  swelling  of  the  articulations  after  antitoxin  injec- 
tions. Personally,  the  author  can  readily  conceive  of  such  a  theory, 
inasmuch  as  he  has  repeatedly  seen  negative  cultural  results  from 
aspirations  of  the  synovitis  of  chronic  nephritis,  explained  in  some 
instances,  at  least,  by  retained  toxins.  Streptococcus  or  staphylococcus 
infections  may  produce  a  clinical  picture  resembling  rheumatism  or 
may  indeed  complicate  it,  but  they  are  not  found  in  the  majority 
of  cases  of  genuine  rheumatism. 

Some  writers  question  the  "unity"  of  acute  articular  rheumatism, 
because  the  clinical  picture  is  not  always  the  same.    Age  modifies  the 


192  THE  SPECIFIC  IXFECTIOXS 

disease,  as  is  shown  by  the  predominance  of  chorea,  pericarditis,  and 
endocarditis  in  childhood,  with  striking  synovial  subordination.  The 
"genius  epidemicus"  changes  the  symptomatology,  the  disease  dura- 
tion, the  medicinal  results,  and  the  frequency  of  nervous,  and  endo- 
cardial complications,  and  of  those  of  the  serous  membranes.  The 
fact  that  the  onset  is  accompanied  by  angina,  enteritis,  icterus,  gas- 
tritis, bronchitis,  and  typhoid  symptoms,  is  an  argument  against  the 
theory  of  clinical  independence  of  inflammatory  rheumatism.  However, 
no  greater  variations  are  noted  than  in  other  diseases, — e.g.,  in  typhoid. 

Predisposing  Factors. — (a)  Cold;  75  per  cent,  of  cases  occur  in 
the  first  half  of  the  year  (McCrae);  (&)  heredity  (25  per  cent.);  (c) 
male  sex  (70  per  cent.);  (d)  age,  the  greatest  susceptibility  exists 
between  ten  and  thirty  years  (60  per  cent.,  McCrae;  81  per  cent.,  Dam- 
ash);  M.  Miller  collected  nineteen  cases  in  nurslings;  (e)  trauma, 
overexertion,  exhaustion,  exposure,  and  occupation,  occurring  frequently 
in  sailors,  divers,  bakers,  and  day  laborers. 

General  Clinical  Picture  and  Course. — The  onset  is  usually  sudden, 
with  moderate  fever,  redness  of  the  skin,  considerable  prostration, 
drenching  sweats  and  polyarthritis.  The  joints  are  involved  in  suc- 
cession, the  inflammation  lasting  a  few  days  in  one  joint  and  then 
passing  to  many  others,  with  frequent  heart  localization  and  the  fever 
ending  in  solution  by  lysis.  There  is  marked  anaemia  and  loss  of 
weio-ht.  If  endocarditis  occurs,  valvular  disease  is  the  usual  sequence. 
The  usual  duration  without  therapy  is  three  to  four  weeks,  though 
abortive  forms  occur.  Recovery  is  usual,  but  death  may  result  from 
hyperpyrexia  and  from  brain  toxaemia.  A  tendency  to  recur  and 
a  family  tendency  in  rheumatism  and  valvular  lesions  are  noted.  The 
articular  disease  is  directly  influenced  by  the  salicylates,  but  cardiac 
localizations  are  much  less  directly  or  not  at  all  affected.  In  adults 
and  adolescents  there  is  febrile  urine,  constipation,  conjunctival  in- 
jection, coated,  moist  tongue,  some  irritability,  restlessness,  and  fever 
which  is  renewed  as  fresh  joints  are  involved. 

Symptoms  in  Detail. — 1.  Prodromal  Symptoms. — ^These  are  an- 
gina or  tonsillitis  (70  to  80  per  cent.,  Garrod;  21  per  cent.,  Gerhart; 
5  per  cent.,  Groedel  and  Reiss;  1.7  per  cent.,  Pribram),  regarding 
which  there  are  two  conceptions;  (a)  that  the  angina  is  primary 
and  rheumatic,  and  (b)  that  the  rheumatism  following  angina  is 
pseudorheumatism  (polyarthritis  anginosa),  characterized  by  exan- 
thems,  occurring  chiefly  in  the  arms  and  reacting  poorly  to  salicylates. 
Mild  gastric  symptoms  are  considered  by  Damash  as  the  most  fre- 
quent prodrome.  Other  prodromes  are  laryngitis,  otitis  media,  chorea, 
chlorosis,  and  erythema  nodosum.  'Whether  the  prodromes  are  indef- 
inite or  wholly  absent,  or  whether  they  are  angina,  albuminuria  and 
fever,  as  Widal  has  often  seen  them,  or  enteric,  as  often  observed  in 
Vienna,  any  diagnostic  doubts  are  setded  by  the  appearance  of  the 
polyarthritis. 

2.  Polyarthritis. — (a)  Localization. — The  joints  most  frequently  in- 
volved are  those  of  the  lower  extremity,  particularly  the  knee  (53  to 


ACUTE  ARTICULAR  RHEUMATISM   {RHEUMATIC  FEVER)    193 

84  per  cent.);  and  usually  one  side  is  affected  after  the  other.  The 
ankles,  elbows  and  wrists  are  the  seats  of  the  next  most  frequent 
localizations.  Though  usually  found  in  the  large  joints,  it  may  in- 
volve the  smaller  articulations,  such  as  the  fingers.  Early  arthritis 
of  the  small  bones  of  the  carpus  was  thought  by  Trousseau  to  pro- 
mote endocarditis.  Rheumatism  may  invade  the  spine,  jaw,  sterno- 
clavicular joints,  the  synchondroses  of  the  ribs,  the  sacroiliac  or  pubic 
articulations,  and  the  larynx.  Occupation  has  a  bearing  on  the  dis- 
ease; for  instance,  rheumatism  may  occur  in  the  arms  of  washer- 
women. If  a  joint  of  an  upper  extremity  is  first  involved,  the  opposite 
arm  is  usually  next  inflamed:  (b)  In  general  the  arthritis  is  ascending, 
fleeting  and  almost  invariably  polyarticular  (Senator).  The  charac- 
teristic erratic  character  of  the  arthritis  is  mentioned  by  the  oldest 
writers,  as  Van  Swieten,  who  spoke  of  it  as  "migratory  inflammation" 
or  "fleeting  gout."  Though  usually  fleeting  in  its  nature,  the  virus 
may  settle  in  one  joint  for  a  considerable  period,  but  persistency  in 
one  joint  always  suggests  pseudorheumatism  (symptomatic  or  secon- 
dary forms),  (c)  Signs  and  Symptoms. — Polyarthritis  is  a  better  term 
than  polysynovitis  because  the  inflammation  pervades  all  structures 
of  the  joint,  the  periarticular  bursse,  cellular  tissue,  muscular  inser- 
tions and  tendons,  and  the  external  oedema  is  usually  greater  than 
the  synovial  effusion.  Rattling  over  the  joints  is  usually  due  to  tendo- 
synovitis.  The  joints  are  swollen,  red,  tender  and  painful.  Pain  is 
the  most  prominent  and  frequent  joint  finding.  Las^gue  attributes 
the  pain  not  to  the  joint  but  to  inflammation  in  the  associated  muscles 
and  tendons,  affirming  that  if  these  be  relaxed  voluntarily  by  the 
patient  or  suitably  supported  by  the  physician,  the  joint  can  be  moved 
freely  in  all  directions.  Lasfegue's  phenomenon  is  said  to  be  absent 
in  gonorrhoeal  and  surgical  arthritis.  The  contiguous  tendon  reflexes 
are  lessened  or  abolished,  (d)  Duration. — The  joint  inflammation 
remains  in  one  joint  from  one  to  eight  days,  seldom  longer,  and  its 
involution  is  shorter  than  its  evolution.  (e)  Sequels. — The  joints 
become  quite  normal;  ankylosis  is  so  infrequent  that  its  occurrence 
usually  reflects  doubt  upon  a  previous  diagnosis  of  rheumatism. 
Suppuration  is  extremely  exceptional,  but  may  result  from  mixed  infec- 
tion and  more  frequently  in  children  than  in  adults.  Spontaneous 
dislocations  are  rarities. 

3.  Temperature. — The  temperature  is  directly  related  to  the  inten- 
sity of  infection,  the  number  of  articulations  involved,  and  to  the  de- 
velopment and  progression  of  visceral  complications.  As  Wunderlich 
noted  in  his  celebrated  communication  on  fever,  the  temperature  is 
usually  highest  when  the  patient  is  first  ^examined.  The  fever  rises, 
with  each  new  localization,  be  it  arthritic,  endocarditic,  or  pericarditic . 
Friedlander  spoke  of  a  short  (monoleptic)  and  a  long  cycle  (poly- 
leptic),  yet  the  fever  curve  is  in  no  wise  cyclic,  beyond  undulation  with 
each  new  manifestation,  and  is  rarely  higher  than  102°  or  104°.  The 
temperature  is  usually  seen  to  drop  when  the  sweats  occur.  Pro- 
dromal fever  was  early  noted  by  Todd,   Graves  and  Fuller.     The 

13 


194  THE  SPECIFIC  IXFECTIOXS 

fever  averages  ten  days,  defervescence  occurring  spontaneously  or 
with  the  saHcylate  therapy.  The  fever  is  longer  when  treatment  is 
commenced  late.  Kahler  held  that  fever  could  occur  independently 
of  joint  inflammation  (febris  rheumatica).  Pleuritis,  renewed  arthritis, 
angina,  ervthemata,  embolic  and  other  complications,  prolong  the 
pyrexia.  Simple  fixation  of  the  joints  reduces  the  fever,  tachycardia 
and  tachypnoea  (Pribram).  Chills  suggest  septicopy^emia  rather 
than  rheumatism.  Hyperpyrexia  is  exceptional.  The  fever  may, 
however,  even  reach  111°  T\dth  severe  nervous  symptoms  ("cerebral 
rheumatism"),  coma,  convulsions,  rapid  pulse,  transitory  paralysis, 
and  stertorous  breathing.  50  to  60  per  cent,  of  cases  of  hj^erpyrexia 
occur  in  the  first  attack  of  polyarthritis  with  lesser  frequency  in  later 
seizures.    It  is  less  frequent  since  the  introduction  of  the  salicylates. 

The  pulse  is  accelerated  and  is  usually  said  to  exceed  100,  although 
McCrae  found  that  its  rate  was  not  over  100  in  59  per  cent,  of  his  cases, 
Dicrotism  and  arrhythmia  may  sometimes  be  noted  before  involve- 
ment of  the  joints.  The  respiration  follows  the  fever;  Pribram  noted 
one  case  with  80  to  100  per  minute. 

4.  Heart  Complications. — These  are  almost  an  integral  part  of 
rheumatism  and  constitute  visceral  rheumatism  as  distinguished  from 
articular  rheumatism.  Heredity  seems  to  be  a  factor  in  certain  cases. 
Heart  lesions  occur  as  frequently  in  light  as  in  severe  forms.  They 
vary  somewhat  with  the  epidemic,  are  most  frequent  at  the  time  of 
puberty  when  they  are  most  dangerous,  and  increase  in  frequency 
mth  repeated  attacks  of  rheumatism.  Lasegue  says:  "Acute  rheu- 
matism licks  the  joints,  the  pleura,  and  even  the  meninges,  but  it 
bites  the  heart." 

(A).  ExDOCAEDiTis. — This,  the  most  vital  complication,  was  first 
described  by  Pitcairn  (1788),  and  Pidoux,  Besnier  and  Homolle  fol- 
lowed Bouillaud  in  developing  the  subject.  Bouillaud  (1832)  formu- 
lated the  statement  that  "  in  every  severe,  generalized  case  of  acute, 
febrile  rheumatism,  endocarditis  was  the  rule."  At  the  present  time 
many  French  writers  hold  the  same  view.  Besnier  and  Widal  main- 
tain that  in  severe  cases  the  "heart  is  diseased  to  some  degree."  The 
frequency  of  endocarditis  is  about  20  per  cent.  (Other  figures  are 
50  per  cent.  Damash,  Fuller,  Latham;  40  per  cent.  Pribram;  20 
to  28  per  cent.  Bamberger,  Jaccoud,  Oettinger.)  ^Mackenzie  finds  endo- 
carditis in  58  per  cent,  of  first  attacks,  63  per  cent,  of  second  attacks, 
and  71  per  cent,  of  third  attacks.  In  McCrae's  series  we  might  di^dde 
the  cases  into  thirds;  in  one  third,  the  heart  is  normal;  in  another 
third,  it  is  doubtful;  and  in  the  last  third,  it  is  diseased.  Hospital 
statistics  are  somewhat  misleading,  because  they  represent  the  severest 
cases.  Clinically,  endocarditis  often  escapes  recognition,  or  is  latent; 
— i.  e.,  it  is  found  more  frequent  at  the  autopsy  table  than  at  the  bed- 
side. It  is  usually  verrucose,  and  rarely  ulcerative,  even  in  the  fatal 
cases.  Accidental  or  "functional"  murmurs  must  not  be  called  endo- 
carditis. To  be  certain  that  an  endocarditis  exists,  two  points  are 
absolutely  necessary:    (1)  Continued  observation  of  the  patient  after 


ACUTE  ARTICULAR  RHEUMATISM   {RHEUMATIC  FEVER)    195 

convalescence;  (2)  attention  to  signs  of  valvular  disease  {q.v.),  other 
than  the  mere  murmur,  such  as  dilatation,  hypertrophy,  and  secondary 
pulmonic  accentuation.  The  distinguished  Trousseau  called  atten- 
tion to  the  po'Ssibility  of  the  functional  murmur.  Potain,  almost  alone 
among  the  present  French  writers,  properly  estimates  its  importance. 
The  diagnosis  of  acute  endocarditis  must  long  be  uncertain.  Accord- 
ing to  Leube,  functional  murmurs  are  rare  in  rheumatism,  though 
Senator  considers  them  frequent;  yet  therapeutically  we  must  keep 
on  the  side  of  extreme  caution  by  keeping  the  doubtful  case  sufficiently 
long  in  bed.  We  may  interpret  the  disappearance  of  a  murmur  in 
two  ways, — first,  as  the  disappearance  of  a  functional  murmur  when 
the  fever  falls,  the  toxaemia  disappears,  the  heart  slows,  and  dilatation 
subsides,  or  the  ansemia  mends;  or,  second,  as  the  healing  of  a  slight 
endocarditis,  though  this  is  always  the  less  probable  issue. 

Valves  Affected. — McCrae  finds  the  mitral  valve  involved  in  95  per 
cent,  of  the  cases,  the  aortic  in  23  per  cent.,  and  both  valves  in  18  per 
cent,  ^r^ (Aortic  lesions  are  usually  estimated  at  12  per  cent.)  The  fever 
may  be  continuous  with  that  of  the  arthritis  but  is  often  higher.  Less 
often  the  fever  is  remittent  with  severe  rigors  and  may  require  differen- 
tiation from  malaria,  pyaemia,  or  gonorrhoeal  endocarditis.  A  low 
remittent  fever  may  suggest  pulmonary  or  serous  membrane  tubercu- 
losis. The  endocarditis  exceptionally  antedates  the  polyarthritis  (Jac- 
coud,  Trousseau). 

Masked  or  atypical  rheumatism  was  known  to  Immermann,  who 
spoke  of  rheumatism  masquerading  under  the  guise  of  an  endocarditis 
or  trifacial  neuralgia  and  yielding  to  salicylate  treatment.  Kahler's 
opinion  of  rheumatic  fever  without  arthritis  has  been  mentioned. 
The  rheumatic  virus  is  claimed  to  sometimes  produce  pericarditis  or 
endocarditis  without  articular  inflammation — "polyarthritis  rheumatica 
sine  arthritide."  We  may  call  this  the  "rheumatic  equivalent,"  bor- 
rowing from  the  nomenclature  of  epilepsy. 

In  old  heart  lesions  with  renewed  rheumatism,  lingering  fever  sug- 
gests the  possibility  of  an  exacerbation  of  the  old  endocarditis  which 
may  have  been  aroused  by  the  last  rheumatic  attack.  Various  em- 
bolisms may  occur.  The  bacteriological  findings  are  most  varied, 
and  not  knowing  the  actual  cause  of  rheumatism,  we  cannot  say  ex- 
actly what  is  rheumatic  and  what  is  mixed  infection.  Many  cultures 
are  negative. 

(B).  Pericarditis. — Osier  states  that  rheumatism  explains  more 
cases  of  pericarditis  than  all  other  causes  combined.  It  is  the  most  fre- 
quent lesion  in  children.  Its  frequency  is  variously  given  as  20  per  cent. 
(Hache,  Wunderlich,  Leudet,  Sibson);  54  to  70  per  cent.  (Williams, 
Omerod, Taylor) ;  13  per  cent.  (Chambers);  10  per  cent.  (Oettinger); 
6  per  cent.  (McCrae),  5  per  cent.  (Pribram).  Pericarditis  is  very  fre- 
quently latent.  In  children,  especially,  a  subacute  or  latent  course 
ending  in  synechia  is  most  common.  Baginsky  found  that  adhesive 
pericarditis  was  the  most  common  autopsy  finding  in  rheumatic  chil- 
dren. 


196  THE  SPECIFIC  INFECTIONS 

(C).  Myocarditis. — Disturbance  of  the  heart  in  the  acute  stage  is 
almost  certainly  myocardial.  It  may  be  toxic  or  mycotic.  Acute  inter- 
stitial myocarditis  (in  28  per  cent.  Poynton),  changes  in  the  heart 
ganglia,  coronary  embolism  or  thrombosis,  direct  myocardial  invasion 
by  contiguity  from  endocarditis  in  the  later  stages,  and  sometimes 
the  use  of  salicylates  or  antipyrin,  are  possible  causes.  Recovery  is 
usual,  but  chronic  fibrous  myocarditis  is  a  not  uncommon  sequel. 
Acute  myocarditis  may  produce  a  systolic  murmur,  and  confusion 
with  early  endocarditis  is  possible.  Myocarditis  may  cause  sudden 
heart  pain  with  weakness,  in  which  case  the  subject  may  die.  This 
is  the  "heart  rheumatism"  of  the  laity.  Transient  palpitation,  fugi- 
tive cardiac  oppression,  or  tachycardia,  due  to  pain  or  excitement,  may 
occur.    Bradycardia  with  vertigo  and  syncope  is  probably  myocardial. 

As  a  practical  point,  it  must  be  remembered  that  the  right  heart 
may  be  dilated  as  in  other  fevers  and  as  in  various  abdominal  affections; 
this  dilatation  disappears  with  convalescence.  When  accompanied  by 
a  murmur  it  may  lead  to  an  incautious  and  wholly  unjustified  diag- 
nosis of  endocarditis.  The  bloodvessels  are  rarely  inflamed,  but 
coronary  or  peripheral  endarteritis  occasionally  develops.  French 
writers  maintain  that  acute  arteritis  is  common;  severe  pain,  well 
localized  over  the  artery,  is  followed  by  parsesthesia  and  pain  over 
its  smaller  branches  and  in  the  extremities;  pathologically  only  part 
of  the  vessel-wall  is  affected  and  healing  usually  follows,  but  gangrene 
may  develop  after  complete  arterial  occlusion.  Endophlebitis  is 
somewhat  more  common. 

5.  SMn. — Sweating  is  most  profuse,  constant  and  characteristic;  in 
odor  it  is  sour  or  mouse-like  (Schoenlein) ;  in  reaction  it  is  first  acid 
and  later  neutral  or  alkaline.  This  may  result  from  decomposition 
or  from  large  doses  of  alkalies.  The  skin  is  frequently  macerated 
and  sudamina  are  common,  usually  sudamina  alba  (in  4  per  cent., 
sudamina  rubra).  Rheumatic  nodes  (first  described  by  Hilliers,  Mey- 
nert,  Hirschsprung,  Barlow  and  Warner)  are  subcutaneous  nodes,  as 
large  as  buckshot,  and  occur  mostly  on  the  fingers,  hands  and  wrists, 
but  also  on  the  elbows  and  spine.  They  may  appear  during  or  after 
an  attack,  or  independently  of  acute  seizures.  They  occur  especially 
in  children,  but  are  also  observed  in  adults,  and  particularly  in  women. 
They  are  abundant,  sometimes  numbering  even  sixty,  are  frequently 
symmetrical,  hard,  and  are  usually  tender.  Sometimes  osseous  or  arterial 
endothelial  proliferation  is  observed.  Nodes  occur  most  often  in 
chronic  cases  or  in  cases  with  severe  endocarditis  or  pericarditis.  If 
very  numerous  or  large  they  indicate  an  unfavorable  prognosis.  In 
contradistinction  to  these  more  fixed  nodosities,  F^reol  has  described 
more  fugitive  and  less  indurated  nodes,  which  are  rather  analogous 
to  the  fugitive  polyarthritis  {nodosities  cutanees  ephemeres).  OEdema 
of  the  skin  (Comby,  Ferret,  Guyon)  may  be  septic,  rheumatic,  or 
angioneurotic.  Erythema  polymorphum  is  generally  regarded  as  an 
independent  affection  but  in  rheumatism  it  does  occur  in  the  nodose 
or  vesiculated  forms.     Some  cases  are  possibly  septic  or  anginose 


ACUTE  ARTICULAR  RHEUMATISM  {RHEUMATIC  FEVER)    197 

eruptions.  The  salicylates  relieve  some  cases  and  fail  to  benefit  others. 
Morbilliform  or  scarlatiniform  rashes  are  infrequent,  and  may  be  attri- 
buted in  part  to  errors  in  "diagnosis,  or  to  drug  eruptions.  Purpuric 
eruptions  are  not  uncommon.  The  intestinal  hemorrhage,  colic,  and 
vomiting,  with  articular  intumescence,  described  by  Henoch,  are  en- 
tirely distinct  from  genuine  rheumatism  and  will  be  considered  under 
Purpura  {q.  v.). 

6.  Muscles  and  Bones. — Myositisis  infrequent,  though mya/^ia is  com- 
mon. Muscular  atrophy  may  follow  inflammatory  extension  from  the 
joints  to  the  muscles.  "Muscle  scars"  are  not  frequent,  and  are  much 
more  often  due  to  trauma,  to  other  infections,  to  septicopyeemia,  poly- 
myositis and  dermatomyositis  than  to  rheumatism,  which  rarely  seems 
causal,  although  undoubtedly  sometimes  coincident.  Cases  of  torti- 
collis in  children  have  recently  been  considered  instances  of  cervical 
rheumatism.  Periostitis  may  occur,  and  is  thought  by  some  authori- 
ties to  be  latent  syphilis  aroused  by  rheumatism.  Some  cases  of  al- 
buminous periostitis  are  clearly  rheumatic.  Isolated  instances  of 
osteomyelitis  (deforming  rheumatism)  are  possibly  rheumatic. 

7.  Respiratory  Tract. — Laryngitis  may  be  prodromal.  It  may  be 
a  possible  atrium  for  a  systemic  invasion,  or  may  occur  later  as 
diffuse  catarrh  or  as  local  nodes.  The  rare  acute  oedema  of  the 
larynx  is  most  dangerous.  Pleurisy  may  result  from  the  rheumatic 
virus  even  when  it  shows  wholly  negative  bacteriological  examinations 
or  it  may  result  from  secondary  infections.  Its  frequency  is  2  to  3 
per  cent,  (to  4  to  6  or  10  per  cent.).  See  described  two  types  (a)  a 
violent  and  (b)  a  mild  (latent)  form,  both  of  which  usually  run  a  favor- 
able, rapid  course,  perhaps  with  considerable  fever.  A  primary  pre- 
arthritic  pleurisy  (Fiedler,  Lasegue)  is  very  rarely  observed.  Pleurisy 
and  pneumonia  are  usually  associated  with  heart  disease.  Pleurisy 
is  found  in  54  per  cent,  of  cases  of  endopericarditis  (Pribram).  While 
the  writer  has  occasionally  seen  cases  of  serous  pleurisy  in  association 
wirh  rheumatism,  he  believes  that  the  so-called  rheumatic  pleurisy  is 
almost  always  tuberculous  (see  Etiology  of  Pleurisy).  Pneu- 
inonia  occurs  in  but  one-tenth  of  1  per  cent,  of  cases  of  rheumatism 
not  involving  the  heart,  and  in  66  per  cent,  of  cases  with  endoperi- 
carditis. Howard  (quoted  by  Osier)  found  lung  and  pleural  com- 
plications in  only  10  per  cent,  of  cases  with  rheumatic  endocarditis, 
in  58  per  cent,  of  those  with  pericarditis,  and  in  71  per  cent,  of  those 
with  endopericarditis.  These  figures  seem  remarkably  high,  and  with- 
out questioning  their  accuracy,  it  is  certain  that  many  cases  are  called 
pneumonia  which  are  pulmonary  infarction,  stasis,  or  compression 
from  pleural  or  pericardial  exudates.  French  writers  describe  two  forms 
of  pulmonary  complications:  (1)  The  forme  pneumonique  (Besnier, 
Herzog,  Hirsch),  which  is  fugitive  or  migrating  (pneumonia  migrans). 
It  may  even  appear  before  arthritis.  It  is  said  to  be  less  typical  in 
onset  and  solution;  in  the  sputum;  in  absence  of  cyanosis  and  dys- 
pnoea; in  its  asthenic  prolonged  course;  and  in  its  lobular  develop- 
ment and  incomplete  hepatization;   (2)  the  forme  oodemateuse  (Houdet, 


198  THE  SPECIFIC  INFECTIONS 

Ball,  Bernheim),  in  which  oedema  may  be  ^\ddespread,  may  resemble 
the  acute  pulmonary  oedema  of  Bright's  disease,  or  may  be  localized 
in  one  lobe  or  in  the  bases. 

8.  Digestive  Tract. — Angina  or  tonsillitis  often  occurs  as  a  prodrome 
(v.  s.)  or  as  a  later  development.  The  tongue  is  coated  and  moist 
except,  in  the  severest  cases  where  it  is  dry.  The  salivary  secretion 
is  sometimes  acid,  and  increased  sulphocyanides  have  been  noted. 
Gastric  symptoms  are  rare,  except  from  such  rare  complications  as 
meningitis  and  ursemia,  though  Damash  considers  that  gastric  disturb- 
ance is  the  most  frequent  prodrome.  Constipation  is  the  rule.  Diar- 
rhoea occurs  as  prodromal  enteritis  or  as  a  rare  complication,  and  is 
rarely  bloody.  Peritonitis,  icterus  and  liver  enlargement  are  most 
exceptional. 

9.  Genito-Urinary  Tract. — Cystitis  resulting  from  the  use  of  canthar- 
ides  blisters  has  been  noted  by  Lebert,  Senator,  and  by  Homolle. 
Pribram  considers  it  suggestive  of  gonorrhoea.  Fibrinuria  is  very  in- 
frequent. Acute  nephritis  is  seldom  seen  (j%  to  1  per  cent.);  it  occurs 
early,  and  chiefly  in  endopericarditis,  and  is  usually  benign  but  may 
become  chronic.  Renal  infarction  usually  occurs  late  in  the  course 
of  cardiac  cases,  and  kidney  suppuration  indicates  the  pyogenic 
pseudorheumatism.  But  few  of  the  author's  cases  in  private  practice 
show  nephritis,  though  it  is  present  in  75  per  cent,  of  hospital  patients. 
In  these  it  is  probably  latent  until  awakened  by  the  fresh  toxaemia; 
it  is  probably  due  to  their  social  status,  vagabondism,  exposure  and 
alcoholism.  Albuminuria  is  mostly  transitory.  It  occurs  late  in  the 
course  or  after  several  attacks,  and  mostly  in  indi^^duals  over  thirty 
vears  of  age.  The  percentage  ranges  up  to  34  (McCrae).  Albumo- 
suria is  frequent,  especially  during  resorption,  whence  it  has  a 
slight  diagnostic  value.  Cylindruria  may  occur  without  albuminuria; 
hsematoporphyrin  has  been  found,  also  urobilin,  formic  acid,  sugar, 
the  characteristics  of  fever  urine,  reduction  of  the  chlorides  and  bac- 
teria (sepsis).  The  sexual  organs  are  involved  chiefly  in  gonorrhoeal 
pseudorheumatism.  Amenorrhoea  is  usual.  Uterine  atrophy,  hemor- 
rhagic endometritis  and  genital  hemorrhage  are  infrequent.  Rheu- 
matic arthritis  as  well  as  gonorrhoeal  "rheumatism"  may  occur  in 
pregnancy.  In  the  puerperium,  gonorrhoeal,  septic  or  endocarditic 
joint  inflammation  may  occur  (see  Diagnosis). 

10.  Blood. — The  blood  shows  increased  fibrin  and,  in  low  dilu- 
tions, is  said  to  sometimes  respond  to  the  ^Yidal  reaction.  The  red 
disks  are  reduced  25  to  30  per  cent,  and  chlorotic  characteristics  are 
noted.  The  fever,  the  aneemia  and  the  intensity  of  articular  involve- 
ment run  more  or  less  parallel  (Hayem  and  Garrod).  The  white 
cells,  in  moderate  cases,  range  between  10,000  and  15,000,  and  higher 
figures  (20,000)  are  only  reached  in  extensive  endocarditis,  pericar- 
ditis, pleurisy,  pneumonia,  or  in  septicfemic  pseudorheumatism  or 
suppurative  arthritis.  The  increase  is  in  the  polymorphonuclear  neu- 
trophiles  while  other  cells  are  normal  or  decreased.  The  eosinophiles 
are  practically  absent,  but  increase  with  betterment  of  the  articular 


ACUTE  ARTICULAR  RHEUMATISM   {RHEUMATIC  FEVER)    199 

findings.  If  they  are  increased  in  a  florid  case,  the  prognosis  is  good, 
since  the  course  will  probably  be  mild.  Bacteriological  findings  are 
(1)  negative,^or  (2)  positive  from  mixed  infection. 

11.  Nervous  System. — The  relation  of  chorea  to  rheumatism  is 
an  unsettled  question.  Chorea,  rheumatism  and  endocarditis  are 
associated  (in  50  per  cent,  of  cases,  Pribram),  or  coordinated,  and 
possibly  a  common,  though  unknown,  infection  is  the  essential  cor- 
relating cause.  A  constant  anatomical  cause  of  chorea,  as  arterial 
change,  encephalitis,  or  embolism,  is  not  known.  Cases  with  rheu- 
matic or  endocarditic  association  usually  run  a  slow  and  often  a 
relapsing  course;  cases  which  react  to  the  salicylates  are  probably 
rheumatic.  Cerebral  rheumatism,  is  very  infrequent;  it  may  develop 
acutely  at  the  acme  of  the  disease,  with  psychical  alteration,  often  with 
hyperpyrexia,  sometimes  with  warnings,  or  again  precipitately.  Delir- 
ium, unrest,  convulsions,  and  coma,  frequently  result  in  death.  High 
fever  may  be  solely  a  cerebral  symptom,  but  cerebral  symptoms  may 
occur  without  high  temperature.  The  course  is  joudroyant  or  lasts 
several  days,  and  even  a  week.  Drug  poisoning,  alcoholism,  inanition, 
previous  exhaustion,  hysteria,  and  the  temperament  cerebrate  are  pos- 
sible factors.  The  author  has  seen  one  case  of  recovery  after  mania, 
convulsions,  meningeal  symptoms,  and  coma.  Chronic  psychoses,  hal- 
lucinations, sopor,  mania,  coma,  convulsions,  or  melancholia,  may 
occur  in  convalescence.  They  are  usually  due  to  inanition  and  the 
patient  generally  recovers.  Brain  embolism  (from  endocarditis), 
hemorrhage  or  rheumatic  meningitis,  are  infrequent,  and  are  not 
classed  with  the  above  varieties.  Spinal  rheumatism  may  be  confused 
with  myelitis,  septic  or  gonorrhoeal  meningitis,  multiple  neuritis,  local 
myopathies  adjacent  to  the  joints  involved,  or  cerebral  embolism. 
Exaggerated  tendon  reflexes,  decubitus,  and  vesical  paralysis,  occur  in 
some  rheumatisms.  In  Kraus'  clinic  the  author  saw  one  fatal  case 
characterized  pathologically  by  meningomyelitis.  Multiple  7ieuritis 
is  often  rheumatic;  it  may  precede  the  polyarthritis,  but  usually 
occurs  in  the  first  or  second  week  of  rheumatism  and  presents  the 
usual  characteristics,  such  as  pain  and  tenderness  over  the  muscles 
and  nerve  trunks,  paralysis,  muscle  atrophy,  skin  dystrophy,  reaction 
of  degeneration,  anaesthesia  and  lost  reflexes.  The  prognosis  is  good 
and  the  neuritis  reacts  well  to  electrotherapy.  Mononeuritis  occurs 
in  the  oculomotor,  sciatic,  trigeminal,  and  other  nerves,  and  usually 
regresses  entirely. 

The  Eye. — Rheumatism  may  result  in  benign  episcleritis,  iritis, 
iridocyclitis,  and  possibly  conjunctivitis.  Optic  neuritis,  with  or 
without  atrophy,  and  retinal  embolism  or  thrombosis  occur  exception- 
ally;  their  prognosis  is  doubtful. 

(Acute  thyroiditis  is  most  uncommon.  Lymphadenitis  is  not  un- 
common, but  is  rarely  marked  or  extreme.  It  occurs,  with  arthritis, 
erythemata,  endocarditis  or  pericarditis.) 

Prognosis. — ^The  prognosis  as  to  life  is  usually  excellent  and  is 
generally  proportionate  to  the  severity  and  duration  of  the  infection 


200  THE  SPECIFIC  INFECTIONS 

and  to  the  number  of  joints  involved.     The  percentage  of  deaths  is 

1.5  per  cent.    (Rubin);    3  per  cent.    (Lebert,  Eichhorst,  Raymond) 

3.6  per  cent.  (Senator),  or  3.7  per  cent.  (Roth),  but  these  are  hospital 
figures  and  therefore  higher  than  in  general  practice.  The  death-rate 
varies  with  the  geography  of  the  disease;  e.  g.,  in  Ireland  2  in  1,000  die, 
in  New  South  Wales,  3;  in  New  York,  3;  in  Paris,  4+;  and  in  Scotland 
the  rate,  including  deaths  from  heart  lesions,  is  nearly  5.  In  statistics 
other  arthritides  are  not  carefully  excluded.  There  are  waves  of 
increased  mortality  every  three  or  four  years.  In  late  years  the  death- 
rate  has  somewhat  decreased.  The  causes  of  death  are  (1)  hyper- 
pyrexia, the  most  important;  (2)  cerebral  rheumatism,  chorea;  (3) 
peri-,  endo-  and  myocarditis;  (4)  pneumonia,  lung  infarcts.  Recur- 
rences occur  in  19  per  cent,  of  cases  (Church)  or  in  a  larger  percent- 
age in  general  practice.  They  are  more  dangerous  in  pregnancy  or 
with  complications  such  as  influenza,  etc.  The  prognosis  is  less 
favorable  m  children  than  in  adults.  The  salicylate  therapy  influences 
the  disease  and  also  its  relapses;  but  the  heart  complications  are 
only  slightly  or  indirectly  relieved.  There  is  some  danger  of  rheuma- 
tism becoming  chronic.  At  the  onset  it  is  impossible  to  declare  the 
case  light  or  severe.  According  to  Trousseau,  the  involvement  of 
the  small  joints  of  the  hands  and  feet  justify  the  prediction  of  a  severe 
course. 

Diagnosis. — 1.  Rheumatism  in  Childhood. — In  the  very  young  the 
disease  is  most  rare  (3  cases  in  85,000  nurslings)  but  becomes  more 
common  after  the  fifth  year.  The  course  is  more  rapid  and  the  urine  is 
normal  or  less  febrile.  Generally  speaking,  the  joints  are  less  suscep- 
tible and  the  arthritis  less  intense,  while  the  skin,  nervous  system,  and 
heart,  are  more  often  involved.  Heredity  is  most  potent  in  the  young, 
and  the  sexes  are  equally  involved.  The  various  phases  of  rheumatism 
occur  separately, — first  arthritis,  then  endocarditis,  later  chorea,  sub- 
cutaneous nodules,  pericarditis,  and  so  on.  The  child  rarely  lies  quietly, 
but  tosses  about ;  the  tendons  and  fasciae  are  more  often  involved  than 
the  joints,  and  in  this  the  rheumatism  may  simulate  talipes.  The 
pain  is  less  and  the  arthritis  may  entirely  escape  recognition.  The 
lower  temperature  is  particularly  remarkable  at  this  epoch  of  life, 
when  high  fever  is  often  excited  by  trivial  lesions.  There  is  much 
less  sweating.  The  anaemia  in  childhood  is  especially  marked, 
and  is  as  rapid  in  development  as  that  of  diphtheria  or  that  of 
malaria  in  adults.  In  children  the  differential  possibilities  are 
acute  osteomyelitis,  acute  pyaemia,  monarticular  arthritis,  especially 
of  the  knee  and  hip  in  nurslings,  gonorrhoeal  arthritis.  Barlow's 
disease,  syphilis,  hsemophilic  joints,  and  infantile  palsy;  if  the 
rheumatism  occurs  in  the  spine,  meningitis  or  torticollis  are  of  dif- 
ferential importance.  Endocarditis  is  usually  not  so  clearly  nor  so 
immediately  connected  with  the  polyarthritis  as  in  adults,  but  it  devel- 
ops more  slowly,  insidiously,  later,  and  twice  as  frequently  as  in  adults 
(80  per  cent.  Vernay).  Thomas  Watson  knew  but  three  instances  of 
acute  rheumatism,  before  puberty,  which  escaped  severe  heart  disease. 


ACUTE  ARTICULAR  RHEUMATISM   {RHEUMATIC  FEVER)    201 

This  is  due  to  the  greater  functional  demands  on  the  child's  heart  and 
to  the  aorta  being  narrow  at  the  isthmus.  Endocarditis  occurs  rela- 
tively early  in  what  Cheadle  terms  the  "rheumatic  progression,"  but 
pericarditis  occurs  later  after  the  valvular  lesion  has  inaugurated  hyper- 
trophy and  dilatation.  Pericarditis  is  almost  always  found  (Sturges) 
in  necropsies  on  children  with  valvular  disease.  Rheumatic  heart  dis- 
ease in  general  at  this  epoch,  leads  to  greater  hypertrophy  because  of 
greater  nutrition,  to  more  marked  dilatation  because  of  greater  tissue 
elasticity,  and  to  more  frequent  recurrence.  The  prognosis  is  there- 
fore much  more  unfavorable  than  in  adults.  In  the  diagnosis,  func- 
tional murmurs  are  not  frequent  in  children,  although  they  do 
occur.  The  pulse  is  often  irregular;  the  precordium  more  readily 
bulges;  left-sided  pleurisy  is  more  frequent  than  in  adults,  and 
delirium  and  rheumatic  nodes  are  more  common.  Oppression 
over  the  heart  is  infrequent,  as  are  pain,  cyanosis,  dropsy,  hepatic  con- 
gestion, pulmonary  infarction,  dyspnoea  and  fever.  Rheumatic  children 
are  more  nervous  and  more  inclined  to  night  terrors,  and  to  ansemia. 
More  marginate,  papular  and  urticarious  erythemata  and  more  purpura 
develop  in  children.  Large  subcutaneous  nodes  (rheumatismus  nodo- 
sus)  are  serious  prognostically  and  always  suggest  danger  from  severe 
intercurrent  valvulitis.  Chorea  is  prone  to  develop  with  arthritis, 
heart  disease,  nodes,  or  with  the  erythemata. 

2.  Anomalous  Rheumatism. — By  anomalous  rheumatism  we  mean 
mixed  infections, — e.  g.,  rheumatism  with  gonorrhoea.  Typical  rheu- 
matism is  easily  recognized,  while  diagnosis  in  the  masked  or  abortive 
variety  is  always  problematical. 

3.  Rheumatoides. — Rheumatoides  (Gerhardt)  or  'pseudorheumatisTn 
(Bouchard)  are  symptomatic  arthritides  resembling  rheumatism  in 
that  fever,  arthritis,  or  endocarditis,  may  occasionally  develop  in  their 
course.  The  nomenclature  of  Quincke,  who  speaks  of  'polyarthritis 
gonorrlioica,  scarlatinosa,  etc.,  is  the  least  objectionable,  (a)  Poly- 
arthritis gonorrhoica  resembles  rheumatism  most  closely  and  most  fre- 
quently. Koenig  holds  that  the  most  common  of  all  joint  diseases  is 
the  gonorrhoeal  {v.  Gonokrhceal  Infection).  (6)  Polyarthritis  scar- 
latinosa often  most  closely  resembles  rheumatism,  occurs  early  or  more 
frequently  in  the  third  to  the  fourth  weeks  of  scarlatina,  and  varies 
with  the  epidemic  (0  to  6.3  per  cent.).  In  66  percent,  of  patients  it 
occurs  in  the  hands,  and  lasts  four  days,  frequently  with  endocarditis 
or  pericarditis  (32  per  cent.  Hodges),  and  sometimes  with  recurrence 
and  serous  or  purulent  exudation.  With  it  have  been  observed  nodes, 
erythema  and  chorea,  (c)  Polyarthritis  may  also  complicate  many 
other  diseases  including  most  of  the  infections;  measles,  smallpox, 
varicella,  erysipelpts,  dengue,  malaria,  typhoid,  typhus,  Malta  fever,  an- 
gina, appendicitis,  diphtheria,  syphilis,  dysentery, pneumonia,  influenza, 
recurrent  fever,  epidemic  meningitis,  neuritis,  mumps,  bronchiectasis, 
glanders,  osteomyelitis,  pyaemia,  puerperal  fever,  septicaemia,  tubercu- 
losis, purpura,  peliosis,  scurvy,  haemophilia,  anaemia,  erythema-nodosum, 
Addison's  disease,  psoriasis  and  some  neuroses  and  intoxications. 


202  THE  SPECIFIC  INFECTIONS 

4.  Severe  Types. — In  grave  types  of  genuine  rheumatism  the  vis- 
ceral findings  may  be  confusing  but  are  least  so  when  secondary,  both 
in  development  and  degree,  to  the  arthritis.  Jaccoud  speaks  of  the 
primary  \-isceral  type,  wherein  the  findings  (e.  g.,  pulmonary  or  car- 
diac) antedate  the  arthritis,  but  here  the  diagnosis  remains  uncertain, 
until  involvement  of  the  joints  develops. 

5.  Gout   (q.v.). 

6.  Arthritis  Deformans  (q.v.). 

7.  Tuberculous  Polyarthritis  (q.v.). 

The  number  of  joints  involved  is  always  highly  suggestive,  but  not 
finally  diagnostic.  True  rheumatism  and  gonorrhoea!  rheumatism  are 
often  polyarticular.  Diagnosis  of  gonorrhoeal  rheumatism  in  women 
is  often  difficult  for  notable  reasons.  In  women,  puerperal  infections, 
and  an  acute  monarticular  osteoarthritis,  beginning  acutely  from 
exhaustion  in  pregnancy  or  lactation,  may  cause  difficulty.  In  grow- 
ing children,  acute  osteomyelitis  may  cause  articular  swelling,  which, 
however,  is  monarticular. 

Treatment. — I.  Diet. — The  diet  should  be  limited  to  fluids,  arrow- 
root, milk,  gruels,  etc.  Biot's  results,  with  a  strict  milk  diet,  were  ex- 
tremely good. 

II.  Clothing. — The  patient  should  wear  a  flannel  gown  and  lie 
between  blankets,  which  are  more  comfortable  than  sheets  on  account 
of  the  sweating.  Care  must  be  taken  lest  the  drenching  sweats  macer- 
ate the  skin.  This  can  be  avoided  by  dusting  talcum  powder  in  the 
axillae,  between  the  toes,  etc.,  and  by  sponging  the  body  with  warm 
water  and  alcohol. 

III.  Local  Treatment — Fixation  lessens  pain,  fever,  pulse  and  res- 
piration-rate. Cold  applications,  boric  fomentations,  and  salicylic 
salve  are  useful  [Acidi  salicylici  oj,  Adipis  lanse  hydrosi  §j].  Davies' 
cantharides  blister  and  the  actual  cautery  are  indicated  for  tardy 
involution. 

IV.  Rest. — The  patient  should  be  in  the  position  in  which  the 
greatest  comfort  can  be  obtained  and  in  which  there  is  the  least  dan- 
ger of  ankylosis.  Splints  afford  relief  to  the  muscles  and  joints,  but 
muscular  atrophy  may  result  from  the  use  of  plaster-of-Paris  casts. 
The  absolute  dorsal  decubitus,  long  into  convalescence,  or  at  least  for 
two  weeks,  must  be  enforced  because  of  the  weak  condition  of  the  heart. 

V.  Sahcylate  Treatment  (Kolbe,  1874,  Buss,  1875,  and  Strieker, 
1876). — 1.  Effect  ox  the  Arthritis. — The  pain  and  swelling  are 
usually  relieved  after  three  to  five  full  doses  have  been  taken,  or  after 
twenty-four  hours  from  the  taking  of  the  first  dose.  Salicylates  are 
the  best  analgesic  in  rheumatism.  Hypodermics  of  morphine  are 
rarely  necessary,  except,  perhaps,  in  the  first  twelve  hours. 

2.  Effect  on  the  Temperature. — The  fever  falls  coincidently 
with  relief  of  the  articular  symptoms,  and  reaches  normal  in  two 
days.  In  the  great  majority  of  cases  the  acute  stage  is  over  within 
three  days.  In  hyperpyrexia  less  influence  is  noted,  especially  if  the 
salicylates  are  administered  late. 


ACUTE  ARTICULAR  RHEUMATISM    (RHEUMATIC  FEVER)   203 

3.  Effect  on  the  Endocarditis. — Though  some  consider  the  sal- 
icylates specific,  the  general  evidence  is  that  endocarditis  occurs  as  fre- 
quently with  their  use  as  without  it, — i.  e.,  salicylates  are  analgesic 
and  antipyretic  but  not  strictly  antirheumatic.  Many,  however,  claim 
that  the  salicylates  are  in  every  sense  antirheumatic.  The  personal 
belief  of  the  writer  is  that  the  salicylates  are  practically  specific  and 
that  heart  complications  are  lessened  by  shortening  of  the  acute  stage. 

4.  Relapses. — Relapses  are  claimed  to  be  more  frequent  with  the 
administration  of  the  salicylates  than  with  the  alkaline  treatment,  and 
especially  so  when  treatment  is  discontinued  early.  This  claim  seems 
unfounded.  Relapses  are  apparently  less  frequent  with  the  continued 
use  of  salicylates  for  two  weeks  after  the  initial  symptoms  are  relieved. 

Physiological  Action  of  the  Salicyl-preparations. — They 
are  absorbed  from  local  applications.  The  smallest  doses  produce 
such  symptoms  as  cinchonism,  fulness  of  the  head  or  roaring  in  the 
head  and  ears.  After  larger  doses  dulness,  headache,  giddiness,  a 
flushed  dusky  and  moist  skin,  disturbed  sight  and  hearing,  and  tremor, 
develop.  Toxic  doses  produce  the  above  symptoms,  plus  eye-muscle 
paralysis,  pupil  dilatation,  deafness,  increased  reflexes,  restlessness, 
delirium,  dyspnoea,  disturbed  circulation,  skin  eruptions,  sweating, 
and  also  green  urine.  Postmortem  breaking  down  of  the  blood, 
visceral  congestion,  and  serous  ecchymoses  are  seen. 

Administration. — Sodium  salicylate  is  the  best  preparation.  Its 
action  is  most  prompt  and  certain;  it  is  soluble  and  least  irritating. 
Where  it  fails,  other  preparations  are  usually  unsuccessful.  All  salicyl- 
preparations  are  absorbed  as  sodium  salicylate  produced  by  the  alka- 
line intestinal  juices.  Grains  xv  of  the  natural  acid,  which  is  better 
than  the  synthetic,  or  grains  xx  of  the  sodium  salt,  are  given  every  two 
or  three  hours  until  cinchonism  appears;  i.  e.,  until  slight  dulness, 
dyspnoea  and  deafness  develop.  This  action  is  maintained  for  twelve 
hours,  when  the  interval  between  doses  is  lengthened  to  four  or  six 
hours.  The  effects  are  better  in  proportion  as  the  disease  is  more 
acute,  the  symptoms  more  pronounced,  the  inflammation  greater,  the 
number  of  involved  joints  larger,  and  the  fever  higher.  It  is  well 
tolerated  by  children  and  usually  can  be  given  by  mouth  in  fluid,  if 
the  taste  be  disguised  by  wintergreen  oil,  syrup  of  ginger,  and  syrup 
of  orange.    Even  then,  however,  it  is  frequently  nauseating. 

Sodii  salicylatis , 3vj. 

Sodii  bicarb 5iv. 

Syrupi  zingiberis oj- 

Syrupi  aurantii oj- 

Aquse q.s.  ad  oiv. 

M.  et  S. — One  teaspoonful  every  three  hours. 

Theoretically  it  should  not  be  given  in  capsules  for  in  this  form  it 
may  irritate  the  stomach,  but  it  may  be  given  in  powders  which  are 
taken  in  starch  wafers.  Because  the  action  of  sodium  salicylate  is 
analogous  to  that  of  quinine,  bromide  of  potassium  may  be  given  to 


204  THE  SPECIFIC  INFECTIONS 

lessen  the  ringing  in  the  ears.  In  case  the  stomach  is  intolerant,  sal- 
icylates may  be  administered  in  pepsin,  or  given  by  rectum  in  pepton- 
ized milk.  When  given  as  an  inunction,  it  is  soon  found  in  the  urine, 
but  absorption  by  the  skin  is  uncertain.  Aspirin  is  less  irritating  to 
the  stomach  than  salicylate  of  soda.  It  is  given  in  doses  of  five  to 
ten  grains  at  the  same  intervals.  Salol  (Phenylis  salicylas)  is  given 
in  the  same  dose  at  the  same  interval,  but  the  kidneys  must  be  care- 
fully watched. 

The  alkaline  treatment  is  said  to  decrease  the  heart  complications 
and  shorten  the  disease.  Though  these  claims  are  not  established, 
the  alkaline  treatment  may  be  used  in  conjunction  with  the  salicy- 
lates, using  vichy  salts  with  enough  citrate  of  potassium  or  bicarbonate 
of  soda  to  make  and  keep  the  urine  alkaline.  I>ong  ago  Fuller  advised 
the  following: — 

Sodii  bicarbonatis oss. 

Potassii  acetatis 3ss. 

Liquoris  ammonii  acetatis      3iij- 

Aquae ad  oij- 

M.  f.  haust. 
S. — ^To  be  taken  in  effervescence  with — 

Acidi  citrici oss. 

Aquse      oij- 

Baginsky  thinks  that  the  administration  of  gr.  xv  to  xl  of  potassium 
iodide  daily  produces  better  results  in  children  than  do  the  salicylates. 
Unusual  Results. — Unusual  results  of  salicylate  treatment: 

1.  Nervous. — Salicylate  delirium  has  been  observed  in  ansemic  girls, 
neurotics,  and  in  alcoholics.  It  may  be  %dolent  and  protracted.  Con- 
vulsions are  quite  infrequent;  they  are  centric. 

2.  Cardiac. — Small  doses  stimulate  the  heart,  and  cardiac  depres- 
sion is  observed  only  when  the  largest  dosage  is  given,  when  the 
preparations  are  impure,  or  when  the  heart  is  already  diseased.  If  the 
heart  becomes  weak  or  irregular,  acute  myocarditis  is  probably  devel- 
oping and  salicylate  treatment  must  be  suspended,  the  dose  must  be 
decreased,  or  the  heart  muscle  must  be  stimulated  by  coffee,  strychnine 
or  alcohol.  Slight  irregularity  without  weakness  is  not  a  contraindica- 
tion. Cardiac  depression  may  be  noted  in  nervous  subjects.  Thorne 
has  observed  collapse  from  aspirin. 

3.  Respiratory. — With  antecedent  or  concomitant  bronchitis,  the 
lungs  should  be  explored  for  possible  congestion  which  may  result 
from  the  remedy.  Cardiac  depression,  sudden  respiratory  failure  and 
violent  expiratory  dyspnoea  are  observed  in  a  few  cases.  Tuberculous 
patients  should  be  carefully  watched. 

4.  Renal. — Caution  is  necessary  in  old  nephritics,  because  the  sal- 
icylates are  excreted  by  the  kidneys  as  salicylic,  oxalic,  or  salicyluric 
acids  and  as  salicin;  however  infective  albuminuria,  directly  due  to 
the  rheumatic  \drus,  indicates,  rather  than  contraindicates,  the  use  of 
the   salicvlates.      The    cjreen   color  of   the  urine   is   due   to   indican 


DENGUE  205 

and  pyrocatechin,  Binz  believes  that  the  salicylates  may  induce 
abortion. 

5.  Alimentary. — Vomiting  {v.  s.)  and  diarrhoea  may  result  from 
salicylate  treatment. 

Diagnostic  Therapy.  —  Senator  claimed  that  sodium  salicylate  is 
specific  in  true  rheumatism  and  inert  in  pseudorheumatism.  Though 
the  general  truth  of  this  statement  is  acknowledged,  its  application 
is  not  absolute.  Salicylates  are  of  some  value  in  the  arthritic  type  of 
grippe.  They  usually  are  useless  in  the  gonorrhoeal,  syphilitic,  tuber- 
culous, septic,  scarlatinal,  and  other  arthritides. 

Convalescence. — Absolute  rest  must  be  enforced  for  two  to  four 
weeks  to  save  the  heart. 


DENGUE. 

Definition. — An  acute  specific  infection,  occurring  chiefly  in  tropical 
and  subtropical  countries,  extremely  contagious,  and  characterized  by 
fever,  an  initial  prodromal  eruption,  violent  articular  and  muscular 
pains,  and  a  secondary  polymorphous  eruption. 

Etiology  and  Epidemiology. — The  actual  cause  is  uncertain.  A 
small  diplococcus  or  bacillus  resembling  the  Bacillus  influenzae  has 
been  described.  Graham  found,  in  the  blood-cells,  an  organism  re- 
sembling the  Plasmodium  malarise,  but  small  and  unpigmented.  For 
this  reason  infection  has  been  connected  with  mosquito-bites.  Eberle 
describes  a  "plasmeba."  The  disease  is  very  contagious  and  seems 
disseminated  less  by  direct  than  indirect  infection,  e.  g.,  by  fomites, 
bites,  etc.  It  is  carried  by  pilgrims,  sailors,  and  emigrants.  The  dis- 
ease spreads  with  remarkable  rapidity  and  infects  large  numbers  of 
people.  Its  home  is  in  the  tropical  and  subtropical  zones  and  it  pre- 
vails chiefly  in  the  hot  months.  It  has  invaded  Europe,  Asiatic  Turkey, 
South  America  and  the  United  States.  It  is  remarkable  that  the  coast 
ports  are  alone  invaded.  It  very  seldom  reaches  inland,  and  even  in 
regions  where  the  disease  prevails  endemically,  closely  contiguous  in- 
land towns  and  higher  places  are  exempt.  Unhygienic  conditions  pro- 
mote its  development.  In  the  first  Philadelphia  epidemic  it  was  called 
"Front  Street  Fever,"  on  account  of  the  squalid  condition  of  the 
houses  along  the  river  front.  The  first  epidemic,  in  1779,  in  Java,  was 
described  by  Brylon,  and  Benjamin  Rush  wrote  of  the  Philadelphia 
epidemic  in  1780.  The  chief  later  epidemics  or  pandemics  occurred 
in  1818,  1824-1828  (reaching  Savannah  and  New  Orleans),  1830- 
1870  (again  reaching  America,  and  seen  even  as  far  north  as  Ohio), 
1876  (Virginia),  1889,  1890,  1895-1897.  The  morbidity  is  enormous 
but  the  mortality  is  strikingly  inconspicuous.  Epidemics  last  two  to 
five  months.  No  immunity  is  conferred  by  one  attack  and  two,  three 
or  even  four,  infections  have  been  observed. 

Ssnnptoms. — After  an  incubation  of  one  to  two  days,  or  some- 
times a  little  longer,  the  disease  begins  suddenly. 


206  THE  SPECIFIC  INFECTIONS 

1.  Febrile  Stage. — The  fever  rises  quickly  to  102°,  104°  or  even 
107°,  usually  with  a  chill,  severe  frontal  or  orbital  headache,  sudden 
and  intense  pains  in  the  back  and  limbs,  which  incapacitate  the 
patient  while  walking  and  which  involve  especially  the  knees.  The 
names  "breakbone  fever,"  first  mentioned  in  Rush's  description,  and 
"dandy  fever,"  given  because  of  the  mincing  gait  which  results,  bring 
out  this  salient  feature.  Dengue  is  thought  by  some  to  originate  from 
the  Spanish  for  "dandy."  The  joints  are  usually  swollen  (pseudorheu- 
matism),  and  many  of  them,  both  large  and  small,  are  involved  one 
after  another.  The  muscles  are  often  painful  and  the  skin  is  some- 
times hypersesthetic.  The  pulse  averages  100.  The  face  is  suffused 
and  swollen,  the  conjunctivae  are  injected,  the  flow  of  tears  is  increased, 
and  in  some  cases  there  is  coryza.  Total  anorexia,  foul  breath,  coated 
tongue,  and  great  thirst,  develop;  vomiting  is  occasional  and  constipa- 
tion the  rule.  The  premonitory  rash,  usually  hypersemic,  is  of  short 
duration.  It  may  last  but  one  to  five  hours,  and  is  frequently  absent. 
The  urine  is  febrile.  Prostration  may  be  marked,  and,  in  some  cases, 
severe  delirium,  convulsions,  and  coma  may  develop.  This  stage  lasts 
three  days  ("three-day  fever")  and  ends  with  profuse  sweating. 
Fever  is  absent  in  the  lightest  cases. 

2.  Exanthematous  Stage. — This  stage  begins  on  the  fourth  day. 
The  eruption  occurs  chiefly  on  the  face,  hands,  forearms  and  chest, 
and  is  decidedly  polymorphous.  It  has  been  described  as  scarlatini- 
form,  morbilliform,  urticarial,  erysipelatoid,  lichen-like,  vesicular,  or 
even  pustular.  It  is  present  in  60  to  100  per  cent,  of  the  cases.  It  is 
evanescent,  lasts  two  to  three  days,  and  is  followed  by  fine  desquama- 
tion and  by  intense  itching,  sometimes  by  falling  of  the  hair,  and  by 
cutaneous  hypersesthesia.  The  throat  is  sometimes  red  or  even  in- 
flamed, and  occasionally  lymph-gland  enlargement,  parotitis  and  orch- 
itis occur.  The  fever  in  this  stage  may  be  elevated,  may  be  absent, 
or  subnormal  temperature  be  noted.  The  pain  often  recurs.  Herpes, 
splenic  tumor,  otitis,  albuminuria  and  leukocytosis  are  absent.  Leuko- 
penia is  persistent. 

3.  Convalescence. —  Convalescence  begins  in  five  to  seven  days, 
after  a  crisis  or  lysis,  and  is  very  tardy.  There  is  great  prostration, 
gastric  uneasiness,  insomnia,  emaciation,  and  anaemia,  all  of  which 
are  remarkable  after  such  a  short  disease.  In  no  other  disease  of  equal 
duration  is  such  marked  constitutional  disturbance  noted. 

Complications  and  Sequels. — These  are  great  rarities.  Cutaneous 
or  gastric  hemorrhage,  neuralgia,  endocarditis,  pericarditis,  nephritis, 
pneumonia,  pleurisy,  oedema  or  ulcers,  rarely  develop. 

Prognosis.— Death  is  rare,  though  the  morbidity  is  enormous.  The 
highest  recorded  death-rate  was  ^  of  1  per  cent.  One  death  occurred 
in  7,435  cases  in  the  Anglo-Indian  army  (1872),  and  10  deaths  in 
100,000  cases  occurred  in  Smyrna.  Relapse  may  occur  in  one  to  two 
weeks. 

Diagnosis. — The  geography  and  the  presence  of  an  epidemic  are 
suggestive.     The  exanthemata,  rheumatism,  insolation,  yellow  fever 


CHOLERA   ASIATIC  A  207 

(q.  V.)  and  epidemic  erythema  exudativum  multiforme  may  be  suggested. 
Influenza  is  differentiated  by  its  epidemic-pandemic  incidence,  its 
occurrence  in  all  climates,  seasons  and  locations  (inland  as  well  as 
on  seaboard),  its  more  frequent  direct  infection,  the  more  general 
immunity  conferred,  the  higher  coincident  mortality  (pneumonia  and 
tuberculosis),  its  more  frequent  respiratory  catarrh  and  lung  compli- 
cations, its  more  severe  nervous,  intestinal  and  cardiac  symptoms, 
and  the  greater  frequency  of  herpes,  splenic  tumor,  otitis  media,  and 
albuminuria.  In  the  rare  cases  of  acrodynia,  observed  in  France, 
Belgium,  Turkey,  Persia,  and  Mexico,  Scheube  gives  the  following 
differential  points :  (1)  digestive  disturbance;  (2)  facial  swelling;  (3) 
pains  in  the  extremities,  sometimes  with  anaesthesia  of  the  soles;  (4) 
spastic  symptoms;    (5)  afebrile  course;    (6)  erythema  multiforme. 

Treatment. — Isolation  and  quarantine  are  necessary.  Pain  is  the 
prominent  indication,  for  which  antipyrin  and  salicylates  serve  fairly 
well,  though  they  are  much  inferior  to  opium. 


CHOLERA  ASIATIOA. 

Definition. — A  specific  infection  caused  by  Koch's  comma  bacillus. 
It  is  chiefly  disseminated  by  drinking-water,  is  characterized  clinically 
by  vomiting,  severe  purging,  and  by  such  symptoms  as  cardiac  failure 
and  suppression  of  urine  which  are  due  to  loss  of  fluids  and  to  toxsemia. 

History. — The  name  has  been  used  since  the  time  of  Hippocrates, 
Galen  and  Celsus,  but  apparently  not  for  Asiatic  cholera.  Asiatic 
cholera  is  said  to  have  existed  before  Christ,  and  travelers  in  India 
in  the  sixteenth  century  spoke  of  it.  Its  first  European  invasion  was 
in  1817,  from  which  time  our  knowledge  of  cholera  dates.  Other  epi- 
demics have  occurred  in  1826,  1832,  1847-1855,  1865-1867,  1873, 
1881-1884,  and  1892-1894.  Cholera  visited  America  in  1832-1835, 
1836,  1848,  1849,  1854,  1865,  1867,  and  1873.  This  was  the  last  epi- 
demic though  isolated  cases  have  occurred  since. 

Bacteriology. — Koch,  while  studying  cholera  in  Egypt  and  India, 
in  1883-1884,  discovered  the  specific  organism  in  the  faeces  during  life 
and  in  the  bowel  at  autopsy.  The  comma  hacillus  is  1  to  1.5  /z  long 
and  half  as  wide;  is  smaller  than  the  tubercle  bacillus,  but  more  plump 
and  curved;  is  motile  and  flagellated  (Loefller).  Gaffky  (1887)  first 
obtained  pure  growths  on  various  media.  In  cultures  its  form  varies, 
being  sometimes  S-shaped,  and  thread-  or  spirillum-like.  The  comma 
bacillus  is  found  in  the  stools  and  in  the  intestines,  usually  in  pure 
cultures.  After  several  days  it  may  be  found  in  the  bowel  wall,  though 
rarely  in  the  stomach  or  vomitus.  It  usually  disappears  from  the 
movements  after  six  to  eleven  days  and  very  rarely  reaches  the  blood 
or  viscera. 

Etiology. — In  its  dissemination  and  contagion,  cholera  resembles 
typhoid  rather  than  the  exanthemata,  i.  e.,  infection  is  less  direct 
than  indirect.     Attendance  on  cholera  patients  is  not  dangerous  if 


208  THE  SPECIFIC  INFECTIONS 

the  hands  are  kept  clean.  The  germ  is  very  susceptible  to  boiling, 
to  acids,  to  ordinary  antiseptics,  to  drying,  and  to  the  presence  of 
saprophytes  in  sewers  and  water.  There  is  little  risk  of  aerial  dis- 
semination, though  flies  may  carry  infection.  Koch  early  maintained 
that  cholera  was  conveyed  by  water  contamination.  He  found  the 
cholera  vibrios  in  a  water-tank  in  Calcutta  from  which  infection  was 
clearly  traced.  Fraenkel,  von  Ermingen,  Biernacki,  Lubarsch,  Loef- 
fler,  and  others,  found  it  in  flowing  and  stagnant  water.  Pettenkofer 
vigorously  objected  to  Koch's  teaching  and  insisted  that  individual 
and  local  disposition  was  more  essential.  He  even  swallowed  pure 
cultures,  and  luckily  escaped  infection.  It  is  well  known  that  cholera 
vibrios  may  be  found  in  the  movements  wdthout  the  existence  of 
cholera  symptoms,  just  as  diphtheria  bacilli  may  be  found  in  healthy 
throats.  The  normal  acid, of  the  stomach  protects  the  individual  and 
animals  are  infected  experimentally  only  when  the  gastric  acidity  is 
neutralized  and  peristalsis  is  arrested  by  opium.  Nevertheless,  the 
terrible  Hamburg  epidemic  (1892-1894)  amounted,  as  Koch  said,  to 
a  demonstration  of  almost  laboratory  exactness.  The  disease  devel- 
oped "explosively."  On  x4ugust  16  there  was  one  case;  by  August 
27  there  were  1,000  deaths,  and  September  3,  there  were  10,000  cases 
and  4,300  deaths.  The  total  mortality  was  over  8,300.  The  Hamburg 
drinking  water  came  unfiltered  from  the  Elbe  River,  which  was  then 
at  a  low  level,  the  weather  being  hot.  The  germ  was  found  in  this 
supply.  Altona  and  Wandsbeck,  which  are  parts  of  Hamburg,  had 
a  supply  of  good  water,  and  practically  escaped.  That  part  of  Ham- 
burg which  used  Altona  water  was  exempt.  Instances  might  be 
multiplied.  The  cholera  germ  is  diflicult  to  find  in  water  because  it 
is  so  easily  overgrown  by  saprophytes. 

Infection  by  ice,  by  milk,  by  green  lettuce,  by  flies,  or  in  the  labora- 
tory, is  less  common.  The  washing  of  infected  linen  is  particularly 
dangerous  to  washerwomen.  In  India,  hundreds  of  thousands  of  pil- 
grims drink  the  "holy  water"  of  the  Ganges,  in  which  they  also  bathe 
and  defecate.  Similar  infections  occur  in  the  pilgrimages  to  Mecca. 
In  former  years  the  caravans  carried  infection  from  India  through 
Persia  and  Afghanistan  to  Russia,  which  was  also  the  route  of  dissemi- 
nation in  1892.     Ships  from  the  Orient  are  extremely  dangerous. 

Individual  Predisposition. — Decrease  of  physiological  resistance  in- 
creases the  risk  of  infection.  Acute  and  chronic  alcoholism,  the  use 
of  strong  purgatives,  dyspepsia,  overexertion,  poor  blood,  lack  of 
hygienic  conditions,  and  debilitating  diseases  are  therefore  predispos- 
ing factors.  By  counting  the  mortality  in  a  cholera-stricken  com- 
munity for  a  few  years,  it  can  be  seen  that  the  total  death-rate  is  not 
increased,  which  means  that  weakly  persons  succumb  to  cholera  and 
that  later  epidemics  of  other  diseases  have  a  diminished  prey. 

Epidemics  involve  a  smaller  percentage  of  the  people  in  large  than 
in  small  cities,  but  they  last  for  months  in  large  cities  and  usually 
only  for  weeks  in  small  towns.  Epidemics  end  with  a  lessening  mor- 
tality, and  both  their  ending  and  the  lessened  mortality  are  probably 


CHOLERA  ASIATIC  A  209 

best  explained  by  the  decreasing  virulence  of  the  germ.  Warm  weather 
tends  to  increase  epidemics,  and  they  are  usually  checked  by  frost. 
Nevertheless,  Russia's  severest  epidemic  occurred  in  the  winter  time. 
Symptoms. — After  an  incubation  of  two  or  three  days  (one  to  eight, 
possibly  fourteen  days),  the  disease  develops  with  varying  virulence. 
The  bacilli  are  found  in  the  stools  of  some  healthy  persons.  Several 
stages  are  usually  described.  These  may  be  presented,  as  they  also 
correspond  to  clinical  types  of  different  severity. 

1.  Prodromal  Diarrhcea. — -The  stools  contain  the  comma  bacillus, 
are  thin  and  normal  in  color,  are  voided  without  pain  or  tenesmus, 
and  sometimes  produce  only  moderate  depression  or  malaise.  The 
trouble  may  cease  here,  when  we  speak  of  cholera  diarrhoea,  or  it 
may  pass  into  the  choleraic  stage. 

2.  Choleraic  Stage. — This  may  usher  in  the  disease  or  follow  the 
first  stage.  The  stools,  at  first  yellow  and  voided  frequently,  become 
colorless  because  the  bile  pigment  is  diluted  and  decreased,  and  be- 
come thin, — the  ominous  "rice-water"  stools.  Diarrhoea  usually 
comes  on  for  the  first  time  at  night.  The  stools  may  number  twenty 
or  thirty  and  a  pint  to  five  quarts  (500  to  5,000  c.c.)  are  voided  daily. 
They  have  a  fetid,  not  a  fecal  odor,  and  contain  98  to  99  per  cent, 
water,  some  salts,  and  a  trace  of  albumin.  In  the  evacuations  are 
seen  fiocculi  which  are  made  up  of  comma  bacilli,  leukocytes,  epi- 
thelial cells  or  shreds,  detritus,  and  sometimes  a  few  red  cells.  There 
is  often  gurgling,  although  little  gas  is  voided.  Much  fluid  is  thus 
lost  to  the  circulating  blood,  and  this  causes  some  of  the  following 
symptoms:  the  abdomen  is  flat,  usually  neither  tender  nor  painful, 
and  fluid  may  be  percussed  in  the  bowels.  Vomiting  is  frequent,  but 
usually  follows  the  diarrhoea.  It  is  painless,  although  exhausting, 
and  is  thin,  and  profuse,  even  to  three  quarts  daily.  Sometimes 
Koch's  bacillus  is  found,  or  again  either  urea  or  its  decomposed  pro- 
duct (carbonate  of  ammonia)  may  be  found  when  uraemia  exists.  The 
skin  early  shows  the  lack  of  fluid;  it  becomes  shrunken,  lax,  wrinkled, 
and  when  pinched,  its  folds  disappear  but  slowly.  The  nose  becomes 
small  and  pointed,  the  eyes  hollowed,  and  the  malar  bones  jut  out 
prominently  (fades  cholerica);  the  extremities,  nose,  and  ears  become 
cold  and  cyanotic,  and  grayish-blue  rings  develop  beneath  the  sunken 
eyes.  If  pleurisy  or  dropsy  are  present  they  are  rapidly  absorbed. 
The  secretions  such  as  the  saliva  and  urine  become  lessened  and  dis- 
appear, though  nursing  mothers  may  sometimes  continue  to  secrete 
milk.  The  loss  of  fluid  occasions  distressing  thirst  and  muscle  cramps, 
especially  in  the  calves  of  the  legs,  but  also  in  other  muscles,  which 
are  found  dry  at  autopsy.  The  immense  transudation  into  the  bowel 
has  other  effects;  it  concentrates  the  blood,  whose  cells  and  haemoglobin 
rise;  the  red  cells  may  total  six  to  eight  millions  and  the  serum  has 
a  specific  gravity  of  1,040  or  even  1,070  (1,028  being  the  normal). 
The  heart  tones  become  iveak  and  the  pulse  rises  to  100,  because  the 
body  cannot  lose  10  per  cent,  of  its  fluid  without  injury.  The  heart 
has  not  enough  blood  upon  which  to  contract  and  the  blood  is  viscid ; 

14 


210  THE  SPECIFIC  INFECTIONS 

the  heart  also  suffers  reflexly,  as  it  does  in  intestinal  incarceration, 
and  degenerates  from  absorption  of  toxins  (soluble  substances  from 
the  bacilli).  The  difficulty  in  oxygenation  increases  the  breathing  to 
thirty  or  forty,  and  occasions  precordial  and  epigastric  anxiety.  The 
vox  cholerica  is  due  to  the  dry  larynx  and  weak  muscles.  The  reflexes 
are  decreased  or  absent,  the  pupils  tardy;  the  sensorium  is  normal, 
although  exhaustion,  apathy,  and  vertigo  are  usual.  The  urine  con- 
tains albumin  and  casts  which  are  largely  hyaline.  While  the  external 
parts  are  colder  by  5°  to  10°  or  more,  the  patient  feels  hot,  and  the 
internal  temperature  may  be  102°  or  higher.  The  loss  of  weight  is 
great  (even  0.5  to  1  per  cent,  hourly!).  In  some  few  cases  the  patient 
dies  before  diarrhoea  develops  {cholera  sicca).  Sometimes  these  are 
cases  incorrectly  diagnosticated.  Recovery  is  possible,  even  with 
these  ominous  symptoms;  reaction  may  set  in,  the  diarrhoea  and 
algidity  may  lessen,  the  heart  may  improve,  and  erythematous,  roseo- 
lous,  urticarial  and  other  rashes  may  develop.  The  urine  is  often 
albuminous,  and  indican,  which  was  previously  absent,  may  reappear; 
the  urea  is  increased  two-  or  threefold  and  the  ethereal  sulphates  are 
increased.  The  symptoms  are  then  chiefly  toxic,  and  probably  result 
from  absorption  of  the  cholera  and  other  toxins  from  the  intestine  (the  so- 
called  cholera  hjphoid, — i.  e.,  cholera  with  a  pronounced  typhoid  state). 

3.  Stage  of  Collapse. — This  stage  is  characterized  by  asphyxia 
(literally  meaning  without  pulse),  paralysis,  or  algidity.  The  heart 
tones  are  inaudible,  the  radial  pulse  is  imperceptible,  the  arteries  are 
empty,  and  the  veins  are  full.  In  days  of  venesection  the  blood  would 
not  drain  from  the  incised  veins,  and  at  autopsy  little  or  no  blood 
escapes  from  the  vessels.  The  picture  is  that  of  collapse.  The  skin 
is  lead-colored,  cyanotic,  even  violet  or  purple,  and  will  not  vesicate 
after  blistering.  There  is  dyspnoea,  the  expired  air  is  cool,  the  voice 
gone,  the  mouth  dry,  the  conjunctivae  dry  or  opaque,  and  the  lids  are 
parted,  yet  the  mind  is  clear.  The  evacuations  cease.  Pericardial 
or  pleural  rubs  may  be  heard,  due  to  the  great  viscidity  found  in  all 
the  serosse  at  necropsy.  Very  few  cases  with  the  symptoms  of  cholera- 
typhoid  react  and  recover,  but  most  of  them  die  within  a  few  hours, 
or  within  a  day  or  two.  After  death  the  muscles  frequently  contract, 
to  the  great  terror  of  observers.  The  face  is  distorted,  the  fingers 
flexed,  and  the  legs  drawn  up.  Post-agonal  rise  in  temperature  may 
occur.  At  autopsy  the  small  intestines  are  injected,  filled  with  rice- 
water  contents,  their  epithelium  or  villi  are  desquamated  or  necrosed, 
the  lymphatic  structures  are  sometimes  swollen,  reddened  and  reticu- 
lated. Comma  bacilli  are  found  in  the  stools  and  intestinal  wall, 
and  occasionally  there  is  an  agonal  invagination  of  the  gut.  The 
muscles  are  dry,  the  spleen  small,  and  the  kidneys  show  a  pale  cortex 
with  great  cortical  degeneration,  especially  in  the  convoluted  tubules; 
the  renal  changes,  once  attributed  to  loss  of  water  and  disturbed  cir- 
culation, are  probably  toxemic. 

Complications. — The  so-called  croupous  or  diphtheritic  enteritis 
is  due  to  the  pyogenic  cocci.    Diphtheroid  changes  may  also  be  found 


CHOLERA   ASIATIC  A  211 

in  the  uterus,  vagina  and  throat.  Hemorrhages  from  mucous  or  serous 
surfaces,  though  usually  small,  may  occur.  Pneumonia  (20  per  cent, 
of  fatal  cases),  pleurisy  or  lung  infarct;  skin,  parotid  or  other  sup- 
purations; icterus,  bronchitis,  venous  thrombosis  or  post-febrile  psy- 
choses, are  uncommon.  Griesinger's  "cholera-typhoid"  is  the  most 
frequent  sequel  (25  per  cent,  of  cases);  nervous  complications  and 
uraemia  are  far  less  common  causes  than  the  toxins  absorbed  late  from 
the  intestine  and  operating  intensely  on  the  already  exhausted,  slightly 
degenerated,  and  anaemic  brain. 

Diagnosis. — Diagnosis  is  usually  easy  in  the  presence  of  an  epi- 
demic. The  first  cases  occasion  the  most  difficulty,  especially  if  they 
are  light.  As  already  stated,  robust  individuals  may  not  react  to  the 
germs  found  in  their  stools;  simple  diarrhoea  may  result  in  other 
cases,  and  only  a  mild  depression  may  mark  some  cases  known  as 
cholerine.  On  the  other  hand,  aged,  weakly,  or  tuberculous  persons 
may  succumb  to  cholera  before  its  characteristic  stages  develop.  In 
clinically  suspicious  cases,  laboratory  measures  are  necessary  for  diag- 
nosis. The  pseudocholera  vibrios  in  the  Elbe,  Seine,  or  Danube 
Canal  (Vienna)  are  differentiated  with  difficulty.  The  comma  bacillus 
is  obtained  (a)  in  nearly  'pure  cultures  from  the  stools,  especially  from 
their  shreds;  (6)  in  peptone  cultures  (1  per  cent.,  with  1  per  cent. 
salt)  in  which  the  germs  are  found  on  the  surface  in  six  hours,  because 
they  rise  to  obtain  oxygen;  (c)  in  10  per  cent,  gelatin  plates,  in  which 
they  develop  in  fifteen  to  twenty  hours;  id)  the  nitrosoindol  (cholera- 
red)  reaction  results  on  adding  sulphuric  or  hydrochloric  acid.  It 
was  thought  that  no  other  bacterium  produced  both  nitrates  and 
indol,  but  the  pseudocomma  organisms  may  produce  the  same  reac- 
tion; {e)  in  animals,  in  which  the  cholera  germ  produces  a  sudden 
fall  of  temperature,  but  this  is  uncertain;  (/)  Pfeiffer's  test  is  the 
sole  absolute  criterion,  according  to  which  the  blood  of  animals 
immunized  to  cholera  produces  agglutination  of  the  true  cholera 
bacillus. 

Cholera  nostras  produces  a  similar  picture.  It  is  usually  less  severe, 
though  sometimes  fatal.  In  some  of  these  cases  the  Finckler-Prior 
comma  bacillus  is  found,  but  in  the  majority  of  cases  it  is  absent  and 
other  microbes  are  present,  such  as  the  colon  bacillus,  and  less  often 
the  streptococcus,  staphylococcus,  and  a  bacillus  like  the  Bacillus 
subtilis;  vibrios,  proteus  and  pyocyaneus  forms;  an  encapsulated 
bacillus;  Gartner's  Bacillus  enterides;  in  meat,  anaerobic  forms;  and 
in  mollusks,  Zieber's  Bacillus  piscicidus  agilis.  It  is  possible  that 
many  of  our  domestic  intestinal  organisms  may  become  virulent. 
Liebermeister  said  cholera  nostras  bears  the  same  relation  to  cholera 
Asiatica  as  varicella  does  to  variola,  German  measles  to  measles,  or 
epidemic  icterus  to  yellow  fever.  It  occurs  at  the  same  season.  Its 
symptoms  differ  chiefly  in  degree,  and  occasionally,  a  large  percentage 
(even  40)  of  deaths  occur,  chiefly  in  the  extremes  of  life. 

Arsenical  poisoning,  peritonitis,  and  intussusception  may  without 
bacteriological  confirmation  closely  resemble  cholera. 


212  THE  SPECIFIC  INFECTIONS 

Prognosis. — The  prognosis  is  always  grave.  Cholera  ranks  next 
after  the  plague  in  death-rate,  and  averages  over  50  per  cent.,  prob- 
ably nearer  60  per  cent.,  and  sometimes  80  per  cent. ;  100,000  to  700,000 
die  yearly  in  India.  In  1883,  28,000  died  in  Egypt,  8,605  died  in  Ham- 
burg, and  800,000  in  Russia  (1892-1894).  About  45  per  cent,  of  the 
deaths  in  Hamburg  occurred  in  the  first  twenty-four  hours  and  17 
per  cent,  in  forty-eight  hours,  whence  the  prognosis  is  more  favorable 
if  patients  last  longer  than  two  days;  85  per  cent,  die  when  the  stage 
of  collapse  is  reached.  Light  cases  may  become  severe  or  the  worst 
cases  may  recover.  Unfavorable  factors  are  youth  and  old  age;  preg- 
nancy; colorless  stools,  early  frequent  movements,  early  vomiting, 
anuria  and  low  peripheral  temperature. 

Treatment. — 1.  Prophylaxis. — Quarantine  of  ships,  isolation  of 
early  cases,  thorough  disinfection  of  the  stools,  soiled  linen,  etc.,  and 
special  attention  to  light  cases  and  to  any  suspicious  diarrhoea,  are 
most  important.  In  convalescence  the  stools  may  remain  infective 
for  seven  weeks  (Kolle).  Despite  the  sudden  outbreaks  in  Germany 
in  1892-1894,  sanitary  measures  kept  the  total  of  deaths  at  10,000, 
while  in  Russia  800,000  died  in  the  same  period.  Individual  prophy- 
laxis concerns  the  maintenance  of  the  physiological  resistance;  moder- 
ation in  eating  and  drinking;  the  boiling  of  water  for  drinking  and 
washing;  the  boiling  of  milk;  care  in  regard  to  ice;  avoidance  of 
green  fruits  or  vegetables,  and  of  contamination  of  food  by  flies.  The 
prophylactic  serum  of  Ferran  and  Haffkine  is  valuable.  In  one  series 
of  cases  the  use  of  the  serum  reduced  the  morbidity  two-thirds  and 
the  mortality  one-half. 

2.  Diarrhoea. — This  should  be  treated  by  absolute  rest  in  bed,  and  by 
initial  cleansing  of  the  bowels  wth  calomel  and  castor  oil ;  thin  gruels 
should  be  given  as  a  diet;  red  wine  with  aromatics,  tea,  and  full 
doses  of  bismuth  and  opium  should  be  given.  Intestinal  antiseptics 
are  inert.  The  diarrhoea,  except  the  early  movements,  is  not  easily 
stopped,  because  absorption  is  arrested.  Cantani  advised  that  1  or 
2  quarts  of  1  per  cent,  tannic  acid  solution  be  given  slowly  by  rectum 
in  the  hope  that  it  would  reach  the  small  intestine,  and  Griesinger 
advised  that  larger  quantities  be  given,  and  that  expulsion  by  the 
rectum  be  forcibly  prevented.  The  fluid  was  given  until  it  was  vomited, 
apparently  with  some  results. 

3.  Vomiting. — Vomiting  is  intractable.  Fluids  should  not  be  with- 
held. The  stomach  may  be  washed  with  normal  salt  solution.  Hot 
wine,  camphor,  coffee,  champagne,  and  hypodermics  of  morphia  are 
also  indicated. 

4.  Heart. — Failing  heart  action  and  renal  secretion  are  sometimes 
helped  by  a  warm  bath.  Hypodermatoclysis  was  recommended  by 
Cantani  (1865)  and  intravenous  transfusions  were  employed  by  Her- 
mann and  Latta  (1830).  Their  use  was  studied  during  the  Hamburg 
epidemic  and  their  employment  often  increased  the  heart's  force 
and  benefited  the  general  condition  greatly,  at  least  for  a  time.  The 
results  are  somewhat  better  than  the  mortality  (65  to  77  per  cent.) 


YELLOW  FEVER  213 

would  indicate,  for  they  were  used  in  the  stage  of  profound  collapse 
(where  the  death-rate  is  as  high  as  85  per  cent.)  If  used  earlier  the 
results  might  have  been  better.  The  kidney  secretion  is  apparently 
little  influenced  by  this  treatment. 

5.  Muscles. — Muscular  cramps  are  helped  by  warm  baths,  sinap- 
isms, friction,  local  heat,  saline  infusions,  and  morphine,  which  should 
be  given  hypodermatically. 

6.  Convalescence. — In  convalescence,  great  care  is  necessary  lest 
the  diarrhoea  return. 

Other  symptoms,  complications  and  sequels  are  treated  expectantly. 


YELLOW    FEVER. 

Definition. — A  specific  infection  of  unknown  etiology,  which  is 
transmitted  by  the  mosquito,  is  endemic  in  the  American  tropics  and 
subtropics,  and  is  characterized  pathologically  by  moderate  degenera- 
tion, especially  of  the  liver  and  kidneys,  and  clinically  by  a  rapidly 
developing  fever,  by  icterus,  albuminuria,  adynamia,  hsematemesis, 
and  by  other  hemorrhages. 

Etiology. — The  cause  is  unknown,  although  two  microorganisms 
have  been  especially  obtained:  (1)  Sanarelli's  Bacillus  icteroides,  which 
is  said  to  be  present  in  the  blood,  spleen,  liver  and  kidneys,  but  not 
in  the  intestine;  it  is  a  facultative  anaerobe,  with  rounded  ends,  2  to 
4  /J.  long  and  half  as  wide;  positive  agglutination  tests  are  said  to 
have  been  made;  its  action  is  said  to  be  fourfold:  (a)  steatogenic 
(producing  fatty  degeneration);  (6)  congestive  and  hemorrhagic;  (c) 
emetic,  and  (d)  icterogenic.  Sanarelli's  organism  is  generally  con- 
sidered as  a  contamination.  (2)  Sternberg's  bacillus,  resembling  the 
influenza  germ.  While  the  cause  is  not  known,  it  is  certain  that  the 
disease  is  transmitted  by  the  mosquito  {Culex  or  Stegomyia  fasciata). 
This  was  first  suspected  by  Carlos  Findlay,  in  1881,  and  the  mosquito 
was  demonstrated  to  be  the  intermediate  host  by  the  investigating 
board  composed  of  Walter  Reed,  James  Carroll,  A.  Argamonte  and 
J.  W.  Lazear.  Dr.  Carroll  recovered  from  a  severe  attack,  but  Dr. 
Lazear  died  from  inoculation.  Dr.  Myers,  of  the  English  Commis- 
sion, also  succumbed.  The  Culex  fasciata  breeds  not  only  in  stagnant 
street  pools,  but  also  in  cesspools  and  sewers,  whence  its  special 
danger  in  unhygienic  subtropical  and  tropical  towns.  Voluntary 
inoculations  by  mosquitoes,  which  twelve  days  previously  had  bitten 
yellow-fever  patients,  in  the  first  three  days  produced  yellow  fever 
in  non-immunes.  Findlay  failed  to  prove  his  correct  suspicion  because 
he  only  allowed  the  mosquitoes  three  to  six  days  in  which  to  develop 
the  germs  which  they  had  absorbed,  while  twelve  days  are  necessary. 
As  in  malaria,  the  tropical  foci,  the  hot  summer  and  autumn  seasons, 
the  invasion  of  low  altitudes,  river  courses  and  coast  towns,  humidity, 
and  exposure  to  night  air,  are  conditions  which  promote  yellow  fever 
because  they  are  suitable  to  the  mosquito.     Frost  stops  infection 


214  THE  SPECIFIC  INFECTIONS 

because  it  kills  the  mosquito.  Direct  contagion  from  person  to  person 
is  unlikely.  Nurses  and  physicians  are  seldom  infected  from  contact 
with  yellow-fever  patients.  Persons  going  from  the  City  of  Mexico 
to  Vera  Cruz  may  acquire  the  disease,  but  on  coming  home  with  it 
they  do  not  cause  its  dissemination,  because  the  mosquito  is  not  pres- 
ent. Postmortem  wounds  and  direct  voluntary  inoculations,  however, 
have  directly  communicated  the  disease.  The  yellow-fever  virus  is 
the  only  virus,  infecting  man,  which  passes  through  fine  filters.  It 
was  thought,  until  recently,  that  fomites,  clothing,  etc.,  were  infective, 
but  Reed's  committee  has  experimentally  exploded  this  theory.  Volun- 
teers remained  in  rooms  occupied  by  yellow-fever  patients  and  slept 
in  their  soiled  linen  without  contracting  the  disease. 

Predisposition. — The  lighter  races  are  more  prone  to  infection. 
The  value  of  acclimatization  has  been  overestimated,  and  it  is  thought 
that  immunes  are  merely  those  who  have  had  light  and  unrecognized 
infections.  Most  cases  occur  in  males  between  twenty  and  forty  years 
of  age.  Yellow  fever  is  kept  alive  in  endemic  foci  by  mild  cases,  espe- 
cially among  the  Creole  children. 

Foci  and  Epidemiology. — The  two  prominent  homes  of  yellow  fever 
are  (1)  Mexico,  the  Antilles,  Mexican  Gulf  and  Caribbean  Sea;  and 
(2)  Africa,  from  Senegal,  through  Sierra  Leone,  to  the  Gold  Coast. 
The  first  clear  description  of  yellow  fever,  according  to  Sodre  and 
Couto,  was  in  1686,  but  certainly  yellow  fever  was  known  before  the 
discovery  of  America.  It  reached  this  country  possibly  in  the  six- 
teenth century  and  has  extended  as  far  north  on  the  coast  as  Boston 
and  on  the  Mississippi  River  as  far  as  St.  Louis.  It  has  reached  Quebec 
and  Chicago.  In  Philadelphia  (1793,  1797-1798),  4,041  died  in  a 
year;  in  New  York,  2,080;  and  in  New  Orleans,  in  1853,  8,000  died. 
Epidemics  occurred  also  in  1802,  1805,  1853,  1867,  1873,  1878,  and  to 
a  slight  degree  in  1897-1899;  New  Orleans  was  visited  severely  in 
1905;  there  were  about  9,000  cases  and  1,000  deaths.  Europe  is 
seldom,  but  South  America  is  frequently,  invaded. 

General  Clinical  Description. — Incubation. — The  incubation  aver- 
ages three  or  four  days.  Prodromal  symptoms  are  not  infrequent  and 
last  less  than  a  day.  They  may  be  malaise,  fatigue,  headache,  dyspep- 
sia, colic,  or  other  indistinctive  symptoms.  The  disease  is  often 
divided  into  stages,  not  all  of  which  are  always  present: 

Stage  I. — The  stage  of  congestion  begins  (a)  with  some  headache, 
frontal,  supraorbital  or  retroocular,  the  earliest  and  most  prominent 
symptom;  (b)  sometimes  with  a  chill;  (c)  with  flushed  face;  the  con- 
junctivee  are  injected  and  sometimes  icteric  even  at  this  stage;  the 
eyes  are  sensitive  to  light,  the  lids  somewhat  puffed  up  and  the  expres- 
sion is  a  mixture  of  pain,  restlessness  and  confusion,  comparable  to 
the  alcoholic  facies;  (d)  with  backache,  and  pains  radiating  into  the 
calves  of  the  legs;  (e)  with  fever  rising  to  104°  or  more;  and  (/)  with 
a  full,  tense  pulse  of  100  to  110. 

The  tongue  is  usually  clean  or  slightly  coated  dorsally,  and  its  tip 
and  edges  are  red.     The  urine  is  febrile  and  very  early  albuminous. 


YELLOW  FEVER  215 

The  skin  is  intensely  red  and  dry.  The  epigastrium  is  tender  early 
in  the  disease  and  there  is  marked  gastric  irritability  and  intolerance 
of  food,  water  and  medicine.  This  stage  lasts  two  days  or  somewhat 
longer. 

Stage  II. — The  remission  stage,  stage  of  calm,  or  deceptive  stage, 
occurs  in  some  cases  and  is  so-called  because  of  later  severe  symptoms 
following  this  remission.  The  fever  may  fall  nearly  to  normal  or  to 
subnormal;  the  pulse  falls  to  80  or  90,  and  pain  and  hypersesthesia 
remit.    Slight  jaundice  may  now  be  first  apparent. 

Stage  III. —  The  Reaction  Stage. — Slight  temperature,  the  "black 
vomit"  {vomito  negro)  of  blood,  hemorrhage  into  the  nose,  intestines, 
uterus  or  skin,  hiccough,  epigastric  pain  and  tenderness,  liver  enlarge- 
ment, and  icterus  of  the  skin  and  accessible  mucosae  usually  mark 
this  period.  The  urine  becomes  scant  and  is  laden  with  bile  pigment, 
or  its  secretion  is  suppressed;  the  pulse  becomes  weaker,  and  such 
nervous  symptoms  as  insomnia,  prostration  and  restlessness  may 
appear. 

Various  issues  are  henceforth  possible:  (a)  Gradual  amelioration; 
(b)  fatal  anuria;  (c)  profuse  hemorrhages;  especially  from  the  ali- 
mentary mucosa,  which  usually  end  in  fatal  collapse,  and  rarely  in 
recovery;  (d)  profound  icterus,  which  results  in  adynamic  phenomena 
and  usually  in  death,  though  recovery  is  possible,  and  (e)  death,  with 
pronounced  cardiac  insufficiency. 

Special  forms  of  yellow  fever  are  described  by  Sonde  and  Couto 
which  vary  with  the  intensity  of  infection  and  of  special  visceral  in- 
volvement. (A).  Variations  in  intensity  include  (1)  light,  abortive, 
ambulatory,  atypical  forms,  especially  in  children ;  (2)  the  usual  severe 
forms,  and  (3)  the  foudroyant  type,  which  is  rapidly  lethal  in  twenty- 
four  to  forty-eight  hours.  (B).  Visceral  forms:  (1)  The  hepatic  type, 
which  is  slow,  with  two  weeks  of  the  status  typhosus,  often  with  nor- 
mal temperature  and  sometimes  with  hemorrhages;  (2)  the  ursemic 
type,  often  with  early  death;  (3)  the  hemorrhagic;  (4)  the  cardiac; 
and  (5)  nervous  or  atactic  type. 

Special  Symptomatology. — 1.  F^ver. — ^The  fever  is  neither  cyclic 
nor  diagnostic,  though  Sternberg  considers  that  there  is  a  single  febrile 
paroxysm  of  two  to  seven  or  eight  days.  It  is  usually  highest  in  the 
first  stage,  and  reaches  an  average  of  104°  (though  sometimes  even 
reaching  108°).  It  may  fall  on  the  second  or  third  day  to  nearly  nor- 
mal in  benign  cases  or  in  the  ominous  ursemic  type.  High  fever  on 
or  after  the  second  day  (second  stage)  is  a  poor  prognostic,  and  is 
sometimes  due  to  secondary  infection  with  the  pyogenic  cocci,  or  the 
typhoid  or  colon  bacillus.  In  the  second  stage  the  fever  is  usually 
between  99°  and  100°,  and  may  rise  in  the  third  stage.  A  high  post- 
mortem rise  is  frequent.  In  convalescence,  the  temperature,  aside 
from  complications,  is  always  subnormal. 

2.  Nervous  Symptoms. — Nervous  symptoms  are  often  absent  in 
both  benign  and  malignant  cases.  Insomnia  and  headache  are  com- 
mon in  the  congestive  period.     Delirium  is  infrequent,  and  in  80  per 


216  THE  SPECIFIC  IXFECTIOXS 

cent,  of  the  cases,  is  ursemic  rather  than  purely  toxeemic.  Atactic  symp- 
toms are  far  more  common  in  children  than  in  adults  although  they 
may  develop  in  alcoholics  and  in  the  debilitated.  In  children,  the 
status  typhosus  or  meningo-encephalitic  symptoms  (convulsions,  even 
unequal  pupils,  Cheyne-Stokes  breathing,  and  coma)  are  possible. 
Pathologically,  few  changes  are  found  except  the  slight  degenerations 
common  to  the  febrile  stage,  punctate  hemorrhage  (mostly  agonal), 
or  bile-tinging. 

3.  Circulatory  Symptoms. — (a)  The  pulse  in  the  congestiA^e  stage 
is  usually  100  to  130  and  is  tense  from  increased  blood  pressure;  on 
the  third  day,  90  to  100  (even  70  to  80);  in  the  second  stage  it  is  still 
lower  in  benign  and  more  rapid  in  severe  cases  (110  to  140),  is  small, 
and  the  manometer  shows  lowered  arterial  tension;  in  convalescence 
it  is  usually  slow  (50  to  60,  or  even  30).  Faget,  of  New  Orleans,  em- 
phasized the  slowing  of  the  pulse  Asdth  maintenance  of  the  fever, 
which  he  and  others  consider  almost  pathognomonic,  (b)  In  severe 
forms  the  first  tone  over  the  apex  of  the  heart  becomes  weak  and  is 
finally  lost.  The  same  is  true  of  the  second  tone.  The  heart  action 
is  rarely  irregular  or  intermittent.  Embryocardia  is  found  in  severe 
cardiac  types.  In  the  second  or  third  stage,  cardiac  dilatation  is  com- 
mon (in  70  per  cent,  of  autopsies).  Cardiac  insufficiency  may  develop 
early  or  late.  These  cardiac  signs  are  due  to  cloudy  and  fatty  myo- 
cardial degeneration;  pericardial  and  endocardial  ecchymoses  are 
frequent.  Cardiac  action  is  exaggerated  when  uraemia  is  present. 
Endocarditis,  pericarditis  and  acute  aortitis  are  infrequent  complica- 
tions, (c)  There  may  be  some  anaemia,  but  often  there  is  none.  The 
white  cells  are  decreased  in  proportion  to  the  severity  of  infection. 
The  polynuclears  are  relatively  increased. 

4.  Respiratory  Symptoms. — Respiratory  symptoms,  such  as  dyspnoea, 
may  be  due  to  intercurrent  inflammation  or  more  often  to  cardiac  or 
renal  complications. 

5.  Digestive  Tract. — Severe  hiccough  is  attributed  to  irritation  of 
the  phrenic  nerve  by  distention  of  the  stomach  or  by  enlargement  of 
the  liver.  Epigastric  pain,  tenderness  and  anxiety  may  be  sympto- 
matic of  cardiac  distress,  premonitory  of  the  black  vomiting,  or  indica- 
tive of  disturbed  circulation  in  the  medulla,  which  is  expressed  in  the 
endings  of  the  vagus. 

6.  Icterus  (Yellow  Fever,  Typhus  Icteroides). — Jaundice  may  ap- 
pear early,  but  usually  develops  on  the  third  to  the  fifth  day.  It  is 
frequently  absent  in  children,  or  in  cases  of  early  death  from  ura?mia 
or  from  nervous  symptoms.  According  to  Feraud,  it  is  absent  in  50 
per  cent,  of  cases  which  recover.  The  explanation  for  this  is  an  open 
question.  Feraud  distinguishes  two  forms  (a)  the  early,  lighter  jaund- 
ice, due  to  blood  pigment,  and  (b)  the  later  and  more  severe  type  due 
to  bile  pigments.  Sodre  declares  that  the  yellow-fever  liver  cannot 
produce  bile  pigments. 

7.  Liver. — The  liver  is  slightlv  enlarged  and  is  tender.  Patho- 
logically,  its  color  is  light,  and  it  has  a  cooked  appearance.    The  left 


YELLOW  FEVER  217 

lobe  may  reach  the  spleen.  On  section,  it  is  oily,  fatty,  anaemic,  and 
under  the  lens,  shows  fatty  degeneration,  disorder,  and  deformation 
of  the  liver  cells. 

8.  Urine.— ^The  urine  is  early  febrile,  is  sometimes  scanty,  and  shows 
decreased  urea,  uric  acid,  chlorides  and  phosphates.  Albuminuria  is 
an  important  finding  and  occurs  in  88  per  cent,  of  cases  in  the  first 
three  days.  Leucin  and  the  bile  pigments  are  common.  Indicanuria 
is  very  infrequent.  Casts  are  common.  The  kidneys,  anatomically, 
are  normal  in  size,  rather  pale  or  yellowish,  and,  microscopically,  show 
great  fatty  degeneration  of  the  tubules,  which  in  severe  cases  are 
actually  choked  by  desquamated  epithelium  and  casts.  The  glomeruli 
show  remarkably  few  changes.  Anuria  is  due  to  these  changes  and 
to  lowered  blood  pressure;  it  is  fatal  in  97  per  cent,  of  cases.  Urcemia 
causes  33  per  cent,  of  the  fatalities;  it  is  marked  by  delirium,  nervous- 
ness, restlessness,  twitching  or  convulsions,  by  decreased  or  suppressed 
urine,  by  rapid,  slow,  forced,  irregular,  labored,  or  Cheyne-Stokes 
breathing,  and  by  tense  pulse.  Death  in  coma  may  occur  as  early  as 
the  third  day.    Uraemia  and  anuria  are  rare  in  children. 

9.  Hemorrhages. — ^These  may  occur  anywhere.  They  are  most 
frequent  in  (a)  the  alimentary  tract,  (b)  the  nose,  and  (c)  the  uterus. 
They  result  from  fatty  degeneration,  undue  permeability,  or  actual 
rupture  of  the  bloodvessels,  (a)  Alimentary  tract.  Hemorrhages 
may  occur  from  the  mouth,  tongue,  lips,  stomach,  or  intestine.  The 
black  vomit  is  gradually  transuded  blood  altered  by  the  gastric  acid; 
it  most  often  occurs  on  the  fourth  to  the  sixth  day;  it  is  the  ordinary 
"coffee  grounds"  vomit  or  is  ink-like;  the  stomach,  at  autopsy,  shows 
the  black  contents,  congestion,  or  even  dark  discoloration,  epithelial 
desquamation  and  fatty  change  in  the  muscularis.  Hemorrhage  from 
the  small  intestine  is  almost  equally  frequent.  (6)  Epistaxis  may 
occur  early  or  late,  is  often  profuse,  and  sometimes  fatal,  (c)  Uterine 
hemorrhages  are  severe,  especially  at  the  menstrual  periods,  and  in 
pregnant  women  cause  abortion  or  premature  delivery.  Less  frequent 
are  (d)  skin  petechice,  which  are  found  sometimes  in  large  plaques  or 
hypostatic  ecchymoses,  clinically  and  at  postmortem;  (e)  muscidar 
hemorrhages  which  are  painful,  often  large,  and  which  sometimes 
suppurate.  (/)  Hemorrhage  in  other  mucosae  (larynx,  urethra,  and 
eye),  theserosse  (pleurae,  endocardium,  or  meninges),  or  in  the  viscera 
(brain,  medulla,  and  lungs). 

Complications  and  Sequelae, — These  include  (1)  secondary  infec- 
tions with  the  pneumococcus,  pyogenic  cocci,  or  the  colon  bacillus, 
such  as  endocarditis,  pericarditis,  pneumonia,  erysipelas,  parotitis, 
arthritis,  suppuration,  and  gangrene.  (2)  Coincident  typhoid,  malaria, 
influenza,  and  insolation.     (3)  Post-febrile  psychoses. 

Diagnosis. — The  diagnosis  is  usually  easy  from  (1)  the  flushed, 
semi-intoxicated  facies;  (2)  icterus;  (3)  the  almost  invariable  and 
early  albuminuria — the  most  valuable  finding  in  doubtful  cases;  (4) 
black  vomit,  gastric  intolerance,  and  epigastric  uneasiness;  (5)  other 
hemorrhages,  and  (6)  the  slow  pulse,  which  is  absent  in  some  severe, 


218  THE  SPECIFIC  INFECTIONS 

but  therefore  clear,  cases.  Dengue  lacks  these  features.  Pernicious 
malaria,  with  icterus,  is  distinguished  by  the  blood  findings,  the  enlarge- 
ment of  the  spleen  (always  absent  in  yellow  fever),  the  infrequency  of 
early  icterus,  albuminuria  and  hemorrhages  (except  hsematuria). 
This  form  of  malaria  is  rare  in  the  cities,  whence  the  constant  sugges- 
tion of  yellow  fever,  when  more  than  sporadic  cases  are  reported, 
Weil's  disease  (infectious  jaundice),  and  acute  yellow  atrophy  of  the 
liver  are  usually  readily  distinguished. 

Prognosis. — The  mortality  of  epidemics  varies  from  10  per  cent,  to 
85  per  cent.  The  average  death-rate  is  about  30  per  cent.  The  mean 
death-rate,  according  to  age,  is  33  per  cent,  (one  to  three  years),  14 
per  cent,  (four  to  eighteen  years),  and  37  per  cent,  (nineteen  to  forty 
years).  Unfavorable  events  are  the  early  development  of  the  third 
stage,  hepatic,  renal,  or  cardiac  insufficiency,  the  typhoid  state,  diffuse 
hemorrhages,  combination  of  special  types  (cardiac  plus  renal,  or 
hepatic  plus  renal),  high  fever  with  hepatic  symptoms,  and  hemor- 
rhages. 

Treatment. — I.  Prophylaxis. — Disinfection  of  the  fomites  is  now 
less  important  than  the  question  of  the  mosquito.  Probably  no  greater 
triumph  of  hygiene  exists  than  the  stamping  out  of  yellow  fever  since 
the  American  occupation  of  Havana.  It  illustrates  not  only  the 
efficiency  of  the  investigating  scientific  commission,  but  also  the  pos- 
sibilities of  medicine  in  administrative  capacity  with  unlimited  dis- 
cretionary power.  In  Havana  the  average  death-rate  was  500  yearly, 
until  Gorgas  cut  it  down  to  nil.  The  patient  should  be  isolated,  not 
to  prevent  direct  personal  contagion  but  to  keep  the  Culex  f asciata 
from  the  infected  person.  Healthy  individuals  should  be  kept  from 
infection  by  the  mosquito  by  the  same  measures  that  are  employed 
in  malaria,  e.  g.,  screens,  and  extermination  of  breeding  foci.  The 
Culex  fasciata  is  found  outside  the  habitual  yellow-fever  foci,  and  after 
biting  patients  from  abroad,  may  inoculate  other  persons.  Infected 
insects,  too,  may  be  carried  by  ships. 

II.  Symptomatic  Treatment. — (a)  In  the  first  stage,  fluidextractum 
aconiti,  vji.  iij,  sodium  salicylat.,  gr.  xx,  and  antipyrin,  gr.  x,  may  be 
given  every  two  to  four  hours  for  a  few  doses,  until  the  congestion  and 
pains  are  relieved.  Coal-tar  products  are  not  to  be  employed  when 
depression  exists.  Fractional  doses  of  calomel,  gr.  ^  every  hour  for 
five  doses,  should  be  given  and  followed  by  two  or  three  ounces  of 
castor  oil.  Overmedication  is  particularly  to  be  avoided  because  of 
the  frequent  gastric  irritability,  and  feeding  by  rectum  is  often  indi- 
cated. Early  or  violent  cerebral,  ursemic,  or  pulmonary  symptoms  are 
sometimes  treated  by  phlebotomy,  (b)  In  the  last  stage,  the  black 
vomit  contraindicates  any  fluid,  food,  or  medication  by  mouth;  warm 
peptonized  milk  and  normal  salt  solution  should  be  given  by  rectum; 
morphine,  when  the  patient  is  in  this  condition,  is  dangerous,  as  is  the 
perch] oride  of  iron,  when  given  by  mouth,  (c)  In  cardiac  insufficiency, 
digitalis  is  especially  good,  and  it  is  apparently  beneficial  to  the  patient 
even  when  cardiac  failure  is  absent;  saline  solution,  by  rectum  or  sub- 


THE  PLAGUE  219 

cutaneously,  produces  better  results  than  intravenous  transfusions. 
The  patient  must  be  kept  absolutely  quiet,  {d)  UrcBmic  symptoms 
are  treated  in  much  the  same  way.  Much  water  should  be  given, 
chiefly  by  the  bowel,  (e)  Nervous  manifestations  necessitate  cool 
spongings,  bromides,  morphine,  and  hyoscine,  as  in  Typhoid.  (/) 
Vomiting  (see  Typhoid)  is  relieved  most  efficaciously  by  chopped  ice. 


THE    PLAGUE. 

Definition. — The  pest,  or  bubonic  plague,  is  a  specific  acute  infec- 
tion caused  by  the  Bacillus  pestis  and  characterized  by  a  pronounced 
typhoid  state,  fever,  buboes  and  carbuncles,  very  frequently  by  sep- 
ticaemia (pesticsemia),  and  by  extrernely  high  mortality. 

History. — The  first  clear  accounts  date  from  the  times  of  Trajan, 
in  the  second  century,  and  of  Justinian,  in  the  year  542.  The  plague 
was  important  among  the  pestilences  of  the  middle  ages.  In  the  four- 
teenth century  the  "black  death"  swept  over  Europe  with  a  mortality 
of  25,000,000  (one-quarter  of  the  world's  population).  It  appeared 
from  time  to  time  in  the  sixteenth  and  seventeenth  centuries,  but  in 
the  eighteenth  century  it  withdrew  southeast,  and  disappeared  from 
Europe  until  the  small  Russian  epidemic  in  1878-1879.  Egypt  was 
the  early  focus  for  African  epidemics,  and  European  epidemics  started 
from  Turkey.  Syria  was  the  leading  Asiatic  focus,  thirteen  epidemics 
occurring  between  1773  and  1843.  The  present  Oriental  focus  seems 
to  be  Southern  Thibet,  whence  India  and  China  have  been  invaded 
thirty  times  between  1823  and  1897.  Uganda  is  considered  a  perma- 
nent plague  home  by  Koch;  plague  is  endemic  in  Asia  near  Mecca, 
in  Mesopotamia  and  in  Siberia.  In  1899-1900,  New  York,  San  Fran- 
cisco, Glasgow,  Cape  Town,  South  America  and  Australia  were 
visited.  Epidemics  appear,  reach  their  maximum,  and  decline  at 
nearly  the  same  time  each  year.  The  theory  that  the  virus  remains 
permanently  in  the  soil  has  many  supporters. 

Etiology. — The  Bacillus  festis  was  found  by  Yersin,  in  1894,  and 
at  the  same  time  Kitasato  found  a  similar,  possibly  an  identical,  bacil- 
lus. Its  ends  are  rounded  and  stain  deeply;  its  sides  are  somewhat 
convex;  it  measures  H  to  If  by  ^  to  f  //  and  is  encapsulated.  It  is 
polymorphous,  and  appears  with  equal  frequency  as  rods  or  as  diplo- 
bacilli.  Atypical  forms  are  oval,  ovoid,  annular,  chain-,  thread-,  or 
branch-like.  Other  degenerative  or  involution  forms  are  the  pyri- 
form,  biscuit,  comma-shaped,  or  spermatozoid.  Though  it  is  most 
often  outside  of  the  cells,  it  may  appear  in  them.  It  contains  no  spores 
nor  flagella.  It  is  found  in  all  organs,  in  the  spleen,  the  lungs  and 
tonsils;  in  the  sputum,  the  urine  and  foeces;  and  in  the  bubo  and  car- 
buncles. Its  cultures  are  typical,  and  superficial,  and  have  bulging, 
wall-like  edges.  It  stains  with  ordinary  stains, — e.  g.,  alkaline  methy- 
lene blue,  etc. — but  not  by  Gram's  method.  It  is  readily  killed  by 
heat,  sunlight,  desiccation,  antiseptics,  and  is  often  overgrown  by  second- 


220  THE  SPECIFIC  IXFECTIOXS 

ary  infection.  It  lives,  at  the  most,  for  three  to  four  weeks  in  buried 
bodies,  but  may  persist  much  longer  (v.i.)  in  the  saliva,  sputum, 
urine  or  faeces  of  convalescents. 

Atrium. — It  may  enter  (1)  by  the  skin,  through  invisible  wounds, 
as  does  erysipelas;  through  scratches,  or  as  shown  by  Albrecht  and 
Ghon,  through  the  intact  integument.  Postmortem  infections  are 
frequent,  even  though  there  is  no  visible  abrasion.  Laboratory  inocu- 
lation is  possible,  as  was  unfortunately  demonstrated  in  the  Vienna 
cases,  among  which  was  that  of  Mliller,  who  was  then  writing  his  well 
known  monograph.  Flies,  fleas,  ants,  bed-bugs,  etc.,  may  inoculate 
the  disease.  (2)  The  accessible  mucosce,  conjunctivae  (experimentally), 
and  clinically  the  nose,  tonsils,  anus  and  external  ^genitalia,  may  be 
primarily  infected.  The  nose  and  throat  are  especially  frequent  points 
of  entrance  in  children,  for  obvious  reasons.  (3)  The  alimentary 
tract  affords  a  possible  atrium.  (4)  The  bacillus  may  cause  prim- 
ary plague  pneumonia,  whence  metastatic  infections  occur. 

Contagion  may  be  direct  or  indirect,  (a)  Direct. — Dissemination 
by  the  sputum  of  plague  pneumonia  is  most  dangerous,  for  the  bacilli 
are  scattered  by  coughing,  as  shown  in  Fliigge's  experiments  in  tuber- 
culosis iq.v.).  The  pest  spreads  rapidly  only  when  it  is  of  the  pneu- 
monic type.  The  bacilli  may  penetrate  from  unruptured  carbuncles 
or  buboes  or  scatter  from  them  after  their  rupture.  The  urine,  the 
fseces,  and  the  milk  of  nursing  women  are  also  dangerous.  Direct 
contagion  may  result  from  autopsies,  from  operations,  or  from  nasal 
or  urinary  hemorrhages,  (b)  Indirect. — This  may  result  from  fomites, 
from  bites  of  animals  or  insects  containing  the  germ,  and,  possibly, 
from  contaminated  water.  Epidemics  among  rats  may  precede  human 
epidemics.  In  Canton,  35,000  dead  rats  were  found  in  one  district. 
The  disease  may  also  exist  among  apes,  cats,  mice,  and  other  animals. 
Infection  by  flies,  fleas,  etc.,  is  certainly  possible,  and  Simond  con- 
sidered the  rat-flea  particularly  responsible,  though  the  parasites  of 
animals  seldom  attack  man.  Flies  may  convey  infection  from  the  urine 
or  faeces  of  infected  rats.    The  bacillus  produces  virulent  toxijis. 

Sjnnptoms. — -There  are  two  factors  in  the  clinical  picture:  (a)  The 
local  changes,  such  as  those  in  the  primary  localization  (bubo  or 
pneumonia),  and  (6)  the  successive  septicaemia  (pesticaemia)  and 
toxaemia.  The  average  incubation  is  five  days  (two,  to  seven  or  ten). 
Occasionally  there  is  transitory  prodromal  depression,  nausea,  or 
glandular  pain,  but  usually  the  onset  is  very  acute,  with  marked  head- 
ache, intense  vertigo,  severe  rigor,  sudden  fever,  and,  in  children,  con- 
vulsions. Early  vomiting  is  quite  frequent.  There  is  early  glandular 
pain,  the  prostration  is  profound,  and  an  early  typhoid  state  develops. 
The  fever  reaches  104°  on  the  second  day,  is  either  continuous  or 
remittent,  in  convalescing  cases  falls  by  lysis  (fifth  to  seventh  day), 
or  may  remain  high  until  death.  Crisis  is  seen  in  light  cases 
only.  The  skin  is  hot  and  dry  or  may  be  covered  with  sweat  as  death 
approaches.  Herpes  never  develops.  Skin  hemorrhages  are  frequent. 
They  are  due  to  embolism  caused  by  the  Bacillus  pestis,  they  occur 


THE  PLAGUE  221 

almost  always  in  the  agony  or  shortly  before  death,  and  are  seen  mostly 
in  the  upper  trunk,  arms,  head  and  neck,  and  sometimes  also  in  the 
muscles  and  periosteum.  Abscesses,  phlegmons,  gangrene,  or  bed- 
sores, are  not  common. 

1.  Characteristic  Local  Finding. — This  is  the  bubo,  for  the  lymph 
glands  are  more  important  than  in  any  other  infection.  The  several 
clinical  forms  of  the  plague  usually  described  are  (a)  the  bubonic 
type  (77.7  per  cent.);  (b)  the  septiccemic  type  (14  per  cent.);  (c)  the 
'pulmonary  type  (4.3  per  cent.);  id)  the  carbuncle  type  (2.5  per  cent.); 
((?)  mixed  infection  (1  per  cent.),  and  (/)  the  ambulatory  type  (pestis 
minor,  0.5  per  cent.),  which  is  considered  by  Scheube  as  not  plague 
but  "climatic  bubo."  The  figures  are  from  Choksey,  of  Bombay. 
In  the  great  majority  of  cases,  probably  in  all  except  in  the  pulmonary 
type,  the  bubo  is  found  very  early  (90  to  98  per  cent.)  and  local  pain, 
tenderness  and  swelling  are  present.  The  primary  bubo  occurs  in 
the  external  lymph  glands  in  the  region  of  the  atrium;  it  is  large, 
very  painful  and  tender,  and  is  attended  by  great  periadenitis,  oedema, 
hemorrhage  and  vesicle  formation  in  the  skin.  Its  size  and  rapid 
growth  are  due  in  part  to  medullary  swelling  of  the  lymph 
glands,  but  chiefly  to  hemorrhage,  which  may  spread  along  the  nerves, 
arteries  or  veins,  into  which  it  may  break,  thus  disseminating  the 
bacilli.  The  glands  may  fuse,  and  a  brawny  mass,  as  large  as  an  egg, 
or  a  man's  fist,  results.  The  glands  and  surrounding  tissues  contain 
enormous  numbers  of  bacilli  at  this  stage.  The  location  is  inguinal 
(70  per  cent.),  axillary  (20  per  cent.),  and  cervical  (10  per  cent.). 
The  inguinal  and  axillary  adenitis  is  more  common  in  males;  cervical 
adenitis  results  in  children  from  infection  of  nose  and  throat  by  dirty 
fingers;  the  popliteal  and  epitrochlear  glands  remain  uninfected  with 
curious  frequency,  being  involved  in  but  1  or  2  per  cent.  Strangely, 
too,  the  lymph-vessels  are  usually  unaffected,  although  they  are 
sometimes  inflamed  near  the  buboes  or  carbuncles,  or  around  the 
atrium  of  infection.  From  the  primary  bubo  (especially  when  the 
blood  is  not  early  infected)  the  contiguous  glands  are  involved; 
e.g.,  after  the  infection  of  the  inguinal  glands,  the  iliac,  aortic,  medias- 
tinal, subpectoral,  infra-  and  supraclavicular  or  cervical  glands  may 
be  involved;  i.e.,  infection  usually  occurs  in  the  direction  of  the 
lymph-current,  but  retrograde  involvement  is  possible.  On  the  fourth 
to  the  sixth  day  necrosis  occurs,  and  on  the  eighth  or  ninth  day  sup- 
puration develops,  resulting  from  mixed  infection  (33  per  cent.),  but 
more  often  (66  per  cent.)  from  the  Bacillus  pestis  alone.  Some  glands 
may  resolve  without  suppuration.  The  primary  bubo  is  often  incon- 
spicuous and  its  size  has  no  bearing  on  the  intensity  of  the  disease, 
although  cases  with  marked  periadenitis  rarely  recover.  Besides  the 
primary  bubo  and  its  contiguous  lymphatic  extension,  Albrecht  and 
Ghon  described  the  secondary  bubo  which  is  infected  by  the  bacilli- 
laden  blood  current.  The  bacilli  have  a  remarkable  affinity  for  lymph- 
atic structures  and  settle  in  them  largely.  These  hematogenous  buboes 
are  generally  smaller  and  less  tender,  painful,  oedematous,  and  hemor- 


222  THE  SPECIFIC  INFECTIONS 

rhagic,  than  the  primary  bubo,  and  rarely  exhibit  periadenitis  unless 
the  clinical  course  is  protracted.  They  contain  the  bacilli  in  numbers, 
as  do  other  lymphatic  tissues,  such  as  the  mesenteric  glands,  the 
pharyngeal  follicles,  the  stomach,  intestine,  and  lung.  Carbuncles 
result  chiefly  from  pesticsemia,  although  apparently  in  some  cases 
they  are  the  atrium.  They  occur  in  10  to  15  per  cent,  of  the  cases, 
often  near  the  primary  bubo.  The  crowning  serous  vesicle  is  rup- 
tured, discharges  bacilli,  and  leaves  an  ulcer,  whose  floor  is  bluish- 
red  from  hemorrhage,  or  yellow  from  swarms  of  bacilli.  A  dark 
crust  then  forms.  There  is  great  peripheral  infiltration,  and  the  whole 
limb  or  part  of  it  may  become  oedematous.  These  lesions  indi- 
cate that  the  pesticsemic  type  is  less  a  distinct  type  than  an  almost 
regular  part  of  the  disease.  Cases  rarely  recover  which  show  bacil- 
Isemia.  The  blood  shows  some  anajmia  and  moderate  polymor- 
phonuclear leukocytosis.  The  spleen  is  increased  three  to  four 
times,  is  reddish,  and  is  somewhat  less  soft  than  it  is  in  typhoid, 
anthrax,  or  streptococcic  infections.  Its  cut  surface  is  finely  gran- 
ular and  is  slightly  glistening.  It  is  infiltrated  with  white  cells 
and  bacilli,  which  are  found  especially  in  the  innumerable  foci 
of  minute  necrosis.  It  is  usually  palpable  on  the  first  or  second 
day. 

2.  Nervous  System. — The  nervous  system  suffers  few  anatomical 
changes  except  meningeal  hemorrhages  and  brain  oedema.  Clinically 
the  toxsemic  nervous  "typhoid"  symptoms  are  as  prominent  as  the 
buboes.  There  is  early  headache  and  marked  prostration.  Vertigo 
is  especially  notable,  causing  a  drunken,  cerebellar  gait,  and  vomiting. 
The  delirium  is  more  often  dull,  dreamy  and  docile,  than  active  or 
maniacal,  though  the  patient  may  fight  the  attendants  or  run  away. 
Motor  twitching,  tonic  or  clonic  spasms,  subsultus,  rigidity  of  the 
neck  or  spine,  and  even  bulbar  symptoms,  such  as  increased  pulse  and 
respiration,  polyphagia  or  polydipsia,  may  be  suggestive  of  meningitis, 
which  sometimes  actually  occurs  by  pesticaemia.  Acute  ataxia,  mye- 
litis, paraplegia,  hemiplegia,  or  isolated  neuritis  (monoplegia,  vagus 
weakness,  aphonia,  palate  paralysis)  and  other  nervous  sequels  are 
uncommon.  Ear  symptoms  are  unusual,  but  are  easily  masked  by 
the  profound  typhoid  state.  Conjunctival  hypersemia,  sometimes  with 
ecchymoses,  is  so  frequent  that  it  is,  together  with  the  fever  and  buboes, 
made  one  of  the  cardinal  symptoms  by  Yamagiwa.  Iridocyclitis  is 
not  uncommon, 

3.  Circulation. — The  circulatory  and  the  nervous  changes  measure 
the  intensity  of  infection  and  forecast  the  prognosis.  Possibly  there 
is  no  other  cardiac  poison  as  intense  as  is  the  plague  toxin  which 
operates  on  the  medulla  and  its  vagus  nucleus.  Early  in  the  attack 
the  pulse  is  full  and  dicrotic,  with  a  rate  of  80  to  90.  Later,  the  pulse 
increases  to  120,  150,  or  even  200;  the  heart  tones  become  muffled; 
tachypnoea,  great  dyspnoea,  and  all  the  signs  of  acute  cardiac  insuffi- 
ciency develop.  In  some  virulent  infections  the  pulse  may  remain 
slow.    At  autopsy  the  heart  is  lax,  the  right  ventricle  dilated,  the  myo- 


THE  PLAGUE  223 

cardium  cloudy,  and  the  serous  investment  ecchj-motic.    Endocarditis 
or  pericarditis  almost  never  occurs. 

4.  Respiratory  Tract. — The  lymph  structures  in  the  larynx,  trachea, 
or  bronchi  are  infected  by  aspiration  from  tonsillar  foci  or  through 
the  blood.  Fatal  laryngeal  oedema  may  occur.  Most  important  is 
the  'plague  'pnewmonia,  of  which  there  are  two  varieties,  (a)  the  pri- 
mary, in  which  the  lung  is  the  atrium  (or  analogue  of  the  primary 
bubo).  It  was  clearly  the  "black  death"  of  the  middle  ages  (Forbes). 
It  was  seen  in  India,  in  1838,  and  became  well  known  in  the 
Indo-Chinese  epidemic  of  1896-1897,  when  Childe  first  found  the 
Bacillus  pestis.  The  bacillus,  if  inhaled,  causes  typical  confluent  lobar 
pneumonia  and  salient  lymphatic  involvement.  The  bacilli  exist  in 
hordes  in  the  lung  and  sputum,  and  may  cause  hsematogenous  buboes 
and  carbuncles.  The  diagnosis  is  positive  only  when  the  sputum 
appears;  this  is  followed  by  cyanosis,  dyspnoea,  profuse  haemoptysis, 
splenic  tumor,  pleuritic  pains,  signs  of  consolidation,  adynamia  and 
collapse.  Death  occurs  in  97  per  cent,  of  the  cases.  (6)  Secondary 
pneumonia  is  (i)  embolic  (Yamagiwa),  and  occurs  with  abscess  in 
the  liver  and  kidney;  it  develops  as  multiple  small  foci,  is  difficult  to 
diagnosticate  surely,  though  bacilli  in  the  sputum,  dyspnoea,  and 
pleuritic  pain  are  suggestive,  (ii)  Aspiration  pneumonia  usually  occurs 
in  the  lower  lobes,  its  diagnosis  is  difficult,  it  follows  bubonic  disease 
of  the  tonsil,  pharynx  or  bronchi,  and  is  almost  invariably  fatal. 

5.  Digestive  Tract. — A  moist,  then  a  dry,  tongue,  hemorrhage  from 
the  gums  or  throat,  vomiting  and  involvement  of  the  tonsils  or  pharynx, 
are  common.  There  may  be  ecchymoses  in  the  stomach  and  intestines, 
hemorrhagic  erosions,  bacilli  in  the  bloodvessels,  and  bubonic  changes 
in  the  lymph  structures.  The  latter,  generally  considered  rare,  were 
found  by  Wilm  in  20  per  cent,  of  his  cases,  and  mesenteric  adenitis  in 
60  per  cent.  Meteorism  and  diarrhoea  sometimes  develop.  The  liver 
is  slightly  swollen  from  cloudy  and  fatty  degeneration  or  from  stasis; 
bacilli  may  be  found  in  the  ecchymoses,  in  the  bile,  or  in  the  faeces. 

6.  The  Genito-urinary  Tract. — The  urine  is  decreased,  the  specific 
gravity  is  1,010  to  1,020,  the  chlorides  are  decreased,  indicanuria  is 
frequent,  and  moderate  albuminuria  is  very  common.  Nephritis  is 
quite  frequent.  Anatomically,  degeneration,  minute  focal  necrosis, 
and  glomerular  hemorrhage  resulting  from  capillary  embolism  of  the 
bacilli,  are  common.  Bacilluria  occurs  in  about  30  per  cent,  of  the 
cases.  The  bacilli  have  been  found  in  the  aborted  foetus.  Genital 
complications,  except  uterine  bleeding,  are  rare. 

Diagnosis. — The  cardinal  signs  are  the  fever,  buboes,  pesticsemia, 
and  the  results  of  examinations  by  means  of  cover  slips,  cultures,  agglu- 
tination, and  inoculation.  Though  the  finding  of  bacilli  in  the  blood 
is  important  in  cases  without  buboes,  the  cultural  results  are  more 
reliable.  The  agglutination  reaction  is  not  well  marked  until  the 
second  week  of  infection,  is  seen  most  advantageously  in  convalescence, 
and  may  still  be  seen  for  eight  weeks  or  more.  A  positive  test  is  final, 
though  negative  results  do  not  exclude  plague. 


224  THE  SPECIFIC  INFECTIONS 

Prognosis. — A  patient  may  become  ill  in  the  morning  and  die 
before  night.  The  average  duration  of  the  disease  is  about  a  week. 
If  the  patient  should  outlive  this  time,  the  chances  of  recovery  are 
good.  Recurrences  are  not  frequent  but  have  occurred,  and  the  im- 
munity conferred  is  only  relative.  Symptoms  which  are  unfavorable, 
are  especially  marked  nervous  and  cardiac  toxaemia,  digestive  disorder, 
hemorrhages,  cervical  buboes,  tonsillar  involvement,  and  pneumonia. 
The  death-rate  varies  with  the  epidemic.  It  is  often  80  per  cent,  and 
sometimes  90  or  95  per  cent.  It  is  highest  between  the  fiftieth  and 
sixtieth  years;  next  between  the  thirtieth  and  fiftieth.  In  Toulon 
(1721),  77  per  cent,  of  the  population  had  the  plague  and  62  per  cent, 
died — higher  percentages  than  in  any  other  epidemic  disease.  In 
Canton,  8  per  cent.  (1894),  and  in  Damaum,  30  per  cent,  of  the  popula- 
tion died;   430,500  died  in  Bombay,  from  1896  to  1899. 

Treatment. — 1.  Prophylaxis. — The  plague  patient  should  be  iso- 
lated and  carefully  covered  with  netting.  Infected  houses  should  be 
isolated,  unroofed  to  admit  the  sun,  fumigated  to  kill  insects  and  rats, 
and  the  walls  should  be  washed  with  antiseptics.  Vigorous  attacks 
should  be  made  on  rats.  Ships  should  be  held  in  quarantine  until 
the  rats  in  their  holds  are  killed,  the  bilge-water  disinfected,  and  all 
clothing  fumigated.  The  sputum  may  be  infective  for  three  months 
and  the  urine  for  one  and  a  half  months.  Carbuncles  and  buboes 
should  be  washed  with  bichloride  of  mercury  and  dressed  antiseptic- 
ally.  Prophylactic  inoculation  with  dead  cultures  and  with  serum 
from  immunized  animals  and  from  convalescent  patients,  is  a  measure 
assured  of  success  (Haffkine,  Yersin,  Roux  and  Lustig). 

2.  Symptomatic  Treatment. — Buboes  and  carbuncles  are  most  effi- 
caciously treated  with  dressings  of  weak  bichloride  of  mercury.  Sur- 
gical extirpation  may  disseminate  infection,  and  injections,  into  the 
buboes,  of  carbolic  acid,  do  not  stay  the  septicaemia.  Digitalis,  alcohol, 
and  hydrotherapy  are  employed  as  in  other  toxaemias.  Bichloride  of 
mercury  is  well  tolerated  and  has  been  used  freely  since  it  was  noted 
that  syphilitics  under  mercurial  treatment  seemed  to  withstand  the 
disease. 


DYSENTERY. 

Definition. — An  acute  contagious  disease,  (a)  with  varying  etiology, 
but  caused  chiefly  by  the  Amoeba  dysenterica  and  Shiga's  Bacillus 
dysenterise;  (h)  attended  anatomically  ])y  bowel  inflammation  (catar- 
rhal, necrotic,  or  ulcerative)  and  (c)  characterized  clinically  by  colic, 
pain,  tenesmus,  and  frequent  muco-bloody  passages. 

History. — The  name  dysentery  dates  from  Hippocrates  (480  B.  C), 
and  the  affection  is  clearly  mentioned  in  the  oldest  medical  script,  the 
Papyrus  Ehers  (1550  B.  C),  and  in  the  Veda.  It  has  been  the 
scourge  of  armies  from  the  times  of  the  Greco-Persian  wars.  The 
most  severe  and  wide-spread  epidemic  occurred  in  1847-1856.     In 


DYSENTERY  225 

our  civil  war  there  were  287,522  cases  among  the  Northern  troops. 
Among  the  English  soldiers  in  India  30  per  cent,  of  the  deaths  were 
due  to  dysentery.  It  prevailed  in  the  recent  South  African  and  Span- 
ish-American wars,  but  was  practically  absent  among  the  Japanese 
forces  (1904-1905).  Though  essentially  a  disease  of  the  tropics  and 
subtropics,  it  is  frequently  observed  in  temperate  zones,  especially 
in  prisons  and  in  asylums.  Lack  of  hygiene,  overcrowding,  eating  of 
spoiled  food  or  fruits,  impure  water,  and  alcoholic  or  other  excesses, 
are  predisposing  causes.  For  several  decades  the  disease  has  decreased 
in  Europe  and  America. 

Classification. — A  classification  and  description  of  dysentery  is  most 
difficult,  because  our  knowledge  of  all  its  causes  is  as  yet  imperfect. 
Two  well  known  forms  will  be  described  first,  and  various  indeter- 
minate allied  forms  afterward. 

I.  Shiga's  Bacillary  Form  of  Dysentery. — ^In  1897  Shiga,  of  Japan, 
described  the  Bacillus  dysentericB  as  the  sole  cause  of  the  Japanese  epi- 
demic form.  His  claims  are  based  on  these  facts:  (a)  it  is  always 
found;  (6)  it  occurs  in  no  other  affection;  (c)  its  numbers,  in  a  given 
case,  correspond  to  the  intensity  of  the  infection;  (d)  it  is  found  in  the 
intestinal  wall;  (e)  the  bacillus  and  its  toxins,  when  inoculated,  produce 
intestinal  hemorrhage;  (/)  there  is  a  specific  agglutination  which 
occurs  in  no  other  disease,  increasing  in  intensity  under  observation 
and  most  marked  in  convalescents;  (g)  the  serum  of  the  immunized 
cases  is  of  prophylactic  and  therapeutic  value;  (h)  actual  inoculations 
in  man  produce  dysentery,  as  in  Strong's  inoculation  of  a  criminal 
under  sentence  of  death,  and  in  Flexner's  assistant,  as  well  as  in  acci- 
dental laboratory  infections.  The  bacillus  resembles  the  colon  and 
typhoid  bacilli  in  form.  It  usually  occurs  singly,  but  sometimes  in 
pairs.  It  is  less  motile  than  the  Bacillus  typhosus  but  is  flagellated; 
it  is  a  facultative  anaerobe,  contains  no  spores,  stains  readily  but  not 
by  Gram's  method,  and  grows  on  all  media.  In  gelatin  it  grows  with 
deep,  pin-point  cultures,  is  brownish-yellow  without  liquefaction, 
and  has  well  marked  borders;  it  develops  best  in  glucose  agar  (gray- 
ish growth  along  the  puncture,  without  fermentation),  or  in  litmus 
milk  (some  slight  acidification,  followed  by  alkalinization  and  a  brown- 
ish color).  Inoculations  by  mouth  succeed,  even  without  first  disorder- 
ing digestion.  Inoculation  intraperitoneally  or  subcutaneously  is 
usually  fatal,  but  sometimes  causes  colitis.  Almost  pure  cultures  are 
obtained  from  the  movements.  They  are  most  abundant  when  the 
lower  intestine  is  greatly  involved,  and  are  less  in  the  early  stages 
from  diarrhoeal  stools  than  they  are  in  the  later  stages  from  muco- 
bloody  stools.  When  the  dejecta  become  purulent  (latest  stages),  the 
bacillus  disappears.  It  is  found  in  the  mesenteric  glands,  but  not  in 
the  blood,  spleen,  or  liver.  Infection  is  probably  carried  by  contami- 
nated drinking  water.  Flexner,  Barker,  Strong,  Musgrave  and  Craig 
have  found  this  type  in  the  Philippines;  Kruse  found  it  in  Germany, 
Flexner  in  America  (1901);  Goodliffe  and  others  also  report  it.  It 
has  been  found  in  Porto  Rico.     Duval,  Bassett,  Wollstein  and  other 

15 


226  THE  SPECIFIC  INFECTIONS 

clinicians  have  found  it  in  infantile  types.  There  are  three  strains 
of  the  bacillus :  (1)  The  Shiga  type,  which  attacks  glucose  but  not  other 
sugars;  (2)  Flexner-Harris  type,  which  attacks  glucose,  mannite  and 
dextrine  but  not  lactose,  and  which  forms  more  acid  than  the  Shiga 
type;  (3)  Hiss-Russell  type,  which  attacks  glucose  and  mannite  but 
not  lactose  or  dextrine.  The  blood  of  a  dysentery  subject  will  aggluti- 
nate all  types,  but  particularly  the  second.  The  bacillus  constituted 
54  per  cent,  of  Strong's  and  Musgrave's  series  of  1,328  cases  in  the 
Philippines.  Epidemics  have  existed  for  centuries  in  Japan,  chiefly 
between  the  months  of  June  and  October.  In  the  Philippines,  dysen- 
tery prevails  at  the  end  of  the  rainy  season. 

Symptoms. — After  an  incubation  of  two  to  eight  days,  there  is  a 
sudden  onset  with  fever,  reaching  100°  to  102°  (even  104°),  colic,  and 
diarrhoea.  Pain  becomes  marked  and  the  simple  diarrhoeal  stools 
soon  show  mucus,  and  then  bloody  mucus  or  pure  blood,  which  is 
voided  with  great  frequency  and  severe  rectal  spasm  (tenesmus). 
The  passages  are  small,  numbering  twenty  to  sixty  or  even  one  hun- 
dred a  day,  and  contain  Shiga's  bacillus.  The  rectum  may  prolapse. 
The  urine  is  scanty.  In  mild  cases  the  symptoms  abate  in  two  to 
three  weeks,  and  the  stools  become  purulent  and  contain  fewer  bacilli. 

The  symptoms  arise  from  local  inflammation  and  from  systemic 
reaction,  not  to  toxins,  according  to  Shiga,  but  to  solution  of  the  bacilli 
themselves  in  the  tissues.  In  the  more  severe  cases  the  systemic  reac- 
tion is  profound,  especially  when  lesions  occur  in  the  lower  small 
intestine,  the  absorptive  power  of  which  is  great.  A  typhoidal  condi- 
tion results,  with  coated  tongue,  nervous  toxaemia,  and  weak  pulse, 
and  death  frequently  occurs  as  early  as  the  fourth  or  seventh  day. 
Shiga  names  this  entero-dysentery,  as  distinguished  from  the  ordinary 
type,  colo-dysentery.  If  the  stools  become  putrid  or  gangrenous,  the 
outlook  is  hopeless.  Ecchymoses  on  the  chest,  epigastrium,  and  inner 
surface  of  the  limbs  are  quite  frequent.  Some  choleriform  cases  occur. 
The  disease  sometimes  lasts  for  weeks  or  months.  Emaciation  is 
marked  in  acute  and  chronic  forms,  which  is  due  to  diarrhoea,  inani- 
tion, pain,  and  intoxication. 

The  symptoms  are  largely  explained  by  the  anatomical  f  ridings . 
The  bacilli  lodge  in  the  small  folds  and  large  flexures  of  the  colon  and 
sigmoid.  Their  action  is  furthered  by  constipation.  The  mucosa  is 
intensely  hypersemic  and  shows  several  degrees  of  inflammation,  which 
varies  according  to  the  intensity  and  duration  of  the  infection.  It 
becomes  catarrhal,  hemorrhagic,  diphtheritic,  and  finally  necrotic  with 
ulceration.  The  rugtie  are  wide  and  swollen;  the  entire  mucosa  is 
swollen,  oedematous,  thickened,  and  shows  superficial  coagulation  ne- 
crosis, fibrinous  exudation,  and  cellular  infiltration;  the  submucosa 
is  infiltrated  and  vascular;  the  muscularis  is  sometimes  infiltrated 
and  the  serosa  is  ecchymotic  and  freshly  fibrinous.  In  marked 
cases  the  necrotic  areas  become  ulcers,  in  or  between  the  follicles; 
they  have  a  flat  base,  occupy  chiefly  the  folds,  usually  reach  only  the 
muscularis  mucosae,  and  in  intense  cases  impart  to  it  a  sieve-like 


AMCEBIC  DYSENTERY  227 

aspect.  The  swelling  may  be  such  as  to  obliterate  the  lumen  of  the 
intestine.  Cocci  and  colon  bacilli  are  in  the  upper  layers  but  never 
in  the  lower  ones,  where  we  find  the  Bacillus  dysenterise  in  and  around 
the  glands.  If  the  small  intestine  is  implicated,  the  mesenteric  glands 
swell.  In  the  virulent  cases  the  gut  becomes  gangrenous.  The  spleen 
is  never  involved.    Stenosis  may  follow  cicatrization  of  the  ulcers. 

Diagnosis. — Local  rectal  disease  (syphilis,  cancer,  or  papilloma)  may 
possibly  be  confusing.     In  contradistinction  to  amoebic  dysentery,  it  is 
generally  acute,  with  a  course  of  two  or  three  weeks;   toxsemic  symp- 
toms, such  as  fever,  headache  and  delirium,  and  hemorrhages,  are  com- 
mon, because  involvement  of  the  small  intestine  is  usual ;  anatomically 
the  ulcers  are  flat  and  are  on  the  folds  of  the  intestine.    Amoebic  dysen- 
tery is  characteristically  subacute  or  chronic.    The  small  intestine  less 
frequently  suffers  (Shiga) ;  liver  abscess  is  common  (20  to  33  per  cent.), 
and  anatomically  necrosis  begins  in  the  submucosa  and  produces  ulcers 
with  undermined  edges.     Agglutination  is  similar  to  that  of  the  Widal 
reaction  in  typhoid;  it  occurs  in  dilutions  of  1  to  20  (even  1  to  50,  100, 
or  1,000).     Shiga  observed  that  it  gradually  increased  as  the  disease 
progressed,  as  Foerster  noted  in  typhoid  fever.    It  may  appear  on  the 
third  day,  but  is  usually  seen  in  the  second  week  and  most  clearly  in 
convalescence.      It  is  therefore  rather  late  for  diagnostic  purposes. 
If  it  increases  while  under  observation  and  is  marked,  it  is  a  good  prog- 
nostic, and  the  converse  is  true. 

Prognosis. — The  prognosis  is  more  favorable  in  involvement  of  the 
rectum  and  sigmoid  flexure  than  when  the  upper  colon  or  csecum  is 
affected.  Intoxication  is  a  bad  prognostic.  The  effect  of  serotherapy 
(v.  i.)  is  another  factor.  The  mortality  is  high,  particularly  in  Japan, 
where,  in  1893,  there  were  167,300  cases  with  25  per  cent,  mortality, 
and  in  1900,  462,000,  with  22  per  cent,  mortality.  No  immunity  is 
conferred.  A  second  attack  was  observed  in  2.7  per  cent,  and  a  third 
in  0.3  per  cent,  in  Ogata's  collection  of  25,279  cases. 

Complications. — These  are  parotitis  or  muscle  suppuration,  which 
are  secondary  infections  occurring  in  severe  cases  and  in  the  third 
to  the  fifth  week;   ascites  in  debilitated  subjects  and  beriberi. 


II.  Amoebic  Dysentery. 

Lambl  (1859)  and  Loesch  (1876)  discovered  an  amoeba  in  the 
bowel  movements,  but  Kartulis,  in  Egypt,  studied  over  500  cases  and 
found  the  amoeba  in  them  and  found  the  secondary  liver  abscess. 
Kartulis  established  his  claims  for  the  Amoeba  dysenterise  on  the 
grounds  that  (a)  it  was  constant  in  certain  forms  of  dysentery,  in  the 
ulcers,  faeces  and  liver  abscesses;  (6)  it  was  inoculable  in  cats;  (c) 
negative  results  were  obtained  with  other  organisms  and  with  the 
amoeba  which  is  found  in  normal  faeces.  This  was  confirmed  by  Koch, 
Hlava,  Fenoglio,  Quincke,  Roos,  Pfeiffer,  Kovacs,  Kruse,  Pasquale, 
and   others  in   Europe,  and  in  America  first   by  Osier  (1890);   the 


228 


THE  SPECIFIC  INFECTIONS 


Fig.  18. 


important  monographs  of  Councilman  and  Lafleur,  Dock,  Simon, 
Musser,  Stengel,  and  Harris  soon  followed.  The  home  of  amoebic 
dysentery  is  in  the  tropics,  especially  in  Egypt,  India,  Formosa,  China, 
Arabia  and  in  Italy,  where  it  is  endemic  and  sometimes  epidemic. 
Sporadic  cases  occur  everywhere  in  the  temperate  zone,  especially  in 
Germany  and  in  America,  where  it  is  the  most  frequent  form.  The 
author  has  seen  six  cases  which  were  clearly  acquired  in  Chicago.  In 
the  Philippines  it  constituted  42  per  cent,  of  the  Strong  and  Musgrave 
series.  According  to  Flexner  and  Strong,  it  is  more  frequent  in 
chronic  than  in  acute  cases.  The  amoeba  is  found  in  the  pus,  glairy 
mucus,  or  blood-tinged  mucus  of  the  evacuations.     It  is  round  in  the 

quiescent  stage  or  irregular  from 
protrusion  of  pseudopodia,  partic- 
ularly when  the  slide  is  slightly 
warmed.  It  measures  12  to  30  /j. 
and  consists  of  a  hyaline  ectoplasm 
and  a  finely  granular  endoplasm. 
The  minutely  granular  nucleus 
measures  5  to  7  //.  Besides  the 
nucleus  one  or  several  vacuoles 
may  be  seen  in  the  cell.  Its  giisten- 
-: '  ing  appearance,  size,  movement, 
swarming  granules,  vacuoles,  and 
frequent  red  blood-cell  inclusions, 
readily  differentiate  it  from  swollen 
epithelia  or  leukocytes.  It  stains 
readily.  The  amoeba  probably 
It  has  been  cultivated  in  pure  cultures 


Amoeba  coli.     (Hallopeau.) 


enters  in  the  food  or  drink. 
(Wooley  and  Musgrave). 

Symptoms. — The  symptoms  of  acute  amoebic  dysentery  begin  rather 
abruptly  with  much  the  same  picture  as  in  Shiga's  type,  although 
the  fever  is  generally  lower  and  shorter,  rarely  lasts  more  than  two 
or  three  days,  and  is  sometimes  absent.  The  movements  are  alkaline, 
pultaceous,  fluid,  and  yellow,  at  first,  and  later,  mucous  and  bloody. 
Sometimes  in  one  movement  faeces  are  voided  first,  followed  by  mucus 
and  blood,  or  blood-tinged  fluid  containing  amoebae,  slightly  yellow, 
glairy  clumps  like  swollen  sago  or  frog  spawn,  pus  cells,  detritus,  and 
sometimes  the  Charcot-Leyden  crystals.  The  stools  may  be  chocolate- 
colored.  Sometimes  large  masses  of  necrotic  tissue  are  voided.  The 
stools  number  5  to  20  or  more  daily;  their  odor  is  fetid  when  foeces 
are  present;  they  are  odorless  when  only  blood  or  mucus  is  present; 
and  are  stinking  when  gangrene  occurs.  The  repeated  and  painful 
movements  cause  straining,  sweating,  and  sometimes  syncope.  Colic 
and  borborygmus  are  nearly  always  present;  pain  is  referred  to  the 
navel;  tenderness  is  usually  marked  over  the  sigmoid,  colon  and  fre- 
quently over  the  caecum,  and  tenesmus  and  a  burning  anal  pain  mark 
involvement  of  the  lower  bowel.  The  rectum  may  prolapse  and  vesical 
symptoms,  such  as  strangury,  may  appear.     The  abdomen  is  some- 


AMCEBIC  DYSENTERY  229 

times  distended.  Very  light  cases  may  only  show  catarrhal  move- 
ments, but  blood,  pus,  membrane,  or  shreds,  indicate  necrosis  and 
ulceration.  ^,  Severe  cases  may  begin  with  chills,  fever  of  103°  or  104°, 
vomiting,  herpes,  and  symptoms  like  those  of  cholera;  e.  g.,  dry  tongue, 
depression,  20  to  100  movements  daily,  leg  cramps,  scanty  urine,  fail- 
ing pulse,  rapid  emaciation  from  loss  of  rest  and  of  fluid,  and  from 
pain.  Early  death  may  result.  Peracute  cases,  with  chill,  high  fever, 
great  abdominal  pain,  collapse,  and  even  sudden  .death,  are  excep- 
tional, but  may  result  from  extensive  rapid  necrosis  or  gangrene.  In 
the  average  acute  case,  the  course  of  one  and  a  half  to  three  weeks, 
or  to  several  weeks,  varies  with  several  factors,  but  especially  with 
the  individual  resistance  and  the  treatment.  Perforative  peritonitis 
sometimes  occurs,  as  well  as  profuse  exhausting  hemorrhages.  Light 
cases,  if  neglected,  easily  become  severe  or  chronic,  and  spontaneous 
recovery  is  quite  uncommon. 

Chronic  amcehic  dysentery  may  result  from  the  acute  form  or  stage, 
or  be  subacute  (subchronic)  from  the  beginning.  The  symptoms  are 
essentially  the  same,  but  less  intense.  As  a  rule  there  is  marked,  and 
sometimes  extreme  emaciation,  particularly  in  the  tropics.  On  the 
other  hand,  some  patients  maintain  their  weight  and  suffer  only  from 
recurrent  diarrhoea  every  few  weeks  or  months,  or  from  irregular 
moderate  intestinal  derangement.  In  the  average  case  the  tongue 
is  lacquered  and  red,  the  abdomen  is  somewhat  distended  and  tender, 
the  lower  colon  and  sigmoid  are  palpable  as  a  thick  cord,  and  some- 
times mental  depression  or.hypochondriasis  is  observed.  The  outcome 
is  (1)  recovery  after  two  to  four  months;  (2)  recurrent  attacks  for 
months  or  years;  (3)  complications,  such  as  liver  abscess  (20  to  33 
per  cent.),  especially  in  the  tropics  (peritonitis,  empyema,  or  lung 
abscess).  Perforative  peritonitis,  exhausting  bowel  hemorrhages,  brain 
or  splenic  abscess,  pseudorheumatism  (Sydenham,  Trousseau),  myel- 
itis (Gubler,  Mitchell),  neuritis,  and  less  frequently,  endocarditis, 
or  chronic  nephritis,  are  other  complications;  (4)  gradually  in- 
creasing anaemia,  emaciation  and  death  from  exhaustion. 

Pathology. — The  early  changes  of  the  mucosa  are  catarrh,  inflam- 
mation with  injection,  swelling,  and  hemorrhage,  mostly  in  the  large 
intestine.  The  essential  change  is  not  superficial  in  the  mucosa,  but  ■ 
in  the  suhmucosa,  as  John  Hunter  first  noted,  though  Councilman  and 
Lafleur  first  brought  out  this  point  clearly.  The  amoebae  enter  by  the 
tubular  glands  and  reach  the  submucosa  where,  by  their  action  alone, 
without  bacterial  cooperation,  they  cause  cellular  accumulations  which 
are  not  leukocytes,  but  chiefly  fibrinous  exudation  and  connective- 
tissue  cells.  Sometimes  the  amoebae  enter  the  bloodvessels  early  and 
pass  through  them  to  the  submucosa.  These  foci  undergo  coagula- 
tion necrosis  and  slightly  elevate  the  mucosa  which  at  first  covers  the 
small  submucous  cavities,  but  afterward  sloughs,  and  exposes  the 
primary  grayish-yellow  necrosis  in  the  submucosa.  When  the  necrotic 
tissue  sloughs  out,  the  dysenteric  ulcers  are  more  apparent.  They  lie, 
according  to  Kartulis,  in  the  whole  of  the  large  intestine  (50  per  cent. 


230  THE  SPECIFIC  INFECTIONS 

of  cases) ;  in  the  colon  descendens  and  in  the  sigmoid  flexure  (25  per 
cent.);  in  the  csecum,  with  ascending  or  descending  colon,  or  in  the 
rectum  (25  per  cent.) ;  in  the  rectum  alone  (20  per  cent.) ;  in  the  caecum 
alone  (5  per  cent.),  and  only  rarely  in  the  small  bowel  or  in  the  appen- 
dix; Musgrave  found  the  appendix  involved  in  7  per  cent.,  the  ileum 
in  3.5  per  cent.,  and  the  entire  bowel  in  80  per  cent.,  of  his  series  of  200 
cases.  The  deep  ulceration  generally  exceeds  the  superficial  ulcera- 
tion, and  the  ulcers  in  the  early  stage  may  communicate  with  the  intes- 
tinal lumen  only  by  fistulous  tracts  which  undermine  the  apparently 
healthy  mucous  membrane.  Even  when  the  ulcer's  opening  is  large, 
its  edges  are  generally  undermined.  Ulceration  of  the  solitary  follicles 
is  less  frequent  than  submucous  necrosis.  The  ulcers  may  be  round, 
serpiginous  and  are  usually  discrete.  They  may  penetrate  to  the  mus- 
cularis  or  to  the  serosa,  which  is  sometimes  perforated,  thus  causing 
diffuse  or  localized  peritonitis.  The  peritoneum  is  often  pigmented 
and  shows  fresh  fibrin  deposits  or  local  adhesions.  Secondary  changes 
may  include  membranous  diphtheroid  deposits  (usually  streptococcic), 
diffuse  sloughing  of  entire  blocks  of  the  intestinal  wall,  gangrene,  and 
great  hyperplasia  of  the  mucosa.  In  chronic  cases  the  muscularis  fre- 
quently thickens,  which  may  greatly  narrow  the  lumen  of  the  intestine. 
The  small  intestine  may  atrophy  or  hypertrophy.  Healing  ulcers 
produce  pigmented  stellate  scars  which  sometimes  cause  stenosis. 
Amoebae  have  been  seen  in  the  mesenteric  bloodvessels,  by  which 
they  reach  the  portal  circulation  (pylephlebitis,  liver  abscess).  The 
liver  shows  focal  necroses  which  are  probably  toxsemic,  and,  in  a  large 
percentage,  it  shows  solitary  or  multiple  abscesses.  _The  single,  large 
abscess  generally  develops  in  the  right  lobe  near  the  diaphragm  or 
colon.  The  multiple  small  abscesses  are  also  superficial.  In  both 
types  there  is  central  necrosis  and  softening,  the  contents  are  yellow, 
green  or  chocolate-colored,  contain  fat  droplets,  liver  detritus,  and  the 
amoebae  lie  on  the  abscess  walls.  In  the  older  cases  there  is  a  firm 
connective  tissue  capsule  but  round  cell  infiltration  is  as  infrequent 
as  it  is  in  the  intestine.  Amoebae  may  be  found  in  the  sputum  when 
the  liver  abscess  ruptures  into  the  lung,  or  in  the  pus  of  secondary 
empyema.  The  pathology  of  complicating  myelitis  is  disputed,  but 
the  pseudorheumatism  and  neuritis  are  probably  toxaemic.  The  diag- 
nosis is  easy  on  careful  microscopic  examination  of  the  stools.  The 
mortality  ranges  from  1  to  20  per  cent.;  7  per  cent,  of  the  deaths  in 
Cairo  are  dysenteric. 

III.  Indeterminate  Dysenteries. 

The  classification  and  cause  of  these  forms  are  not  yet  defined;  but 
some  are  apparently  primary  and  others,  are  secondary  infections. 
Various  microorganisms  have  been  found,  such  as  the  colon  bacillus, 
proteus,  pyocyaneus,  pneumococcus,  streptococcus,  and  staphylococcus, 
but  their  action  is  still  undetermined.     Varieties:  (a)  Catarrhal  dYscn- 


INDETERMINATE  DYSENTERIES  231 

tery,  m  which  the  mucous  membrane  is  injected,  cloudy,  and  infiltrated; 
the  solitary  follicles  are  swollen  and  often  ulcerated, —  the  "acute  fol- 
licular colitis"  seen  especially  in  children;  the  ulcers  are  round,  deep, 
and  small.  In  some  instances  there  is  also  inflammation  in  the  small 
intestine.  The  symptoms  are  usually  mild  pain,  and  muco-bloody 
evacuations.  (6)  The  croupous  or  diphtheroid  dysentery  represents 
a  severe  stage  or  degree.  The  epithelium  necroses,  the  submucosa  is 
considerably  infiltrated,  and  there  are  membranous  deposits  on  the 
rugae  over  slight  superficial  ulcerations,  or  there  may  be  deeper,  wider 
ulcers  with  great  thickening  of  all  the  intestinal  layers.  This  may 
occur  (1)  as  a  primary  infection,  with  dysenteric  symptoms,  marked 
typhoidal  symptoms,  fever  and  chill,  and  frequently  has  a  fatal  out- 
come; or  (ii)  as  a  secondary  incident  in  various  infections;  e.  g.,  in 
pneumonia  particularly,  in  typhoid,  scarlatina,  diphtheria,  cholera, 
syphilis,  cardiac  affections,  cachectic  conditions,  mercurial  or  other 
poisonings  and  in  ursemia.  This  secondary  form  may  produce 
marked  symptoms  or  may  be  clinically  latent,  (c)  The  gangrenous 
dysentery  is  attended  by  the  same  changes,  but  results  in  enormous 
swelling,  softening,  and  sloughing  of  dark,  gangrenous  shreds,  meas- 
uring one-quarter  to  three-quarters  inch  in  thickness,  and  sometimes 
resulting  in  tubular  sloughs  of  the  larger  part  of  the  intestinal  cir- 
cumference. Perforation  sometimes  occurs.  In  the  Cochin  China 
endemic  form,  enlarged  glands,  splenic  tumor  and  intumescence  of 
the  liver  are  found.  Coprostasis,  foreign  bodies  and  parasites  are  pro- 
moting factors  in  all  these  types.  In  some  cases  the  Cercomonas, 
Trichocephalus  dispar,  or  Anguillula  stercoralis  may  be  found.  The 
Distoma  htematobium  (Bilharz)  may  cause  symptoms  closely  resem- 
bling those  of  dysentery;  bloody  urine,  and  strangury  result  from 
invasion  of  the  vesical  venous  plexus  by  the  Distoma;  anatomically, 
hypertrophy  of  the  mucosa,  even  to  the  extent  of  small  or  large  poly- 
poids,  may  result,  as  well  as  superficial  ulceration  and  infiltration  of 
the  submucosa. 

Treatment  of  all  Forms. — l.  Specific  Treatment. — This  is  limited 
to  the  bacillary  type.  Shiga's  bactericidal  serum  seems  to  have  re- 
duced the  mortality  at  least  one-half  and  to  have  shortened  the  course; 
in  mild  cases  one  and  a  half  to  two  and  a  half  drams  [6  to  10  c.c] 
are  injected  once;  in  medium  cases  two  and  a  half  drams  [10  c.c] 
twice,  and  in  severe  cases  one  to  two  ounces  [30  to  60  c.c]  daily.  The 
best  results  are  obtained  by  early  injection. 

2.  Prophylaxis. — Drinking  water  should  be  boiled,  and  fruits  and 
vegetables  should  be  cooked.  In  the  tropics,  sudden  variations  of 
temperature  are  to  be  carefully  avoided. 

3.  Diet.— Acute  and  chronic  cases  must  be  carefully  dieted  and  the 
patient  must  be  kept  in  bed.  Boiled  milk,  raw  or  slightly  cooked  eggs, 
or  the  whites  of  eggs  beaten  with  water  should  be  given  to  relieve 
colic  and  tenesmus.  The  nearest  approach  to  solid  food  which  is 
allowable  is  well-cooked  rice  or  sago.  Broths  and  cold  drinks  irritate 
the  stomach  and  excite  peristalsis.     Some  lemonade  is  permissible. 


232  THE  SPECIFIC  INFECTONS 

In  convalescent  acute  or  in  chronic  cases,  solids  should  be  given  late, 
commencing  with  well-cooked  tender  meat  and  starches,  and  avoid- 
ing vegetables  and  fruit  until  convalescence  is  absolutely  established. 

4.  Eliminative  Treatment. — Sodium  or  magnesium  sulphate  are 
given  in  early  cases  to  cleanse  the  bowel  and  to  minimize  the  danger 
of  ascent  from  the  lower  intestine  (5j  every  two  hours  until  the  bowel 
is  thoroughly  emptied).  Aromatic  sulphuric  acid  mxx  p.  c.  is  sometimes 
given  after  the  saline  treatment.  Castor  oil  is  a  mild  laxative  but  is 
of  little  use  except  in  the  early  stages.  Calomel  is  considered  beneficial 
by  some  writers,  by  whom  it  is  given  in  frequent  doses  and  in  small 
amounts  until  slight  mercurialization  is  noted. 

5.  Antisepsis. — Beta-naphthol  and  salol  (phenylis  salicylas)  aa  gr. 
X,  t.  i.  d.  or  q.  i.  d.,  are  sometimes  helpful,  although  probably  but  small 
parts  of  the  drugs  reach  the  larger  intestine.  Bichloride  of  mercury, 
gr.  3^0  to  sV,  is  efficient  in  some  cases. 

6.  Ipecac. — This  was  introduced  from  Brazil,  by  Piso,  in  1648.  It 
is  considered  almost  specific  in  India  and  Brazil,  but,  like  the  drugs 
above  named,  has  little  effect  in  the  amoebic  type.  Frayer  held  that 
it  reduced  the  mortality  from  11  per  cent,  to  5  per  cent,  in  his  series. 
In  India  it  is  given  as  follows:  food  is  withheld  for  four  or  five  hours, 
and  then  a  hypodermic  of  morphine,  or  opium  by  mouth,  is  admin- 
istered to  quiet  the  stomach  and  lessen  nausea;  15  grains  of  pow- 
dered ipecac  are  administered  every  hour  for  two,  three,  or  possibly 
four,  doses.  If  the  first  dose  is  vomited,  the  opium  and  ipecac  are  given 
again.  A  mustard  plaster  should  be  applied  to  the  epigastrium  or  a 
turpentine  stupe  to  the  abdomen.  In  Brazil,  a  decoction  is  preferred. 
The  Pulv.  ipecac,  et  opii  and  salol  may  be  given  aa  gr.  x  for  a  few  doses. 

7.  Pain. — Pain  necessitates  the  use  of  opium,  which  also  decreases 
tenesmus  and  peristalsis.  It  is  given  most  efficaciously  by  rectum  in 
a  suppository,  or,  if  poorly  retained,  by  enema,  mixing  Tr.  opii  deo- 
dorat.  TTg  XX  with  an  ounce  of  starch  water. 

8.  Local  Measures. — Under  this  caption  the  use  of  6 i5?/iw^/i  by  mouth 
may  be  mentioned,  because  its  action  is  for  the  most  part  local ;  doses 
of  5j  to  ij  are  necessary,  and  even  two  ounces  daily  are  given.  Mus- 
grave  dislikes  the  use  of  bismuth  because  it  cakes  in  the  ulcers.  La- 
vage is  difficult  because  of  tenesmus  and  bowel  intolerance,  and  is 
Bot  without  danger,  for  perforation  has  resulted  from  copious  irriga- 
tions. The  rectal  tube  must  be  introduced  carefully  as  the  rectum  is 
very  sensitive.  Tenesmus  may  be  avoided  by  injection  of  a  cocaine 
x)r  laudanum  solution,  or  a  cocaine,  opium,  or  iodoform  (five-grain) 
suppository. 

Ac.  tannici gr.  xv. 

Extr.  opii gr.  iv. 

Extr.  belladonnae .    .    .  gr.  j. 

Olei  theobromatis q.  s. 

M.  et  ft. —  Suppos.  No.  iv. 

Carbolic  acid  and  bichloride  of  mercury  solutions  are  seldom  em- 
ployed ;  Bellei  employs  as  an  antiseptic  and  anaesthetic  douche,  carbolic 


MALTA   FEVER  233 

acid  TT^xx,  tannin  3j)  marshmallow  root  oij  to  a  quart  of  warm  water. 
Among  the  other  solutions  of  value  are  quinine  (1  to  1,000  or  5,000, 
Osier),  or  a  weak  peroxide  solution  for  the  amoebic  variety,  and 
Thiersch's  solution  of  boric  and  salicylic  acids;  all  enemata  should  be 
warm.  Strong  silver  solutions  (1  to  500  or  less)  cause  great  pain, 
and  weak  dilutions  are  inert;  silver,  however,  is  most  suitable  for 
chronic  cases.  In  the  author's  experience,  Kartulis's  method  is  the 
most  valuable; — e.g.,  ^  per  cent,  solution  of  tannic  acid,  injecting  as 
much  as  the  bowel  will  tolerate  and  retain.  It  kills  the  amoebee  and 
two  or  three  injections  are  usually  sufficient.  Kartulis  has  "never 
been  disappointed  in  hundreds  of  cases."  It  may  be  given  in  the 
genupectoral  position  as  an  enteroclysis,  as  advocated  by  Cantani  in 
cholera.  An  irrigator  at  an  elevation  of  two  feet  should  be  used  and 
the  ordinary  rectal  syringe  should  be  avoided. 

9.  Turpentine  Emulsion. — ^This  may  be  used  for  tympanites,  and 
the  ice-bag,  or  Leiter's  coil  with  opium,  may  be  used  for  hemorrhage 
or  peritonitis. 

10.  Colostomy. — In  chronic  cases,  colostomy  has  been  advocated. 


MALTA   FEVER. 

Definition. — A  specific  infection,  which  is  endemic  on  the  coast 
and  in  the  islands  of  the  Mediterranean  Sea,  is  caused  by  the  Micro- 
coccus melitensis,  somewhat  resembles  typhoid,  but  is  character- 
ized by  a  much  longer  course,  by  recurrent,  irregular,  "undulant" 
fever,  severe  sweats,  splenic  tumor,  and  rheumatoid  or  neuralgic 
pains. 

History. — Observed  about  a  century  ago,  it  was  first  described  by 
Marston  (1858)  as  a  separate  disease.  Marston,  Bruce  and  Hughes, 
English  army  surgeons,  have  been  the  largest  contributors  to  our 
knowledge  of  Malta  fever.  Its  distribution  is  fairly  well  covered  by 
its  names, — Mediterranean,  Rock  or  Gibraltar  fever,  Malta  fever,  Neo- 
politan  or  Levant  fever.  It  has  also  been  seen  on  the  Danube,  Red 
Sea,  Bosphorus;  in  China,  India,  the  Philippines;  in  the  Canaries, 
Azores,  and  Antilles;  in  Venezuela  (Caracas  fever),  Brazil,  and  South 
Africa.  Less  than  a  dozen  cases  have  come  to  this  country.  Musser 
and  Sailer  published  an  account  of  the  first  one. 

Etiology. — ^The  Micrococcus  melitensis,  which  was  discovered  by 
Bruce  (1887),  is  round  or  oval,  measures  0.3  tJ-,  often  occurs  in  chains, 
is  non-motile,  and  stains  with  methylene  blue,  or  gentian  violet,  but 
not  by  Gram's  method.  It  grows  best  on  1.5  per  cent,  beef-water, 
with  peptone  and  agar,  in  which  state  cultures  grow  in  the  form  of 
small  pearl-like  spots.  These  after  a  few  weeks  become  yellowish- 
brown.  The  bacillus  is  not  found  in  the  blood,  but  in  the  urine,  even 
after  recovery,  and  in  the  liver  and  spleen.  The  apes  inoculated  by 
Bruce  and  Hughes  showed  a  typical  clinical  course  and  postmortem 
findings.    The  disease  prevails  chiefly  between  the  sixth  and  thirtieth 


234  THE  SPECIFIC  INFECTIONS 

years,  in  the  hot,  dry  weather  from  May  to  mid-October,  and  in  old 
and  unhygienic  buildings.  It  is  not  directly  contagious.  The  atrium 
is  the  lungs  (by  dust,  Hughes),  or  the  alimentary  tract  (by  food  or 
drinking-water,  Bruce).  In  Strong's  laboratory  infection,  the  con- 
junctiva was  the  point  of  entrance.  It  has  been  recently  suggested 
that  mosquitoes  and  goats  convey  infection. 

Symptoms. — Symptoms  appear  after  an  incubation  of  six  to  ten 
days.  Some  of  them  so  resemble  those  of  typhoid  and  malaria  that 
the  three  diseases  were  formerly  confounded.  The  fever  rises  grad- 
ually, reaching  104°  to  105°  after  a  few  days.  The  face  is  red,  there 
are  chilly  sensations,  frontal  headache,  insomnia,  depression,  and 
pains  in  the  back  and  legs.  Epistaxis  is  occasional.  The  tongue  is 
coated,  is  at  first  moist,  then  dry,  and  fissured,  and  sometimes  bleeds. 
The  tonsils  are  frequently  swollen,  and  the  pharynx  is  red  or  at  times 
ulcerated.  Anorexia,  nausea,  epigastric  pain  and  tenderness,  and  con- 
stipation, are  the  rule,  and  vomiting,  icterus,  meteorism  and  diarrhoea, 
with  dark,  malodorous,  mucous,  and  even  bloody  stools,  are  sometimes 
seen.  One  of  the  chief  anatomical  findings  is  intestinal  hypersemia, 
and,  in  rare  cases,  swelling  or  ulceration  of  Peyer's  patches  occurs 
(4  per  cent.).  There  is  considerable  bronchitis  and  the  sputum  is 
often  streaked  with  blood.  Dyspnoea  is  quite  frequent.  The  pulse- 
rate  is  at  first  between  80  and  90;  later  it  becomes  faster,  and  is  fre- 
quently attended  by  palpitation.  Severe  sweats  occur,  usually  after 
midnight,  and  are  accompanied  by  sudamina  {febris  sudoralis).  Ros- 
eolse  are  never  observed.  An  acute  splenic  tumor  and  hepatic  intumes- 
cence develop,  which  are  due  to  degeneration  and  infiltration  by 
round-cells. 

i^fter  one  to  three  weeks,  the  fever,  which  at  first  is  continuous, 
remits,  other  symptoms  abate,  and  convalescence  is  apparently  estab- 
lished; but  the  symptoms  again  return,  and  frequently  recur  severa 
times.  The  fever  curve  shows  waves  accompanying  each  relapse 
(literally  "  undulant  fever").  The  patient  becomes  weak,  emaciated 
and  pallid.  There  is  no  leukocytosis,  the  urine  does  not  show  the  diazo 
reaction,  and  albuminuria  is  very  uncommon. 

Complications. — Complications,  which  are  uncommon  in  typhoid, 
are  frequent.  Pseudorheumatism  in  one  or  more  joints  occurs  in  50 
per  cent,  of  the  cases  (Bruce)  and  is  accompanied  by  redness,  swelling, 
and  pain  in  the  shoulders,  knees,  hips,  and  sacroiliac  joints,  and  some- 
times also  in  the  bursse,  periosteum  and  fibrous  tissues.  Neuralgias 
are  common.  Orchitis  and  epididymitis  occasionally  develop,  and  are 
usually  unilateral  and  ephemeral.  Mastitis  is  very  rare.  Occasionally 
polyneuritis  develops  and  is  evidenced  by  partial  anaesthesia,  hyper- 
sesthesia,  especially  of  the  soles  of  the  feet,  parjesthesia  and  rarely 
paralysis.  These  result  from  intoxication  and  exhaustion.  Psych- 
oses and  disturbance  of  the  special  senses  may  result  from  ^lalta 
fever. 

Skin  eruptions  occur  late  in  the  relapses  and  are  chiefly  erythem- 
atous or  hemorrhagic,   and  are  sometimes  accompanied  by   hemor- 


MALTA  FEVER  '  235 

rhages  from  the  nose,  tongue,  gums  or  lungs;  desquamation  in  scales, 
in  large  shreds,  particularly  from  the  soles  of  the  feet,  and  falling  of 
the  hair,  are  common.  Glomerular  nephritis,  pneumonia,  and  endo- 
carditis are  very  unusual.  In  convalescence,  tuberculosis  not  infre- 
quently develops. 

Course  and  Prognosis. — In  the  majority  of  cases  relapses  occur 
after  two  or  three  weeks.  The  fever  sometimes  remains  near  104° 
continuously  for  months.  The  average  duration  of  the  disease  is 
ninety  days,  but  Bruce  records  a  case  which  lasted  over  two  years. 
Hughes  describes  three  types:  (a)  the  undulant,  as  above  described, 
which  is  the  most  common  type;  (b)  the  malignant,  which  ends  in 
death  in  from  one  to  three  weeks  from  weak  heart,  from  hyperpyrexia 
(110°  or  111°),  or  possibly  from  lobular  pneumonia;  (c)  the  inter- 
TThittent,  which  lasts  for  months.  The  severity  of  the  infection  varies; 
Melland  found  that  50  per  cent,  of  cases  in  the  Canary  Islands  lasted 
from  two  to  three  weeks,  and  in  only  10  per  cent,  did  the  protracted 
undulating  type  occur.  The  death-rate  is  constantly  decreasing.  In 
the  seventh  decade  of  the  last  century  it  was  over  3  per  cent.,  but  it  is 
now  under  1  per  cent.  Immunity  after  one  attack  is  usual,  but  is  not 
absolute. 

Diagnosis. — The  diagnosis  of  Malta  fever  is  often  difficult,  espe- 
cially the  difPerentiation  from  typhoid.  In  Malta  fever  the  roseolse, 
and  the  bacillsemia  are  absent;  the  blood  does  not  respond  to  the 
Widal  test;  nor  does  the  urine  show  the  diazo  reaction.  The  course 
of  Malta  fever  is  longer  than  that  of  typhoid,  the  sweats  are  more 
severe,  and  the  joints  are  inflamed;  orchitis,  and  neuralgias  develop. 
A  positive  diagnosis  can  be  made  by  the  use  of  Wright's  serum  reaction. 
The  blood  responds  to  this  test  after  the  fifth  day,  and  continues  to 
do  so,  in  some  cases,  for  three  years.  Agglutination  may  be  obtained 
equally  well  with  the  living  or  dead  cultures;  the  dilution  of  the  blood 
is  1  to  50,  and  the  time  for  the  test  is  limited  to  one  hour.  The  severe 
bronchitis,  fever,  and  sweats  may  cause  confusion  with  tuberculosis. 
Indeed,  the  older  writers  spoke  of  Malta  fever  as  "Mediterranean 
phthisis."  The  bronchi  in  Malta  fever  are  intensely  hypersemic  and 
the  sputum  is  frequently  blood-tinged.  Malaria,  ulcerative  endocar- 
ditis, febrile  pseudoleuksemia,  and  liver  abscess,  are  differentiated 
by  the  agglutination  test. 

Treatment. — ^There  is  no  specific  treatment,  though  serum  therapy 
is  likely  to  prove  valuable  (Aldridge,  Fitzgerald,  Ewart).  Quinine 
and  arsenic  are  ineffectual.  Headache  and  backache  are  relieved  by 
antipyrin  and  morphine;  insomnia  by  bromides,  chloral  and  hyo- 
scine;  diarrhoea  by  tr.  ferri  chlor. ;  pseudorheumatism  by  heat,  by 
wool  investment,  by  tr.  iodi,  locally,  and  by  salicylates,  internally; 
orchitis,  by  local  heat  and  by  suspensory  elevation.  The  general 
therapy  is  the  same  as  it  is  in  typhoid.  Milk  diet  lessens  the  chance 
of  intestinal  complications,  though  Dalton  advocates  a  solid  diet.  In 
convalescence  a  change  of  climate  is  necessary. 


236  'THE  SPECIFIC  INFECTIONS 


BERIBERI. 

Definition. — Beriberi,  or  polyneuritis  endemica  (Baelz,  Scheube),  is 
an  endemic  and  epidemic  affection  of  the  tropics  and  subtropics,  of 
unknown  etiology,  characterized  anatomically  by  degenerative  inflam- 
mation of  the  peripheral  nerves,  and  clinically  by  motor  and  sensory 
disturbances,  anasarca,  cardiac  disturbance  and  by  a  subacute  or 
chronic  course.  Beri  is  said  to  signify  a  sheep's  gait,  and  kakke  also 
means  disturbance  of  the  gait. 

History. — Beriberi  is  mentioned  in  the  oldest  Chinese  writings  and 
was  observed  in  the  Roman  legions,  24  B.  C,  by  Strabo  and  Cassius. 
In  the  seventeenth  century,  beriberi  was  noted  in  Brazil  and  in  the 
Malay  archipelago;  in  recent  times  (1835)  it  has  been  described  by 
Malcolmson  in  India;  by  Baelz,  Scheube,  Grimm,  and  Miura  in 
Japan;  by  the  physicians  in  the  Dutch  Oriental  colonies;  and  by 
Birge,  Putnam,  and  Bonduret  in  this  country. 

Distribution. — The  main  foci  of  beriberi  are  (1)  the  Malay  archi- 
pelago, Sumatra,  Borneo,  and  Java;  also  China,  India  (where  it  is 
decreasing),  the  Philippines,  Japan,  and  even  Australia.  The  mor- 
tality has  been  very  high  among  the  Chinese  coolies  in  the  Dutch 
possessions,  where  epidemics  developed  from  endemics.  (2)  Africa, 
including  the  mainland  and  the  islands.  (3)  America  and  the  West 
Indies,  Brazil,  Honduras,  and  Cuba.  Cases  have  appeared  in  Dublin 
(1894-1898,  with  forty-two  deaths),  in  England,  and  in  Paris.  Scheube 
doubts  that  the  cases  which  developed  in  the  United  States,  in  the  epi- 
demic at  Tuscaloosa,  Alabama,  were  beriberi,  but  from  description, 
they  are  apparently  identical  with  oriental  beriberi. 

Etiology. — ^The  etiology  is  greatly  disputed  and  there  are  two  dis- 
tinct views:  (1)  that  it  is  an  acute  injection  (Baelz,  Scheube),  because 
it  occurs  in  the  young  (fifteen  to  thirty-five  years)  and  healthy,  it 
occurs  in  certain  localities  as  epidemics  and  endemics,  it  occurs  in  the 
summer  months,  and  in  moist,  alluvial  land  near  the  sea,  and  near 
the  river  mouths, — i.  e.,  the  same  telluric  conditions  promote  beriberi, 
which  promote  malaria.  It  is  considered  by  some  persons  to  be  con- 
tagious, though  no  constant  microorganism  has  been  found.  The 
fact  that  many  cases  develop  in  houses,  barracks,  and  ships  is  an  argu- 
ment in  favor  of  the  theory  of  contagion.  In  the  80,000  cases  which 
developed  among  the  Japanese  troops  in  the  Russo-Japanese  War, 
Kokubo  frequently  found  a  coccus.  (2)  The  second  view  is  that  beri- 
beri results  from  food.  Shelled  rice  is  said  to  have  caused  it  in  the 
Dutch  East  Indies,  and  raw  fish  is  considered  the  cause  of  the  disease 
among  the  Japanese  (Miura).  The  use  of  fish  in  the  navy  was  for- 
bidden by  Takaki,  and  the  mortality  fell  from  25  per  cent,  to  almost 
nothing.  Natives  are  more  often  affected  than  Europeans,  and  males 
more  frequently  than  females.  Improper  diet  may  be  a  cause  of 
beriberi  or  at  least  an  indirect  factor.  In  1879  there  were  8,197  cases 
in  Japan  and  in  1891  this  number  decreased   to  one.      Poor  food, 


BERIBERI  237 

overcrowding  and  lack  of  hygiene  are  important  and  avoidable 
factors. 

Sjnnptoms. — The  incubation  is  long,  probably  several  months,  and 
the  development  of  the  disease  is  due  to  repeated  infections.  The 
symptoms  are  threefold:  (a)  those  of  multiple  neuritis;  (b)  dropsy, 
and  (c)  cardiac  insufficiency. 

(A).  Neuritic  Symptoms.— A  more  detailed  description  of  these 
symptoms  will  be  given  under  Multiple  Neuritis.  Anatomically 
there  is  the  same  symmetrical  degeneration  (or  inflammation)  in  the 
distal  parts  of  the  peripheral  nerves  to  which,  however,  it  is  not 
limited;  the  phrenic  and  pneumogastric  nerves  and  the  cardiac,  renal, 
and  solar  plexuses,  are  often  involved;  the  nuclei  of  the  sheath 
multiply;  the  axis  cylinders  degenerate;  there  is  a  lumpy  de- 
generation in  the  medullary  sheath;  and  later,  there  is  connective- 
tissue  hypertrophy.  In  eight  cases  there  were  degenerative  changes 
in  the  cord,  anterior  horns,  and  posterior  ganglia.  Clinically,  the 
neuritis  comes  on  gradually  and  runs  a  chronic  course,  which  is 
varied  by  acute  exacerbations. 

1.  Motor  Symptoms. — The  muscles  of  the  calves  of  the  legs,  the 
knee  extensors,  and  the  abductors  and  flexors  of  the  thigh  are  weak- 
ened, flaccid,  swollen  and  are  frequently  atrophied.  The  muscles  are 
more  frequently  tender  than  the  nerve-trunks.  In  severe  cases  the 
trunk,  arms  and,  rather  frequently,  the  face,  are  involved.  The  muscles 
are  anatomically  much  degenerated.  Phrenic  weakness  and  vagus 
symptoms,  such  as  rapid  heart,  vomiting,  epi^'astric  oppression,  or 
digestive  disorder  are  not  infrequent;  the  lungs  are  sometimes  acutely 
emphysematous,  which  results  from  involvement  of  the  pulmonary 
plexus.  Symptoms  of  involvement  of  the  larynx,  of  glossopharyngeal, 
hypoglossal  or  ocular  participation  are  more  rare.  Cramps  in  the 
calves  of  the  legs  and  fibrillary  contractions  are  frequent,  but  ataxia 
is  rather  uncommon,  although  the  name  beriberi  refers  specifically  to 
disturbed  locomotion.  The  gait  is  described  as  like  that  of  one  walk- 
ing in  wet  clothes  or  wading  in  water.    Tremors  are  rare. 

2.  Sensory  Symptoms. — Parsesthesia  is  common;  Hypsesthesia  is 
most  marked  in  the  distal  parts,  though  the  sole  of  the  foot  is  exempt; 
it  is  more  frequent  than  anaesthesia,  which  is  rarely  complete.  Hyper- 
sesthesia  is  not  very  frequent,  but  may  occur  over  the  spine  and  ab- 
domen.   Pains  over  the  joints  and  intercostal  spaces  are  quite  common. 

3.  Trophic  Symptoms. — These  are  uncommon.  They  include  joint 
relaxation,  herpes  or  skin  atrophy. 

4.  Reflexes. — The  skin  reflexes  are  seldom  abolished.  Reduc- 
tion of  the  tendon  reflexes  develops  equally  with  the  paralysis. 

5.  Degeneration. — Slight  reaction  of  degeneration  is  common  and 
may  be  marked  in  severe  cases.    It  occurs  particularly  in  the  leg. 

(B).  Dropsy. — Dropsy  to  some  degree  occurs  in  97  per  cent,  of  cases; 
it  may  be  marked  in  the  legs,  and  face,  and  in  all  the  serous  cham- 
bers. It  is  most  severe  in  the  pericardium,  is  quite  severe  in  the 
pleurse,  and  is  least  severe  in  the  peritoneum.     It  is  caused  by  cardiac 


238  THE  SPECIFIC  INFECTIONS 

and  perhaps  also  by  vasomotor  involvement.  Dropsy  invariably 
occurs  in  fatal  cases. 

(C).  Cardiac  Insufficiency. — This  occurs  particularly  in  the  acute 
cases;  death  may  result  in  a  day,  and  acute  forms  in  65  per  cent,  of 
the  cases  lead  to  a  protracted  and  distressing  death  within  two  weeks. 
There  is  palpitation,  cardiac  or  epigastric  oppression,  or  actual  pain; 
tachycardia,  dyspnoea,  and  cyanosis  develop;  the  right  ventricle  is 
dilatated,  the  first  apical  tone  is  weak;  there  is  splitting  of  the  heart 
tones,  gallop-rhythm,  and  systolic  or  even  diastolic  functional  bruits; 
the  urine  is  decreased  in  amount,  in  phosphates,  and  in  uric  acid; 
the  liver  is  turgid.  Ansemia  is  marked  and  the  leukocytes  may  be  in- 
creased. The  heart  failure  may  be  accompanied  by  vocal  cord  par- 
alysis and  weakness  of  the  respiratory  muscles.  Acute  pulmonary 
oedema  is  usually  fatal.  The  heart  muscle  is  pale,  friable,  colloid, 
or  is  the  seat  of  acute  myocarditis. 

The  types  of  beriberi  only  accentuate  some  of  the  above-named 
symptoms,  any  one  of  which  may  stand  out  prominently.  (1)  The 
rudimentary  jorm  may  begin  with  slight  fever,  and  with  catarrh  of 
the  nose,  air-passages,  and  alimentary  tract.  There  is  a  slight  oedema 
of  the  ankles;  muscular  weakness,  which  occurs  especially  in  the 
legs,  indicates  neuritis;  muscular  tenderness,  paraesthesia,  hypsesthe- 
sia,  and  palpitation  are  also  symptoms.  (2)  The  atrophic  jorm  is 
marked  by  atrophy  and  paralysis.  If  oedema  does  not  develop,  both 
of  these  types  may  be  called  the  "dry  forms."  (3)  The  dropsical 
form  is  characterized  by  much  transudation  and  by  pronounced  insuffi- 
ciency of  the  heart.     (4)  The  acute  cardiac  or  pernicious  jorm  (v.s.). 

Diagnosis. ^Diagnosis  of  beriberi  is  difficult  when  it  occurs  in  the 
temperate  countries.  The  leading  points  are  (a)  the  multiple  neuritis, 
which  is  most  marked  in  the  legs;  (6)  vagus  neuritis  and  cardiac 
insufficiency;    and  (c)  dropsy. 

Prognosis. — The  death-rate  varies,  even  in  the  same  endemic 
locality.  In  Japan  and  the  Dutch  Indies  it  ranges  between  3  and  4 
per  cent. ;  in  Brazil  it  formerly  varied  from  50  to  75  per  cent. ;  and  in 
the  Malay  archipelago  it  reached  40  to  50  per  cent.  Death  results 
primarily  from  heart  failure,  secondarily  from  paralysis  of  respiration, 
less  frequently  from  uraemia,  embolism  of  the  lungs,  aspiration  pneu- 
monia, intercurrent  disease,  or  marasmus.  Even  in  recovery,  perma- 
nent residua  are  common,  such  as  weakness,  obstinate  contractures 
of  the  legs  (necessitating  tenotomy),  absence  of  knee-jerk,  and  cardiac 
instability  and  hypertrophy.  Recurrences  during  ten,  twenty,  and  even 
thirty  years,  are  common. 

Treatment. — In  the  early  stages  of  the  disease  purgation  and  salicy- 
lates are  beneficial.  In  the  later  stages,  electrotherapy  and  other 
measures  which  are  employed  in  multiple  neuritis  (q.  v.)  are  indicated, 
and  the  heart  should  receive  stimulation.  Venesection  is  advisable 
in  order  to  relieve  the  overladen  right  heart  and  the  dyspnoea,  and 
promote  action  of  the  kidneys.  Digitalis  is  strongly  recommended  by 
some,  whereas  others  fail  to  find  any  benefit  from  its  administration 


ANTHRAX  239 


and  attribute  such  a  result  to  degeneration  of  the  vagus.  In  dropsical 
forms  it  is  helpful  as  is  caffeine.  Blisters  and  the  ice-bag  over  the 
heart,  bromides  and  belladonna,  may  mitigate  cardiac  unrest  and 
palpitation."  (See  Treatment  of  Valvular  Disease  of  the  Heart.) 


ANTHRAX. 

Anthrax  is  one  of  the  zoonoses — (diseases  acquired  from  animals). 
Glanders,  foot-and-mouth  disease,  vaccinia  and  hydrophobia  consti- 
tute the  remainder  of  this  group.  Actinomycosis  is  less  a  zoonosis 
than  a  disease  acquired  from  a  common  cause  by  man  and  beast. 
Anthrax  is  also  called  splenic  fever,  pustula  maligna,  and  carbunculus 
contagiosus. 

Definition. — It  is  an  acute  infection  caused  by  the  Bacillus  anthracis, 
and  is  usually  communicated  to  man  from  the  herbivora. 

History.— Over  a  century  ago  Morand  and  Fournier  distinguished 
between  the  simple  carbuncle  and  that  of  anthrax,  which  could  be 
inoculated.  The  bacilli  were  seen  by  Pollanders  (1855)  and  Branell 
(1858),  but  Davaine  (1864-1873)  worked  out  all  the  essentials  of  the 
disease  and  noted  that  the  organisms  were  bacteria.  It  remained 
for  Koch  with  his  epoch-breaking  technique  to  find  the  spores  and 
to  absolutely  differentiate  the  disease,  which  is  now  one  of  the  best 
known  maladies. 

Bacteriology. — The  anthrax  bacillus  is  the  largest  pathogenic  mi- 
crobe, and  measures  3  to  10  by  1  to  1.5  //..  In  growths  it  may  occur 
singly  or  in  chains  of  2  to  10  bacilli.  The  ends  are  slightly  rounded, 
and  the  chains  somewhat  resemble  the  phalanges  of  the  finger  for 
the  organisms  lie  end  to  end.  They  are  non-motile,  and  transparent, 
and  may  be  stained  by  Gram's  method,  and  also  with  various  dyes, 
especially  with  Bismarck  brown.  At  high  temperatures  they  grow  in 
long,  thread-like,  winding,  segmented  filaments.  Spores  are  absent 
in  the  cadaver  or  in  the  living  tissue,  possibly  because  of  the  presence 
of  carbonic  acid;   in  the  living  tissues  they  multiply  by  fission. 

In  attenuated  cultures,  one  spore  develops  for  each  bacillus;  these 
become  bacilli,  which,  when  young,  may  be  slightly  motile,  and  are 
extremely  resistant  to  drying  and  to  high  temperature. 

Cultures. — The  bacillus  is  an  obligate  aerobe  which  requires  oxygen 
and  carbon  dioxide,  and  grows  best  on  neutral  or  weakly  alkaline 
media  and  at  a  temperature  between  95°  and  102°.  Stab  cultures  of 
agar  are  characteristic.  A  white,  milky  yet  transparent  and  band-like 
growth  appears  in  one  or  two  days,  which  develops  horizontally  in 
blood  serum,  and  grows  downward  at  an  acute  angle,  so  that  in  three 
days  it  resembles  a  quill  with  a  feathered  upper  end.  Growths  on  gel- 
atin appear  to  have  a  thick,  wooly  covering.  The  gelatin  liquefies  after 
a  few  days,  and  a  white,  granular  sediment  falls  to  the  bottom  of  the 
tube.  The  bacillus  loses  its  virulence  in  blood  which  has  been  rapidly 
dried,  but   in  blood  which  has  been  slowly  dried,  it  develops  spores. 


240  THE  SPECIFIC  INFECTIONS 

Anthrax  is  endemic  and  epidemic  in  Europe  and  Asia.  There 
are  persistent  foci  in  Germany,  especially  in  Saxony,  parts  of 
Bavaria,  and  in  Frankfort;  in  France,  in  the  provinces  of  Burgundy, 
and  Auvergne;  in  Hungary;  in  Russia,  principally  in  Siberia  (the 
"Siberian  plague");  in  China,  India,  and  in  South  America. 
Anthrax  is  rare  in  America,  though  small  epidemics  have  appeared 
in  Delaware  and  in  Pennsylvania.  Among  animals,  the  herbivora 
are  most  often  affected,  especially  sheep  and  cattle,  and  in 
Russia,  horses.  Omnivora  are  more  susceptible  than  carnivora. 
Mice,  guinea-pigs,  rabbits,  dogs,  and  fowls,  rarely  acquire  the  disease. 
Pasteur  thought  that  earth-worms  carried  the  bacilli  from  buried 
bodies  to  the  surface.  Transmission  of  the  spores  by  means  of  snails, 
flies  and  fleas  is  possible.  Spores  reaching  water  may  be  widely 
disseminated.  The  germ  may  have  a  facultative  saprophytic  exist- 
ence on  vegetable  media. 

Infection  may  be  carried  to  man  from  animals,  and,  on  rare  occa- 
sions, from  other  human  beings.  Of  Koranyi's  cases,  65  per  cent, 
were  attributed  to  sheep  and  35  per  cent,  to  cattle;  Bourgois  considers 
that  the  greatest  percentage  comes  from  cattle,  the  second  largest 
from  sheep,  and  the  third  largest  from  horses. 


I.  External  Anthrax. 

External  anthrax  is  by  far  the  most  common  type.  The  atrium 
is  through  an  abrasion  of  the  skin,  and  possibly  through  intact 
hair-follicles.  Koch  observed  that  sheep  were  infected  by  fly-bites 
on  the  exposed  skin  of  the  neck.  Shepherds,  coachmen,  and  all 
those  who  may  attend  diseased  animals;  butchers,  tanners,  wool- 
sorters  and  persons  who  may  handle  diseased  hides  or  meat;  and 
saddlers,  tanners,  rag-pickers  and  gardeners  are  most  likely  to  acquire 
the  disease.  The  bacillus  may  enter  the  system  through  insect-bites, 
and  bruises.  Jacobi  records  infection  from  a  hypodermic  needle 
which  was  first  used  on  a  patient  suffering  from  anthrax.  The  spores 
are  more  virulent  than  the  bacilli. 

Site  of  the  Pustula  Maligna. — In  Koch's  collection  of  1,077  cases, 
the  exact  distribution  is  noted  in  966;  51  per  cent,  developed  on  the 
head  and  face,  38  per  cent,  on  the  upper  extremities,  2  per  cent,  on 
the  lower,  5  per  cent,  on  the  neck,  and  4  per  cent,  on  the  trunk.  That 
is,  the  exposed  parts  are  the  usual  seat  of  primary  infection.  The 
lesion  is  usually  single,  but  several  pustules  or  carbuncles  may  develop, 
possibly  from  inoculation  by  the  finger-nails  in  scratching. 

Symptoms. — The  incubation  lasts  two  or  three  days.  A  small  red 
prominence  is  first  seen,  which  resembles  an  insect-bite.  It  itches,  and 
burns,  and  in  about  twelve  hours  develops  a  small  vesicle.  This  is 
filled  with  yellowish  or  blood-stained  serum,  which  is  purulent  if  rup- 
tured or  scratched,  and  which  dries  with  scab  formation.  It  develops 
a  dark,  dry,  central,  necrotic,  leathery  slough,  which  is  caused  by 


EXTERNAL  ANTHRAX  241 

streptococcic  infection,  and  is  surrounded  by  dense  round-cell,  fibrin- 
ous, and  often  hemorrhagic,  infiltration.  This  in  turn  is  surrounded 
by  oedema  of  the  connective  tissue,  in  the  deeper  lymphvessels  of 
which  the"  Bacillus  anthracis  abounds.  If  the  carbuncle  becomes 
extended,  a  circle  of  new  vesicles,  or  even  two  or  three  concentric 
circles  of  vesicles  appear,  which  fuse  and  increase  the  infiltration  and 
oedema.  The  eyes  may  be  closed  by  swelling  of  the  lids,  or  the  lips 
may  be  so  swollen  that  the  jaws  cannot  be  opened.  Demarcation 
may  now  occur,  followed  by  sloughing;  granulation  tissue  and  cica- 
trization or  general  infection  develop,  and  the  adjacent  lymphvessels 
and  glands  become  infected,  soft,  and  hemorrhagic.  This  usually 
occurs  on  the  fourth  to  the  sixth  day,  or  earlier  in  cases  of  violent 
infection  or  of  reduced  physiological  resistance.  It  is  marked  by  de- 
pression, by  headache,  backache,  pain  in  the  limbs,  chilliness,  con- 
tinuous or  remittent  fever,  soft  pulse,  rapid  breathing,  vomiting  of 
mucus  or  blood,  vertigo,  leukocytosis  (20,000  to  70,000),  colic,  diar- 
rhoea, and  collapse.  Hemorrhages  may  occur  or  even  gangrene  may 
develop  around  the  carbuncle.  Anthrax  bacillsemia  is  sometimes 
found.  The  mind  is  usually  clear,  although  delirium,  convulsions  or 
coma  may  develop,  and  death  may  occur  on  the  seventh  to  ninth  day 
with  an  antemortem  fall  of  temperature.  Toxaemia  and  septicaemia 
cause  the  symptoms  given  above.  In  fatal  cases  there  is  only  slight 
rigor  mortis  but  rapid  decomposition,  dark  fluid  blood,  hemorrhages 
into  various  tissues,  swelling  of  the  lymph  glands,  and  lymphadenoid 
tissue  of  the  intestine  and  sometimes  of  the  spleen.  In  the  liver, 
kidneys,  brain  and  meninges,  deposition  of  bacilli,  and  hemorrhages 
and  swelling  may  be  found;  the  bacilli  are  seen  less  in  the 
large  vessels  than  in  the  capillaries  of  the  brain,  kidneys,  lungs, 
spleen  and  heart.  Bourgois  describes  another  cutaneous  form 
of  the  disease  in  which  there  is  great  oedema  (charbon  blanc,  anthrax 
oedema),  but  no  pustule  or  carbuncle.  He  considers  that  it  occurs 
more  often  on  the  trunk  of  the  body  than  does  the  carbuncle. 

Diagnosis. — In  most  cases  this  is  not  difficult.  The  simple  car- 
buncle resembles  that  of  anthrax,  in  that  it  is  also  hard,  has  a  prom- 
inent central  necrosis,  is  surrounded  by  oedema,  and  sometimes  is 
vesiculated.  It  usually  causes  great  pain,  has  numerous  openings 
which  discharge  ordinary  pus,  and  is  often  malodorous.  The  anthrax 
carbuncle,  however,  may  be  differentiated  by  the  presence  of  bacilli, 
by  depression  of  the  necrotic  centre,  by  the  corona  of  vesicles,  by 
more  rapid  evolution,  by  greater  oedema,  and  by  lack  of  odor.  Glan- 
ders may  be  distinguished  by  involvement  of  the  mucosae,  by  painful 
nodes  without  eschars,  and  by  ulcerations  which  discharge  the  Bacil- 
lus mallei.    It  is  often  difficult  to  recognize  Bourgois's  charbon  blanc. 

Prognosis. — The  prognosis  is  more  favorable  in  children  than  in 
adults,  in  cases  with  local  than  in  those  with  general  symptoms,  and 
in  those  with  simple  carbuncle  than  in  those  with  oedema.  In  Koch's 
collection  of  cases,  68  per  cent,  recovered.  Nasarow's  figures  show 
26  per  cent,  mortality  when  anthrax  occurs  in  the  head  and  face,  23 

16 


242  THE  SPECIFIC  IXFECTIOXS 

per  cent,  ^'hen  it  occurs  in  the  trunk,  19  per  cent,  in  cases  of  infection 
in  the  neck,  14  per  cent,  in  the  upper,  and  5  per  cent,  in  lower  ex- 
tremity localization. 

Treatment. — Prophylaxis. — Infected  animals  should  be  cremated 
entire  and  their  hides  and  wool  should  be  destroyed.  Toussaint 
(1880)  and  later,  Pasteur,  Chauveau  and  Colbert,  attenuated  the  viru- 
lence of  anthrax  cultures  by  exposing  them  to  sunlight  or  to  increased 
atmospheric  pressure,  and  used  them  to  immunize  animals.  In  France 
(1882-1893),  1,788,677  sheep  were  thus  inoculated,  \nth  a  resulting 
mortality  of  0.9  per  cent,  and  200,962  cattle  were  also  inoculated, 
and  a  0.3-per-cent.  mortality  occurred. 

Active  Treatment. — Wounds  in  those  who  have  been  exposed  to 
infection  should  be  promptly  washed  with  strong  sublimate  solution. 
Cauterization  with  the  live  cautery,  ^dth  carbolic  or  nitric  acids,  caus- 
tic potash;  surgical  excision  through  sound  tissue;  injections  of  iodine 
or  corrosive  sublimate;  these  have  all  been  recommended,  but  it  is 
also  maintained  that  equally  good  results  may  be  obtained  by  eleva- 
tion, by  the  use  of  mercurial  paste,  and  by  expectant  treatment, 
which  at  least  avoid  dissemination  of  the  parasite  through  sound 
tissues.  Erysipelas  serum  has  apparently  been  useful  in  anthrax  in- 
fections. Sclavo  (1903)  reported  164  cases  which  were  treated  by 
serotherapy;  the  mortality  was  but  6  per  cent.  In  1,073  cases  treated 
with  Mendez's  serum,  the  mortality  was  but  4  per  cent. 

II.  Internal  Anthrax. 

Internal  anthrax  is  less  frequent  than  the  external  type.  It  occurs 
in  the  alimentary  and  respiratory  tracts. 

1.  The  alimentary  form  (mycosis  intestinalis),  was  first  described 
by  Wahl  and  Recklinghausen,  and  was  more  fully  discussed  by  Wal- 
deyer  and  ^Nliinch.  Bacilli  may  enter  the  system  through  cuts  in  the 
mouth  and  throat,  but  usually  directly  invade  the  intestines  and  stom- 
ach, which  are  more  frequently  infected  by  spores  in  milk  or  water 
than  by  diseased  meat.  The  gastric  juice  kills  the  bacilli  but  not 
the  spores.  Peasants  often  eat  the  pickled  meat  of  diseased  animals 
without  being;  infected.  In  AVurzen,  Saxonv,  there  were  206  cases  of 
intestinal  anthrax  in  1877. 

Symptoms. — There  may  be  prodromal  chills,  fever,  epigastric  or 
lumbar  pains,  or  depression.  The  onset  is,  however,  usually  abrupt, 
with  fever,  coated  tongue,  thirst,  and  vomiting  of  mucus  or  of  blood. 
This  is  followed  by  sensitiveness  or  great  pain  over  the  bowels,  by 
serous  and  afterward  by  bloody  movements,  meteorism,  dyspnoea, 
weak  pulse,  and  by  symptoms  of  collapse  which  resemble  those 
seen  in  the  generalization  of  infection  in  the  cutaneous  form. 
Secondary  carbuncles,  or  more  often  hemorrhages  into  the  skin  of 
the  neck  and  of  the  abdomen,  may  develop.  The  course  is  usually 
severe    and,    in    some    instances,    is    peracute;    death  may  result  in 


INTERNAL  ANTHRAX  243 

two  or  three  days,  in  well  marked  cases,  although  recovery  is  possible. 

Diagnosis. — The  history  of  the  case,  the  finding  of  bacilli  in  the 
stools  and  in  the  blood,  or  the  findings  at  autopsy,  determine  the  diag- 
nosis. In  the  small  intestine  there  are  changes  like  those  of  the  cuta- 
neous carbuncle.  These  consist  of  localized  induration  with  central 
sloughing  which  usually  occurs  opposite  the  mesenteric  attachment 
and  is  accompanied  by  surrounding  hemorrhage  and  oedema  in  the 
mucosa,  and  of  swelling  of  the  solitary  follicles,  of  Peyer's  patches, 
of  the  mesenteric  glands,  and  of  the  omental  and  retroperitoneal  cel- 
lular tissue.  The  bacillus  is  found  in  these  lymphadenoid  structures 
in  large  numbers  and  sometimes  also  in  the  chylevessels  and  portal 
bloodvessels.  The  greatest  changes  most  frequently  occur  in  the 
upper  small  intestine,  sometimes  in  the  stomach  or  ileum,  seldom  in 
the  colon,  and  most  rarely  in  the  rectum.  More  than  thirty  or  forty 
foci  may  be  seen  in  the  small  gut,  but  the  lesions  in  the  stomach 
or  rectum  are  fewer  in  number  and  more  discrete.  Secondary  em- 
bolism of  the  intestinal  arteries  may  result  from  anthrax  of  the  skin, 
in  which  event  hemorrhagic  stools  are  uncommon.  Serohemorrhagic 
fluid  may  be  found  in  the  peritoneal  cavity.  Treatment  is  without 
effect,  though  ipecac,  calomel  and  bichloride  of  mercury  are  often 
recommended. 

2.  The  respiratory  form  was  described  by  Bell  (1840),  and  by 
Spear  and  Carpenter  (1881)  in  England,  as  the  "wool-sorters'  disease"; 
and  by  Eppinger  (1894)  in  Steiermark,  Austria,  as  the  "rag-sorters' 
disease."  Infection  may,  on  rare  occasions,  occur  in  the  nose,  larynx, 
tonsils  (Wiggin),  or  bronchi.  Particles  of  inhaled  chalk  are  thought 
to  facilitate  infection  by  producing  minute  traumata,  but  the  bacilli 
are  apparently  capable  of  entering  the  uninjured  bronchioles  and 
alveoli.  Wool-sorters'  disease  results  especially  from  infection  by 
hides  imported  from  Russia  and  Brazil,  and,  in  1897,  anthrax  developed 
in  this  country  from  hides  of  Chinese  origin. 

Symptoms. — Prodromes  are  uncommon.  The  symptoms  begin  sud- 
denly with  chill  and  high  fever,  tachypnoea,  and  dyspnoea;  there  are 
bronchitic  and  irregular  pneumonic  findings;  and  the  sputum,  which 
contains  in  some  instances  the  pathognomonic  bacilli  is  viscid  or 
hemorrhagic.  The  later  symptoms  are  cyanosis,  which  is  caused  by 
diffuse  mediastinal  infiltration;  serous  pleurisy,  weak  heart,  and  the 
terminal  collapse  and  antemortem  fall  of  temperature.  Icterus,  hsema- 
turia,  glycosuria,  and  anthrax  endocarditis  have  been  observed.  The 
sensorium  is  clear  to  the  end  in  most  of  the  fatal  cases,  though  con- 
vulsions and  coma,  which  in  some  cases  are  due  to  meningeal  hemor- 
rhage, may  occur.  The  patient  may  die  as  early  as  the  second  or 
third  day.  The  mortality  in  rag-sorters'  disease  is  50  to  87  per  cent., 
and  is  rather  lower  in  wool-sorters'  disease.  At  the  autopsy  the  special 
findings  are  as  follows:  the  bacilli  enter  the  ultimate  air-tubes  and 
alveoli,  wherein  they  may  produce  alveolar  desquamation  and  cellulo- 
fibrinous  exudation — the  analogue  of  the  carbuncle — and  much  sero- 
hemorrhagic exudate.     The  latter  is  comparable  to  the  skin  oedema. 


244  THE  SPECIFIC  INFECTIONS 

In  cases  where  there  is  much  cellular  exudate  the  bacilli  become 
decreased,  and  recovery  may  result  from  demarcation;  where  there 
is  much  serous  infiltration  the  bacilli  are  abundant,  and  extension  of 
the  infection  is  likely  along  the  lymphvessels  in  the  direction  of  the 
mediastinal  cellular  tissue,  of  the  peribronchial  lymph  glands  and  of 
the  pleurae,  which  may  hold  as  much  as  four  quarts  of  anthrax-infected 
serous  blood-stained  exudate. 

Treatment. — The  disease  may,  to  a  great  extent,  be  prevented  by 
sterilization  of  the  germ-laden  hair,  of  hides,  or  of  hair  used  in  the 
manufacture  of  paper.  The  actual  therapy  is  wholly  symptomatic 
and  supportive. 

3.  Anthrax  septicsBmia  is  a  rare  form  in  which  the  blood  is  charged 
with  bacilli,  though  no  point  of  entrance  can  be  found.  It  is  almost 
always  fatal. 

GLANDERS. 

Definition. — An  acute  or  more  often  a  chronic  contagion,  which  is 
caused  by  the  Bacillus  mallei.  It  is  characterized  by  the  formation  of 
nodules  and  ulcers,  which  occur  chiefly  in  the  nose  and  skin,  and  less 
often  in  other  structures.  It  is  observed  largely  in  the  horse,  which 
is  the  main  source  of  human  infection. 

Etiology. — Glanders  and  farcy  were  known  to  Aristotle  and  Hip- 
pocrates. The  Bacillus  mallei  was  discovered  by  LoefBer  and  Schuetz 
(1882),  and  independently  by  Bouchard,  Capitau,  and  Charrin.  By 
its  discovery,  glanders  and  farcy  were  identified  as  one  disease.  Weich- 
selbaum  (1885)  first  found  the  bacillus  in  human  infection.  It  closely 
resembles  the  tubercle  bacillus  morphologically,  but  is  shorter  and 
thicker,  and  measures  2  to  5  by  0.4  to  1.5  /i;  it  is  straight  or  slightly 
bent;  its  ends  are  somewhat  rounded;  it  is  usually  single,  but  may 
lie  in  pairs  or  groups;  and  it  has  no  movement.  It  stains  with  the 
alkaline  anilines,  easily  in  cultures  but  with  more  difficulty  in  sections, 
and  the  bacillus  tinges  unevenly,  showing  lighter  areas,  which  are 
thought  by  some  to  be  spores.  It  is  a  facultative  aerobe  and  its  most 
characteristic  culture  is  that  grown  on  the  potato,  in  which  a  thin 
light  yellow  film  develops  in  two  days,  soon  becomes  amber- 
colored,  and  in  eight  days  assumes  a  weakly  red  tinge  with  somewhat 
greenish-blue  borders.  The  atrium  is  usually  the  skin,  through 
which  the  bacillus  enters  by  some  small,  perhaps  microscopic, 
lesion.  Babes  considers  that  infection  may  take  place  through  the 
intact  mucosa  of  the  nose  and  air-passages.  Horse-bites  may  cause 
inoculation.  Infection  may  also  occur  through  the  conjunctiva,  the 
nose,  the  respiratory  tract,  or  very  rarely,  the  digestive  tract  (Nocard). 
Man  is  usually  infected  by  chronically  diseased  horses;  man-to-man 
infection  is  far  less  frequent.  The  bacillus  is  found  in  the  nasal 
nodes  (glanders);  in  the  skin  nodes  (farcy);  in  the  lymphvessels  and 
glands  (in  which  its  virulence  is  greatest);  in  the  saliva,  urine,  sweat, 
semen  and  in  the  blood-current,  where  it  occurs  more  frequently  in 


GLANDERS  245 

man  than  it  does  in  animals,  for  in  the  latter  it  is  found  in  the  most 
acule  cases  only. 

The  vitality  of  the  bacillus  is  not  great.  It  is  soon  destroyed  in  pus, 
but  may  endure  for  three  or  four  weeks  in  the  viscera  of  cadavers  or 
three  or  four  months  in  cultures;  it  is  rapidly  killed  by  sunlight,  but 
persists  two  or  more  weeks  in  damp  protected  places.  It  is  killed  in 
two  minutes  at  212°,  in  fifteen  minutes  by  1  to  1,000  sublimate  solution, 
and  in  one  hour  by  5  per  cent,  carbolic  solution.  Babes  (1890)  and 
Kalming  (1891)  isolated  a  toxin,  and  Kalming,  during  his  re- 
searches, succumbed  to  acute  glanders.  Hellmann  (1891)  isolated 
mallein,  and  Babes  (1892)  morvine^  both  of  which  are  successfully 
injected  for  diagnosis  and  for  immunization.  The  horse,  ass,  and 
mule  are  the  most  susceptible  animals,  and  from  them,  goats,  sheep, 
cats,  lions,  rabbits  and  guinea-pigs  may  be  inoculated.  Babes  found 
that  in  some  localities  half  the  horses  have  latent  glanders.  Cattle, 
mice,  rats,  and  fowls  are  practically  immune.  Infection  is  carried  by 
the  nasal  or  cutaneous  discharge,  whence  glanders  and  farcy  are  chiefly 
observed  in  stable-boys,  coachmen,  farmers  and  veterinary  surgeons. 

S3nnptoms,  Pathology  and  Course. — These  are  considered  under 
two  topics:  {A).  Farcy,  the  cutaneous  type;  (1)  acute  or  (2)  chronic; 
and  {B).  glanders,  the  nasal  type,  (1)  acute  or  (2)  chronic.  In  most 
cases  the  types  are  not  wholly  distinct,  though  symptoms  of  one  local- 
ization may  prevail. 

{A).  Farcy. — 1.  Acute  Form. — The  incubation  is  from  three  to  five 
days,  rarely  two  to  three  weeks,  and  is  attended  by  depression,  anorexia, 
nausea,  headache,  and  leg  pains.  The  infected  point  on  the  skin 
shows  infiltration,  which  may  heal  only  to  break  out  anew.  Lymph- 
angitis and  lymphadenitis  are  present,  but  are  less  marked  than  in 
the  horse,  and  result  in  lymphangitic  farcy-buds.  Subcutaneous  and 
cutaneous  nodes  or  areas  of  diffuse  infiltration  develop.  These  swel- 
lings are  classed  with  the  infective  granulomata,  are  composed  of 
epithelioid,  lymphoid,  and  white  blood  cells,  and  contain  the  bacilli, 
which  are  free,  rarely  intracellular,  and  most  abundant  in  the  centre 
of  the  node.  Early  sections  are  succulent  and  show  central  necrosis, 
which  is  followed  by  suppuration  and  ulceration.  The  ulcers  are  pain- 
ful, deep,  and  crater-like,  with  sharply  cut,  everted  borders,  and  with 
speckled  bases;  they  have  a  thin,  puriform,  hemorrhagic,  or  ichorous 
discharge,  and  they  often  fuse.  Thrombo-phlebitis,  diffuse  phlegmons, 
or  gangrene  may  develop.  The  rise  of  the  fever  may  closely  resemble 
the  ladder-like  ascent  of  the  temperature  in  typhoid.  Chills  are  com- 
mon. Polyarthritis  and  large  muscular  abscesses  are  frequent.  In 
some  cases  a  skin  eruption  occurs  which  is  successively  macular,  papu- 
lar, and  pustular,  and  resembles  that  of  smallpox  except  that  it  is 
rarely  umbilicated;  it  may  be  scant  and  scattered,  or  very  diffuse, 
and  even  confluent;  and  may  affect  the  face,  extremities,  mouth, 
throat,  and  conjunctivae.  The  patient  is  often  delirious,  and  has  an 
offensive  diarrhoea;  the  pulse  becomes  rapid,  and  fresh  skin  nodes 
develop,  which  are  accompanied  by  ulceration  or  perhaps  gangrene. 


246  THE  SPECIFIC  INFECTIONS 

The  pulse  is  fast,  small,  and  irregular;  the  urine  contains  albumin, 
or  casts,  or  shows  the  diazo  reaction,  and  death  occurs  in  about  two 
weeks  from  exhaustion  or  from  lung  inflammation.  In  the  horse,  acute 
farcy  occurs  with  acute  nasal  localization. 

2.  Chronic  Form. — Chronic  farcy  shows  the  same  skin  changes, 
but  they  are  very  gradual  in  onset,  slow  in  progression,  are  unaccom- 
panied by  essential  inflammatory  reaction  or  by  lymphatic  invasion. 
For  the  first  month  or  two  there  are  pains  in  the  limbs  and  joints,  and 
after  a  few  weeks,  indolent  swellings  in  the  extremities  and  in  the  peri- 
articular tissues  appear.  These  are  followed  by  ulceration.  The 
ulcers  may  cicatrize,  but  break  out  again  after  several  months,  and 
therefore  somewhat  resemble  lupus,  which  heals  on  one  side  and  de- 
velops on  another.  Muscular  abscesses  may  appear,  and  are  very 
often  located  in  the  pectoralis,  biceps,  brachialis,  and  gastrocnemius. 
The  course  lasts  for  months  or  years  (two  to  eleven).  Recovery  occurs 
in  50  per  cent,  of  the  cases  (Bollinger),  or  death  results  from  exhaus- 
tion and  acute  dissemination.  In  horses  the  lymphvessels  and  glands 
are  greatly  swollen,  and  appear  as  sausage-shaped  masses,  on  account 
of  which  fact  the  term  "farcy"  was  used  by  Vegetius.  In  horses  the 
skin  eruptons  and  orchitis  are  more  frequent  than  in  man. 

(B).  Glanders. — 1.  Acute  Nasal  Form. — The  conjunctivae  are 
sometimes  swollen,  but  the  process  generally  begins  in  the  nose  after 
an  incubation  of  three  or  four  days.  Miliary  nodules  develop.  These 
are  elevated,  are  yellowish- white  in  the  centre,  grow  to  the  size  of  a 
pea,  are  surrounded  by  a  pale  red  zone,  and  become  ulcerated.  New 
nodes  form  on  the  edges  of  the  ulcers,  which  break  down,  fuse  with 
them,  and  discharge  a  thin,  puriform,  dirty,  sanguinolent  fluid.  Diph- 
theroid deposits  or  crusts  form;  desiccation  may  also  occur.  Ulcera- 
tion may  erode  the  bone  or  cartilage,  and  cause  perforation  of  the 
septum.  The  nose  is  swollen  and  eroded  externally,  and  the  lesions 
may  resemble  those  of  erysipelas.  The  process  reaches  the  mouth  by 
the  lymph  channels  or  by  thrombophlebitis.  Perforation  of  the  palate 
may  occur;  the  tongue,  gums,  or  tonsils  are  invaded;  the  angular 
lymphatic,  parotid  and  submaxillary  glands  are  swollen,  and  the  larynx, 
and  finally  the  lungs,  are  infected.  Beregin  found  that  microscopic 
nodes  may  develop  in  nearly  all  the  parenchymatous  organs,  the  liver, 
kidney,  spleen,  and  brain.  In  the  lungs  the  nodes  may  resemble 
miliary  tubercles,  or  actual  hepatization  (pneumonia  malleosa)  may 
develop,  and  is  frequently  accompanied  by  hemorrhage,  abscess  form- 
ation, gangrene,  a  distressing  cough,  and  raspberry,  mucopurulent,  or 
sometimes  stinking  sputum.  Secondary  suppuration  in  the  bones, 
muscles,  joints  or  skin,  may  develop.  The  course  is  that  of  acute 
farcy,  though  perhaps  more  rapid,  and  is  attended  by  drenching 
sweats,  diarrhoea,  clouded  sensorium,  and  convulsions;  and  death 
occurs  in  one  or  two  weeks.  The  blood  is  thin  and  the  leukocytes  are 
increased. 

2.  Chronic  Nasal  Form. — This  is  similar  to  acute  glanders  except 
that  it  is  chronic.     It  is  less  frequent,  and  in  forms  which  are  limited 


TETANUS  247 

to  the  nose,  confusion  with  other  diseases  is  frequent.  When  nasal 
involvement  is  slight  it  may  clinically  and  pathologically  resemble 
pulmonary^  tuberculosis,  chronic  coryza,  pyaemia,  or  osteomyelitis. 
Recovery  is  infrequent,  though  healing  by  cicatrization  may  result. 
According  to  Babes,  recovery  may  take  place  or,  at  least,  the  malady 
may  "slumber,"  possibly  to  be  aroused  later  by  trauma  or  some 
other  infection,  notably  symbiosis  with  the  staphylococci.  Death 
occurs  from  exhaustion  or  from  generalization  by  the  lymphangitis 
or  thrombophlebitis. 

Diagnosis  of  Glanders  and  Farcy. — Typhoid,  pyaemia,  rheumatism, 
erysipelas,  variola,  syphilis,  lupus,  tuberculosis,  and  anthrax  may  cause 
confusion,  but  the  surroundings,  the  history  and  the  bacteriology  of 
the  case  determine  the  diagnosis.  The  cultural  findings  are  proven 
by  intraperitoneal  inoculation  of  a  guinea-pig,  in  which  orchitis  should 
develop  rapidly.  Injections  of  mallein  difi^erentiate  the  disease  in  90 
to  95  per  cent,  of  the  cases  for  they  produce  a  rise  of  temperature  of 
three  degrees  or  more.  The  bacilli  are  agglutinated  by  the  serum  of 
normal  horses  in  a  dilution  of  1  to  200,  and  of  those  subject  to  glanders 
in  a  dilution  of  1  to  1,000. 

Treatment.— The  prophylaxis  of  glanders  is  like  that  of  anthrax. 
The  principal  measures  indicated  are  isolation  of  diseased,  and  crema- 
tion of  dead,  animals,  and  the  use  of  strong  antiseptics  in  wounds  in 
persons  exposed  to  infection.  Skin  ulcers  should  be  curetted  and 
bandaged  antiseptically;  if  they  are  obstinate,  the  live  cautery  should 
be  applied.  Infection  of  the  nose  should  be  treated  by  carbolic  douches, 
zinc  chloride  paste,  iodol,  or  iodoform.  Arsenic,  mercurial  inunctions, 
iodides,  and  quinine  and  alcohol  for  the  maintenance  of  strength  are 
recommended.  Injections  of  mallein  may  prove  of  therapeutic  as 
well  as  of  diagnostic  value  (Babes,  Pilavios).  Large  doses  of  potas- 
sium iodide  have  been  recently  recommended. 


TETANUS. 

Definition. — Tetanus,  or  lock-jaw,  is  an  acute  infection  caused  by 
the  tetanus  bacillus  and  is  characterized  clinically  by  greatly  increased 
reflexes,  by  muscular  rigidity,  and  by  tonic  spasms,  such  as  trismus, 
and  opisthotonos.  Tetanus  is  literally  tension  or  stretching.  The  dis- 
ease is  described  in  Hippocrates'  aphorisms. 

Etiology. — In  1884,  Carle,  Rosenbach,  and  Rattone  produced  the 
disease  by  inoculations  of  pus,  and  in  the  same  year,  Nicholaier  dis- 
covered the  tetanus  bacillus,  of  which  Kitasato  (1889)  first  obtained 
pure  cultures  from  wounds  and  from  earth,  and  found  it  an  obligate 
anaerobe.  The  Bacillus  tetani  measures  3  to  5  by  ^  to  ^  //,  and  is  en- 
larged at  one  end,  in  which  there  is  a  spore,  thus  having  a  pin-head 
or  drum-stick  shape.  It  becomes  thread-like  in  cultures.  It  stains 
readily  by  Gram's  method,  and  is  delicately  flagellated  and  therefore 
motile.     It   is   anaerobic  and  cultures  emit   a  smell  like  that  of  an 


248  THE  SPECIFIC  INFECTIONS 

onion.  It  is  very  difficult  to  isolate  but  grows  well  in  sugar  solutions. 
The  bacillus  is  very  enduring,  and  lives  long,  even  if  dried  or 
frozen;  the  spores  may  live  eight  years.  It  always  exists  in  the 
primary  wound  and  is  thought  to  exist  only  on  rare  occasions  in 
the  tissues  of  the  brain  and  cord,  but  recent  figures  show  that 
it  is  present  in  44  per  cent,  of  the  severest  infections,  so  that 
tetanus  no  longer  seems  to  be  a  simple  toxaemia.  The  bacillus 
has  been  found  in  the  blood  and  sputum.  Tetanus  is  usually 
classified  as  traumatic  or  idiopathic  (rheumatic);  the  so-called 
idiopathic  form  is  similar  to  idiopathic  erysipelas,  for  the  atrium 
is  either  unseen,  is  microscopic,  or  is  apparently  through  the  pharynx. 
The  bacillus  produces  toxins  which  are  100  to  400  times  as  toxic 
as  strychnine  and  which  in  turn  produce  the  symptoms.  Brieger 
and  Cohn  speak  of  tetanin,  tetanotoxin,  and  spasmotoxin;  Ehrlich 
and  Babes  of  tetanus  spasmin  and  lysin,  and  Faber  of  a  toxin  which 
resembles  the  diastases.  The  bacillus  does  not  produce  inflammation, 
though  mixed  infections  are  usual.  Tetanus  symptoms  result  from 
the  tetanus  toxin  alone,  but  both  infection  and  virulence  are  enhanced 
by  association  with  various  putrefactive  microorganisms,  and  innocu- 
ous solutions  of  tetanus  poison  become  lethal  if  combined  with  steril- 
ized cultures  of  these  putrefactive  bacteria.  Mice,  guinea-pigs  and 
rabbits,  are  inoculable.  In  nature  the  bacillus  is  found  in  the  alimen- 
tary tract  of  herbivora,  whence  it  also  occurs  in  manure,  in  garden 
earth,  in  street  or  house  dust,  in  hay,  in  putrefying  fluids,  and  in  splin- 
ters. Though  it  is  spread  over  the  world,  the  disease  is  ten  to  twenty 
times  as  frequent  in  the  tropics  as  it  is  in  temperate  zones,  because 
the  bacillus  thrives  in  heat.  More  cases  exist  in  Prague  than  in  Ber- 
lin. It  may  lurk  in  certain  districts,  as  it  did  formerly  in  the  Eastern 
end  of  Long  Island,  or  as  it  does  in  the  West  Indies  where  negroes  are 
more  often  and  more  seriously  affected  than  whites. 

Mode  of  Infection. — Incised  wounds  are  obviously  less  dangerous 
than  punctured,  gunshot,  or  contused  wounds  or  haematomata.  Tet- 
anus occurred  less  frequently  in  our  Civil  War  than  it  did  in  the 
Spanish-American  conflict,  in  which  many  cases  developed  among  the 
Spaniards.  It  may  result  from  such  minor  operations  as  circumcision, 
hypodermic  injections,  the  administration  of  antitoxin,  tooth-extrac- 
tion and  vaccination  (95  cases),  and  also  from  major  operations. 
Parturition,  lack  of  attention  to  the  navels  of  the  new-born,  the  use 
of  imperfectly  sterilized  cat-gut,  and  leech-bites  or  pin-pricks  may 
also  cause  its  development.  Chauffard  (1903)  collected  18  cases  in 
which  injection  occurred  from  injections  of  gelatin  for  various  acute 
hemorrhages,  and  in  6  cases  it  has  followed  similar  injections  for 
aneurysm.  The  germ  is  very  frequently  found  in  gelatin,  which  should 
therefore  be  sterilized  three  times  and  in  very  small  amounts,  each 
time  for  thirty  to  forty-five  minutes  at  212°.  H.  G.  Wells  has  placed 
emphasis  on  the  danger  resulting  from  the  use  of  toy  pistols  and  blank 
cartridges  for  Fourth-of-July  celebrations.  He  noted  that  39  per 
cent,  of  the  tetanus  mortality  of  1903  occurred  near  that  date;    415 


TETANUS  249 

deaths  from  tetanus  are  listed  in  the  United  States  for  that  year  as 
against  105  in  1904;  75  per  cent,  of  cases  occur  between  the  tenth  and 
fortieth  yea^'  of  life. 

Incubation. — This  lasts  from  six  to  twelve  hours  in  severe  experi- 
mental inoculations,  from  two  to  nine  days  in  less  intense  inoculations, 
and  in  man,  from  one  to  sixty  days.  The  incubation  in  66  per  cent, 
of  the  cases  lasts  from  five  to  fourteen  days;  Rose  observed  that  in 
33  per  cent,  of  his  cases  the  symptoms  appeared  in  one,  and  in  45  per 
cent,  in  two,  weeks. 

Symptoms. — These  appear  suddenly,  without  any  or  with  only 
indeterminate  prodromes,  and  are  due  to  toxaemia.  This  is  proven 
by  the  fact  that  autopsies  show  no  constant  gross  or  minute  altera- 
tions except  those  common  to  all  convulsive  conditions — e.  g.,  points 
of  congestion  or  punctate  hemorrhage.  Ehrlich's  side-chain  theory  is 
a  fairly  satisfactory  explanation,  for  the  anterior  cells  of  the  cord  and 
medulla  combine  with  the  toxins.  Babes  believed  that  some  third 
substance  formed  and  produced  the  symptoms.  These  are,  at  first, 
rigidity  of  the  jaw  ("lock-jaw,"  trismus)  and  stiffness  of  the  neck. 
In  most  animals  the  muscles  become  rigid  near  the  seat  of  inoculation 
first,  and  sometimes,  in  injuries  received  in  war,  the  muscles  of  the 
leg  may  be  first  involved.  The  probable  explanation  of  this  is  that 
the  toxin  travels  along  the  nerve  trunks  (Marie,  Morals,  Ransom, 
Meyer).  The  horse,  like  man,  develops  trismus  first.  The  poison 
excites  the  anterior  cells  of  the  cord  and  medulla  to  tonic  contraction. 

The  fades  tetanica  results  from  a  spasm  of  the  zygomatic  muscles, 
which  produces  the  risus  sardonicus,  and  imparts  a  smiling  expression 
to  the  upper  and  a  sad  expression  to  the  lower  part  of  the  face  (Konig) ; 
there  are  folds  in  the  forehead;  the  eyebrows  are  raised  and  approxi- 
mated, the  eyeballs  directed  forward,  the  masseters  prominent,  the 
teeth  set,  and  the  nares  dilated.  The  spinal  extensors  are  tonically 
contracted,  arching  the  head  backward  and  the  trunk  forward  (opis- 
thotonos); the  abdominal  muscles  are  hard  and  retracted,  and  are 
occasionally  even  ruptured  by  their  violent  contraction;  in  rare  cases 
the  contracture  is  lateral  (pleurothotonos),  or  forward  (emprosthot- 
onos),  or  the  body  is  straight  and  rigid  (orthotonos).  The  limbs  are 
extended,  the  legs  more  so  than  the  arms,  and  the  feet  and  hands  least. 
The  spasms  are  chiefly  tonic,  but  clonic  exacerbations  for  a  few  seconds 
may  result  from  peripheral  stimulation  of  the  sensory  nerves  or  those 
of  special  sense,  by  the  least  touch,  jar,  breath  of  air,  bright  light  or 
sound.  The  reflexes  are  enormously  increased,  particularly  those 
of  the  skin.  The  spasms  occasion  violent  muscular  pain,  oppres- 
sion over  the  lower  chest  and  epigastrium,  speechlessness,  insomnia, 
and,  from  participation  of  the  medulla,  profuse  sweats  and  increased 
and  irregular  heart  action.  Fever  may  be  present  (even  105°  to  111°), 
or  the  temperature  may  be  normal  or  subnormal.  After  death  a  tem- 
perature of  114°  has  been  observed.  The  sensorium  is  usually  clear. 
Evacuation  of  the  bladder  and  rectum  is  difficult,  and  erection  or 
ejaculation  may  occur.     The  urine  is  decreased  and  sometimes  con- 


250  THE  SPECIFIC  INFECTIONS 

tains  albumin,  sugar,  acetone,  or  indican;  but  increased  excretion  of 
urea  and  creatin,  which  might  be  anticipated  because  of  the  muscular 
action,  is  not  noted.  In  some  cases  the  lymph  glands  adjacent  to  the 
seat  of  infection  are  enlarged.  In  very  rare  cases  the  toxins  cause 
death  without  muscular  spasm;  i.  e.,  they  combine  with  tissues  other 
than  the  nervous  system. 

Death. — Sixty-six  per  cent,  of  the  cases  die  in  a  paroxysm.  The 
fatal  factor  is  a  respiratory  spasm,  an  oedema  or  spasm  of  the  larynx 
or  an  increasing  heart  weakness;  death  from  collapse  or  in  coma  is 
exceptional. 

Diagnosis. — The  diagnosis  is  based  on  the  nature  of  the  wound, 
the  presence  of  the  Bacillus  tetani,  trismus  (which  is  necessary  for  a 
diagnosis),  the  facies,  substernal  oppression,  and  opisthotonos.  Serum 
from  cases  of  tetanus,  obtained  by  blistering,  is  fatal  to  white  mice 
in  twelve  to  twenty-four  hours.  In  strychnine  poisoning  the  history 
of  the  case,  tests  for  the  drug  in  the  stomach  washings  and  urine,  the 
more  abrupt  onset  of  the  spasm  and  of  the  reflex  excitability,  the  more 
diffuse  and  severe  clonic  intermittence  of  the  convulsions,  their  greater 
involvement  of  the  hands  and  feet,  and  the  later  appearance  of  trismus 
and  its  interparoxysmal  relaxation,  are  entirely  distinctive.  Hysteria, 
hydrophobia,  and  tetany  (q.v.)  are  wholly  different  from  tetanus. 
In  meningitis  the  sensorium  is  affected.  Trismus  may  be  due  to  such 
other  causes  as  dental  caries  or  parotitis.  Inflammation  of  the  temporo- 
maxillary  joint  usually  results  in  a  tender  area  in  front  of  the  tragus, 
produces  unilateral  masticatory  cramp  and  is  easily  distinguished  by 
the  clinical  evolution  alone.  Escherich's  pseudotetanus  is  characterized 
by  tonic  contractures  of  the  jaw,  the  back,  and  the  limbs,  which  occur 
oftener  after  an  acute  infection  than  as  an  independent  disease.  Con- 
valescence is  usual  after  a  few  weeks. 

Prognosis. — The  death-rate  ranges  from  45  to  90  per  cent.,  aver- 
ages between  80  and  90  per  cent.,  and  is  modified  by  the  following 
factors : 

1.  Incubation. — The  later  after  inoculation  tetanus  develops,  the 
better  is  the  outlook.  The  mortality  is  91  per  cent,  if  it  appears 
in  the  first  week,  81  per  cent,  if  in  the  second,  and  52  per  cent,  if 
later  (Rose). 

2.  Site  of  Infection. — Infection  in  the  arms  results  in  a  70  per  cent, 
mortality;  in  the  legs,  90  per  cent.  (Norris);  in  cephalic  tetanus  (the 
tetanus  facialis  or  kopftetanus  of  Rose,  first  described  by  Charles  Bell, 
in  1830),  the  mortality  is  almost  100  per  cent.  J.  H.  Lloyd  collected 
100  cases  of  this  type  (1905);  he  finds  the  prognosis  better  than  in  the 
ordinary  tetanus;  Lloyd  found  seven  cases  of  facial  diplegia.  In  this 
type  there  is  facial  paralysis  and  involvement  of  the  pontine  and  medul- 
lary nuclei,  which  sometimes  causes  dysphagia  (hydrophobic  type),  or 
paralysis  of  the  eye.  The  author  observed  these  symptoms  in  a  boy 
who  had  been  kicked  over  the  ear  by  a  horse.  Tetanus  or  trismus 
neonatorum,  especially  described  by  Beumer  (1SS7),  is  an  infection  of 
the  navel  which  occurs  in  the  second  week  of  life.    It  prevents  nursing 


TETANUS  251 

and  is  fatal  on  the  third  or  fourth  day  in  83  per  cent,  of  the  cases.  In 
the  West  Indies  50  per  cent,  of  the  children  died  of  tetanus  at  one 
time,  in  tl^g  Western  Hebrides,  67  per  cent.,  and  in  Iceland,  100  per 
cent.  Tetanus  puerperalis,  particularly  described  by  Heyse  (1893), 
is  a  uterine  infection  and  usually  follows  difficult  labor,  abortions,  or 
ministration  by  midwives,  and  is  generally  fatal.  In  three  years  there 
were  232  cases  in  Bombay  (Gowers). 

3.  Course. — Hippocrates  observed  that  patients  who  survive  the 
fourth  day  may  recover;  68  per  cent,  of  cases  die  in  the  first  four  days. 
According  to  Willard,  88  per  cent,  of  acute  and  25  per  cent,  of  chronic 
cases  die. 

4.  Trauma. — The  death-rate  in  traumatic  cases  is  over  80  per  cent.; 
in  the  so-called  idiopathic  cases  it  is  50  per  cent,  or  lower. 

5.  Sex. — ^lore  women  recover  than  men. 

6.  Symptoms. — Slight  trismus  and  response  to  antispasmodics  are 
favorable;  high  fever  and  involvement  of  the  pons  or  medulla,  respir- 
atory spasm,  dysphagia,  and  ocular  paralysis,  are  unfavorable. 

Treatment. — 1.  Prophylaxis. — This  consists  of  general  surgical 
antisepsis  and  special  care  of  punctured  wounds,  hsematomata  and 
injuries  caused  by  blank  cartridges.  Iodine  and  silver  nitrate  are 
very  helpful,  but  wide  incision  (in  order  to  open  the  punctured  wound, 
for  the  bacillus  is  anaerobic),  thorough  lavage  and  packing  are  most 
essential.  Antiseptic  conduct  of  labor,  and  care  of  the  navel  in  the 
new-born,  need  but  little  emphasis  at  the  present  day. 

2.  Antitoxin  Therapy. — Behring  and  Kitasato  (1880)  discovered  an 
antitoxin  and  were  able  to  immunize  animals  by  cultures  which  were 
heated  from  122°  to  140°,  or  treated  with  Lugol's  solution,  which 
changes  the  toxins  to  toxoids  (Ehrlich).  The  antitoxin  was  found  in 
animals  which  are  naturally  immune  to  tetanus,  such  as  crocodiles 
and  chickens;  and  it  was  found  in  the  fluids  (the  blood,  milk,  and 
bile)  but  not  in  the  tissues.  Tetanus  antitoxin  is  not  bactericidal, — i.  e., 
it  does  not  act  on  the  bacilli.  It  neutralizes  the  tetanus  toxin  in  the 
blood,  but  not  after  the  toxin  has  become  fixed  in  nervous  tissue, 
from  which  the  antitoxin  cannot  dislodge  it.  Behring  and  Ehrlich 
think  that  the  antitoxin  neutralizes  the  toxin  chemically,  while  Babes 
and  others  consider  that  cell  metabolism  is  the  most  important  factor, 
and  that  possibly  a  third  substance  is  secreted.  Tizzoni  and  Cattani 
(1891)  produced  a  serum  somewhat  different  from  that  of  Behring. 
From  the  above  it  is  obvious  (a)  that  serum  prophylaxis  may  be  suc- 
cessful in  suspected  cases  of  earth  infection  or  in  dirty  abortions, 
although  the  term  "successful"  is  presumptive,  as  it  implies  that 
tetanus  would  certainly  have  developed;  it  has  been  successful  in 
cases  of  wounds  received  on  the  Fourth  of  July,  and  it  also  succeeded 
in  the  Prague  obstetrical  clinic,  in  which  latter  instance  every  other 
measure  failed;  (6)  that  if  used  early  it  may  neutralize  circulating 
toxins  which  have  not  yet  become  attached  to  nervous  structures  and 
(c)  that  when  the  toxins  have  combined  with  the  motor  cells,  it  must 
be  ineffectual.     Babes  estimates  the  mortality  at  70  per  cent,  even 


252  THE  SPECIFIC  INFECTIONS 

when  the  serum  is  used,  which  confutes  the  alleged  lowering  of  the 
death-rate  (34  per  cent.,  Engleman;  43  per  cent.,  Koehler,  16  per 
cent.,  Behring).  The  first  dose  should  be  20  to  30  c.c,  and  later  15 
to  20  c.c.  should  be  given  two  to  four  times  daily.  It  should  be  injected 
near  the  site  of  inoculation,  and  especially  into  the  nerve  trunks  near 
the  injury,  in  order  to  reach  more  readily  the  toxins.  Subdural  inocu- 
lations saved  a  severe  case  of  cephalic  tetanus  (Holub).  The  technique 
is  the  same  as  in  lumbar  puncture  (see  Meningitis). 

3.  Clonic  Convulsions. — These  may  be  minimized  by  absolute  quiet 
and  seclusion,  by  darkening  the  room,  and  by  careful  handling  of  the 
patient.  Morphine  may  be  given  hypodermically  to  relieve  pain, 
insomnia,  and  cutaneous  reflex  irritability;  one-quarter  grain  may  be 
given  every  four  to  six  hours  for  a  day  or  two,  but  the  pupils  of  the 
eyes  and  the  respiration  rate  should  be  carefully  watched.  Occasion- 
ally a  corrective  hypodermic  of  atropine  should  be  given.  Chloral 
hydrate  depresses  the  motor  elements  of  the  cord;  twenty  grains  may 
be  given  every  two  hours  for  three  doses,  but  even  this  amount  may 
cause  dangerous  cardiac  symptoms  in  alcoholics  or  in  cases  of  arterio- 
sclerosis. Digitalis  may  be  given  with  chloral  hydrate  to  steady  the 
heart,  and  morphine  and  potassium  bromide  to  enhance  its  depresso- 
motor  action  and  to  lessen  the  cutaneous  irritability.  The  bromides 
should  be  given  5ssj  every  three  hours,  for  six  doses,  after  which  the 
interval  should  be  lengthened.  Inhalations  of  chloroform  and  amyl 
nitrate  may  inhibit  the  onset  of  severe  attacks.  Hot  baths  relieve 
tension,  but  the  lifting  of  the  patient  apparently  more  than  counter- 
balances their  benefits. 

4.  Nutrition. —  This  must  be  carefully  maintained  by  the  nasal 
catheter  (see  Typhoid)  or  by  the  rectum.  In  this  way,  the  difiiculties 
offered  by  trismus  or  dysphagia  are  overcome. 

5.  Other  Measures. — (a)  J.  B.  Murphy  performs  lumbar  puncture 
and  injects  a  weak  solution  of  eucaine  and  morphine,  with  apparent 
results;  (6)  Baccelli,  Aseoli  and  Babes  secure  better  results  with 
hypodermics  consisting  of  10  drops  of  3  per  cent,  carbolic  solution, 
than  they  do  with  serotherapy';  no  ill  effects  were  observed  from  long- 
continued  daily  use;  (c)  Wassermann's  proposal  to  inject  subdurally 
an  emulsion  of  sheep  brains  is  endorsed  by  Babes  and  others,  (d) 
Meltzer  has  recently  been  successful  with  intraspinal  injections  of  a 
dram  of  a  25  per  cent,  solution  of  magnesium  sulphate. 


HYDROPHOBIA   (LYSSA;  RABIES). 

Definition. — An  acute  specific  infection,  of  unknown  causation, 
peculiar  to  carnivora,  the  bites  of  which  convey  infection  to  other 
animals  and  to  man.  The  disease  is  characterized  by  tonic  and  clonic 
spasms  of  the  oesophagus  and  of  the  respiratory  muscles,  which 
spread  to  other  muscles,  and  by  an  inevitably  fatal  evolution.  It 
was  described  in  ancient  Jewish,  Egyptian,  and  Indian  writings,  and 


HYDROPHOBIA   {LYSA;  RABIES)  253 

was  discussed  by  Democritus  in  the  fourth  and  fifth  centuries,  B.  C. 
The  first  adequate  account  was  one  by  Youatt  (1828,  London). 

Etiology. — In  Germany  it  is  infrequent,  because  of  the  strict  laws; 
from  1887  to  1894  only  16  cases  occurred.  In  England,  France,  and 
America  it  is  far  more  common,  and  in  Russia  many  cases  develop. 
Dogs  are  most  susceptible,  are  most  frequently  affected,  and  are  the 
chief  cause  of  dissemination  (90  per  cent.);  next  come  wolves,  cats, 
and  cattle;  and  finally  skunks,  horses,  pigs,  rabbits  and  even  fowls 
may  be  inoculated.  The  character  of  the  virus  is  unknown.  It  is  found 
in  the  nervous  tissues  most  abundantly,  in  the  saliva,  and  also,  though 
in  small  quantities,  in  the  blood,  tears,  sputum,  semen,  urine,  and 
milk,  and  in  the  adrenals,  lymphatics  and  muscles.  Its  propagation 
has  been  held  to  occur  along  the  nerve  trunk,  but  it  must  also  reach 
the  blood  current.  It  resists  putrefaction  for  fourteen  to  twenty-four 
days  but,  on  drying,  becomes  attenuated  in  ten  to  fifteen  days.  The  dis- 
ease prevails  chiefly  in  warm  weather,  particularly  in  the  "dog  days," 
and  most  laws  are  based  on  this  assumption;  but  it  is  also  fairly  com- 
mon in  cool  weather.  In  Paris  most  cases  occur  in  March  and  May. 
Sixty  per  cent,  of  cases  occur  in  men  and  40  per  cent,  are  in  subjects 
under  fifteen  years  of  age.  Inoculation  occurs  through  the  skin,  and 
nearly  always  results  from  bites  of  infected  animals,  which  may  trans- 
mit the  disease  even  during  the  incubation  period.  Punctured  or 
deep  wounds,  and  those  in  the  nerves  or  muscles  are  most  dangerous; 
33  per  cent,  of  those  bitten  by  mad  dogs,  62  to  90  per  cent,  of  those 
bitten  by  wolves,  and  60  per  cent,  of  those  bitten  by  cats,  die.  In 
exceptional  cases,  rabies  results  from  being  licked  by  an  infected  dog, 
from  kissing  an  infected  person,  or  from  dissecting  an  infected  body. 

The  incubation  period  varies  greatly,  averaging  from  six  to  ten 
weeks.  The  extremes  are  from  one  and  a  half  weeks  to  five  months, 
or  in  exceptional  cases,  one  or  two  years.  It  varies  with  (a)  the  age, 
being  shorter  in  children  than  in  adults;  (6)  the  site  of  the  wound. 
If  this  is  on  the  face  or  head,  the  incubation  is  very  short  and  the 
symptoms  are  very  severe.  The  incubation  is  longer  and  the  symp- 
toms less  intense  when  the  point  of  infection  is  on  the  body,  because 
the  clothing  tends  to  clean  the  virus  off  the  teeth. 

Symptoms. — Three  stages  are  described,  which  are  somewhat  arbi- 
trary and  variable. 

First  or  Prodomal  Stage. — The  scar  may  become  tender,  parses- 
thetic  or  painful ;  the  adjacent  glands  sometimes  swell,  or,  if  the  wound 
is  on  the  face,  there  may  be  sneezing.  Distinct  psychical  alteration 
is  usual,  such  as  depression,  irritability,  or  anxiety.  Headache,  in- 
somnia, hypersesthesia  to  light,  sound  and  touch,  anorexia,  and  some 
elevation  of  the  temperature  and  pulse  rate  are  usual.  Sometimes 
speech  is  slightly  disturbed,  the  voice  is  hoarse,  the  pupils  are  some- 
what dilated,  and  premonitions  of  the  later  dysphagia  are  experienced. 
This  stage  lasts  from  one  to  two  days. 

Second  or  Excitation  Stage. — (a)  The  excitement  is  more  motor 
than   psychical.      The   cutaneous   and   deep   reflexes   are   increased. 


254  THE  SPECIFIC  INFECTIONS 

There  is  such  hypersesthesia  that  the  least  sound  or  light,  the  slight- 
est breath  of  air,  or  food  and  water  in  the  throat,  induce  violent  reflex 
spasms,  whence  the  patient's  dread  of  these  excitants  (photophobia, 
aerophobia,  hydrophobia).  Tonic  spasms,  following  attempts  at  swal- 
lowing affect  chiefly  the  muscles  of  the  mouth,  the  hyoid  elevators, 
and  the  laryngeal  and  respiratory  muscles.  Even  without  involve- 
ment of  the  larynx,  the  respiration  is  labored,  with  irregular,  jerky, 
and  often  deep  or  sighing  inspirations,  during  which  the  shoulders 
are  lifted  and  the  epigastrium  is  protruded.  The  spasms  may  extend 
to  the  trunk  and  limbs,  (b)  The  excitement  is  also  psychical,  and  is 
marked  at  the  time  of  the  spasm  by  restlessness  and  often  late  in  the 
course  by  delirium,  or  even  by  violent  mania.  Delirium  tremens  may 
be  simulated.  The  mind  is  usually  clear  between  the  spasms.  The 
patient  rarely  attempts  to  injure  attendants,  although  such  an  im- 
pression may  be  made  by  the  patient's  restlessness,  the  peculiar  growl- 
ing sounds  occasioned  by  pharyngeal  and  laryngeal  spasm,  and  the 
"frothing  at  the  mouth,"  which  is  due  to  inability  to  swallow  the  in- 
creased flow  of  saliva.  Other  less  constant  symptoms  are  elevation  of 
temperature  from  100°  to  103°  or  105°,  though  some  cases  are  afebrile; 
salivation  and  lachrymation;  thirst;  tremors,  erections  and  ejacula- 
tions; increased  pulse  rate;  scanty,  albuminous  urine  (25  per  cent.), 
often  with  casts  and  sometimes  with  sugar  or  acetone.  The  excita- 
tion stas'e  lasts  one  and  a  half  to  three  davs. 

Third,  Paralytic  or  Terminal  Stage. — -This  stage  is  less  common  in 
human  than  in  animal  rabies.  In  animals  it  may  be  marked  from 
the  beginning  and  the  other  stages  may  be  lacking  or  rudimentary — 
the  "dumb"  rabies  as  contrasted  with  the  furibund  type.  The  spasms 
and  excitement  cease,  the  pulse  becomes  fast,  small,  and  irregular, 
the  pupils  are  wide  and  irregular,  sweating  is  profuse,  swallowing 
becomes  impossible,  and  paralyses  develop,  mono-,  para-,  or  hemi- 
plegic,  or  of  the  acute  ascending  type  of  Landry.  The  sphincters  are 
sometimes  paralyzed.  The  patient  dies,  unconscious,  of  cardiac  col- 
lapse, rarely  of  asphyxia  or  convulsions.  The  third  stage  seldom 
lasts  more  than  eighteen  hours. 

Autopsy  Findings. — Pathologists  are  not  absolutely  unanimous  in 
regard  to  the  specific  autopsy  findings.  Minute  hemorrhages  and 
special  congestion  of  the  medulla  and  cord  mark  hydrophobia  as 
they  do  other  convulsive  states.  Babes's  rabic  tubercles  are  aggre- 
gations of  leukocytes  around  the  vessels  and  nerve  cells.  The  latter 
may  degenerate.  Rapid  diagnosis  of  rabies  may  be  made,  accord- 
ing to  von  Gebuchten  and  Nelis,  by  examination  of  the  sympathetic 
and  cerebro-spinal  ganglia,  under  the  capsules  of  which  are  found  accu- 
mulations of  epithelioid  and  lymphoid  cells.  Babes  considers  them  less 
important  than  the  rabic  tubercles.  The  bodies  described  by  Negri 
and  Pavia  (1903)  in  the  cell  processes,  may  be  protozoal  parasites  or 
artefacts. 

Course  and  Prognosis. — In  twelve  hours  to  ten  days — on  the  aver- 
age two  to  four  days — all  untreated  cases  die,  10  per  cent,  in  the  first 


HYDROPHOBIA    {LYSA;  RABIES)  255 

day,  and  60  per  cent,  in  the  first  three  days.  Laveran,  Chantemesse, 
Novi,  Poppi,  and  others  report  recoveries,  but  Hogyes'  is  the  only 
recovery  verified  by  inoculations  of  the  saliva. 

Diagnosis". — The  diagnosis  is  usually  made  with  ease.  After  bites 
from  supposedly  rabid  animals,  microscopic  examination  can  be  made 
and  also  subdural  inoculations  in  rabbits,  which  die  in  two  to  three 
weeks  with  the  paralytic  symptoms.  Tetanus  of  the  cephalic  and 
hydrophobic  type  is  easily  distinguished  by  the  invariable  trismus. 
Hysteria  (pseudohydrophobia,  lyssophobia)  in  one  bitten  by  a  dog 
may  at  first  cause  suspicion  but  rarely  any  protracted  doubt.  The 
initial  spasmodic  dysphagia  and  irritability  are  not  followed  by  the 
other  symptoms  and  stages  of  hydrophobia,  and  the  clinical  evolution 
alone  is  distinctive. 

Treatment. — 1.  Prophylactic. — In  Germany,  where  laws  concern- 
ing dogs  are  not  only  passed  but  are  enforced,  hydrophobia  is  almost 
extinct,  while  in  Roumania  over  100  cases  occur  yearly.  In  human 
rabies  it  must  be  remembered  that  the  saliva  is  infective. 

Preventive  Inoculation. — Pasteur,  in  1881,  found  the  rabic  virus  in 
the  nervous  tissues.  "The  virus  of  the  street,"  as  Pasteur  called  it, 
varies  in  virulence,  and  subdural  inoculations  from  the  brains  of  rabid 
dogs,  into  rabbits,  killed  them  in  periods  varying  from  fourteen  to 
twenty  days.  By  inoculating  a  series  of  rabbits,  the  incubation  period 
is  progressively  shortened  to  a  fixed  period  of  seven  days,  this  virus 
being  called  the  "fixed  virus."  Pasteur  attenuated  this  virus  by 
suspending  the  spinal  cord  of  the  rabbit  in  a  clean  jar  and  desiccating 
it  with  caustic  potash.  Animals  were  inoculated  with  virus  which 
had  been  desiccated  for  two  weeks,  then  with  virus  a  little  stronger, — 
i.  e.,  with  virus  desiccated  for  ten  or  twelve  days,  until  finally  immuni- 
zation was  secured  against  inoculations  which  would  previously  have 
been  fatal.  In  1885,  human  beings  bitten  by  rabid  beasts  were  thus 
treated  by  two  inoculations  daily,  for  fifteen  days,  and  immunization 
was  secured,  for  the  slow  rabic  incubation  gives  ample  time  for  treat- 
ment. Early  treatment  secures  the  best  results.  Statistics  show  that 
the  former  mortality  of  80  per  cent,  in  untreated  bites  in  the  head  or 
face  has  been  reduced  to  1.25  per  cent.;  the  mortality  of  60  per  cent, 
in  those  bitten  in  the  hands  is  reduced  to  0.75  per  cent.;  the  mor- 
tality of  30  per  cent,  in  those  bitten  in  the  covered  parts  of  the  arm 
and  trunk,  and  of  15  per  cent,  in  those  bitten  in  the  leg,  is  reduced 
to  0.25  per  cent.  The  total  mortality  has  been  reduced  to  0.5  per  cent. 
Babes  (1905)  very  rarely  found,  as  sequences  of  Pasteur's  treatment, 
the  following:  neuroses,  neuritis,  bulbar  or  spinal  paralysis  and  Ivan- 
dry's  paralysis. 

2.  Primary  Wound  Treatment. — The  wound  may  be  sucked  by 
the  victim,  but  not  by  any  other  person.  It  should  be  washed  with 
strong  antiseptics,  burned  with  caustic  potash,  pure  carbolic  acid, 
or  nitrate  of  silver,  and  as  soon  as  possible  should  be  exposed  surgi- 
cally, treated  with  the  live  cautery,  and  packed  with  gauze,  so  that 
healing  may  be  delayed  for  over  a  month. 


256  THE  SPECIFIC  INFECTIONS 

3.  Late  Treatment. — In  developed  cases  the  mortalitv  is  100  per 
cent.,  whence  curative  therapy  is  out  of  the  question.  The  treatment 
of  the  convulsions  is  similar  to  that  of  tetanus,  and  nutrition  is  main- 
tained by  nutritive  rectal  enemata.  Morphine  and  inhalation  of  chloro- 
form are  better  than  chloral  and  bromides,  and  should  be  given  until 
they  show  their  full  physiological  effects.  Cocainization  of  the  mouth 
and  pharynx  may  overcome  the  pharyngeal  spasm  incident  to  swallow- 
ing milk  and  water,  and  to  medication.  Tracheotomy  is  useless  for  the 
respiratory  spasm,  which  reaches  further  than  the  larynx,  and  in- 
volves the  muscles  of  the  chest  and  diaphragm;  and  besides,  it  is 
maintained  by  many  that  the  larynx  itself  is  not  closed. 


ACTINOMYCOSIS. 

Definition. — An  infection  caused  by  the  actinomyces  (literally  "ray- 
fungus");  it  is  mostly  sporadic  in  cattle,  and  less  frequently  so  in 
swine,  horses,  deer,  or  elephants;  it  occurs  occasionally  in  man;  it  is 
rarely  endemic  or  epidemic;  it  is  marked  by  chronic  inflammation 
(a)  in  the  mouth,  head  or  neck,  (&)  in  the  lungs,  or  (c)  in  the  intestines 
or  abdomen;   and  it  usually  runs  a  chronic  course. 

History. — Von  Langenbeck  (1845),  Davaine  (1850),  Laboulbene 
and  Robin  (1853),  and  Lebert  (1857),  observed  the  peculiar  sulphur 
granules  in  the  discharges  of  pus.  Rivolta  (1868)  and  Perroncito 
(1875),  described  the  fungus,  Bollinger  (1877)  first  scientifically  estab- 
lished its  constant  occurrence  in  cattle,  and  Hartz  named  it  Actino- 
mycosis hovis.  J.  Israel  (1878)  first  found  the  parasite  in  human, 
cases,  but  to  Ponfick  (1879)  is  due  the  credit  of  identifying  the  bovine 
and  the  human  types.  William  T.  Belfield,  of  Chicago,  first  found 
actinomycosis  in  this  country.  The  monographs  by  Ponfick,  Israel, 
Bostroem  and  Illich  are  the  most  important. 

Etiology. — Its  distribution  varies.  Statistics  in  Berlin,  Breslau  and 
Vienna  show  large  numbers  of  cases.  There  are  more  cases  in  Scot- 
land, Denmark,  Italy,  and  Russia,  than  in  America,  where  it  is  less 
frequent  in  the  United  States  than  in  Canada.  Seventy  per  cent,  of 
the  cases  occur  in  males,  and  most  of  them  are  in  subjects  between 
twenty  and  forty  years  of  age  (33  per  cent,  between  twenty  and  thirty; 
82  per  cent,  between  ten  and  fifty).  The  fungus  enters  the  system 
chiefly  by  the  mouth,  in  which  ragged  teeth,  abrasions,  etc.,  favor 
its  access.  Though  almost  nothing  is  known  of  it  outside  of  the  body, 
it  occurs  in  straw,  hay,  barley,  oats,  and  similar  cereals,  remnants  of 
which  are  often  found  in  actinomycotic  foci.  Most  cases  occur  in 
young  cattle  at  dentition;  89  per  cent,  in  the  last  half  of  the  year, 
when  the  hair  and  the  grain  which  are  ingested  are  dry.  The  drinking 
water  may  be  the  source  of  infection. 

Bacteriology. — The  'parasite  of  actinomycosis  is  classed  as  a  strepto- 
thrix  and  is  found  in  small  granules  which  measure  0.15  to  0.75  milli- 
meters, are  usually  ovoid  in  shape,  and  show  a  "radiate"  form  when 


ACTINOMYCOSIS  257 

squeezed  under  the  cover  glass.  The  younger  forms  are  transparent, 
sago-like,  white-gray  bodies  which  may  be  easily  overlooked,  and  the 
older  forms  are  more  yellow.  These  suphur-like  granules,  on  minute 
examination,  consist  of  threads  and  coccoid  bodies  which  some  con- 
sider spores.  The  older  yellow  forms  become  clubbed,  which  is  con- 
sidered a  degenerative  change.  The  threads  divide  and  branch.  The 
fungus  is  therefore  phleomorphic.  It  stains  fairly  well  with  the  usual 
stains  and  by  Gram's  method.  Cultures  are  successfully  grown  in 
50  per  cent,  of  the  cases,  and  are  best  obtained  by  mixing  the  granules 
thoroughly  with  softened  gelatin  and  bouillon,  and  then  by  spread- 
ing or  inoculating  them  as  usual.  The  colonies  are  thick,  folded, 
membranous,  resistant,  and  at  first  have  a  mucoid  or  crystalline  appear- 
ance. Experimental  inoculations  succeed,  but  infection  is  very  rarely 
direct  either  from  animals  to  man  or  from  one  person  to  another. 

Forms  of  Actinomycosis. — Incubation  averages  four  weeks.  Clin- 
ically there  are  three  main  forms:  (1)  That  of  the  head  and  neck;  (2) 
that  of  the  lower  digestive  tract;   and  (3)  that  of  the  respiratory  tract. 

1.  The  forms  localized  in  the  head  and  neck  constitute  50  per  cent, 
of  actinomycosis.  The  atrium  is  in  the  soft  tissues  of  the  mouth 
and  throat.  Entering  these,  the  fungus  is  surrounded  by  a  massive 
accumulation  of  round  cells  which  soon  degenerate  centrally.  The 
reaction  of  the  connective  tissue  is  marked  and  the  proliferation 
shows  numerous  round  or  polygonal  cells  with  large  nuclei, — the  epi- 
thelioid cells.  Giant  cells  also  form.  The  process  is  designated  by 
Bostroem  as  a  chronic  inflammation,  and  by  Israel  as  an  infective 
granuloma,  resembling  the  tuberculous,  syphilitic,  or  leprous  process. 
The  further  destiny  of  these  granulations  of  the  tissue  is  modified  by 
the  resistance  of  the  tissues  and  by  the  animal  diseased,  (a)  In  man 
the  granulation  wall  usually  melts  so  that  the  fungus  is  surrounded 
by  a  mucoid,  creamy,  cloudy  fluid,  in  which  there  are  oil,  fibrin,  blood, 
pigment,  and  actinomycotic  cocci  and  threads;  the  abscess  is  formed 
by  the  fungus  itself  which,  unaided  by  pyogenic  organisms,  burrows 
and  reaches  the  surface  by  circuitous  fistulse;  it  discharges  a  thin, 
puriform  secretion  like  that  of  scrofulous  glands  but  which  contains 
the  sulphur-like  grains.  (6)  In  cattle  and  horses  the  granulation  tissue 
is  more  effectually  obliterative  and  limitative,  and  hard,  board-like, 
or  ligneous  tumors  develop  ("lumpy  jaw,"  "wooden  tongue");  sup- 
puration and  miliary  dissemination  are  less  frequent,  and  calcification 
is  more  frequent  than  in  man.  In  human  subjects  the  infiltration 
may  involve  the  neck,  face,  tongue,  pharynx,  tonsils,  larynx,  and  thy- 
roid gland.  In  general,  the  most  frequent  involvements  are  inflam- 
mation of  the  soft  tissues  about  the  jaws,  especially  those  under  the 
lower  jaw,  submaxillary  or  submental  infiltration,  and  superficial  in- 
vasion of  the  bones.  In  the  tongue,  actinomycosis  may  resemble 
gummata  or  cancer  but  in  cancer  there  is  more  pain  and  glandular 
invasion.  In  some  few  cases  the  maxillfie  may  be  primarily  invaded 
(Israel,  Murphy).  Sarcoma  and  caries  may  be  simulated.  The  pro- 
cess sometimes  spreads  regionally  along  the  bones  to  the  base  of  the 

17 


258  THE  SPECIFIC  INFECTIOXS 

'brain  and  results  in  meningitis;   along  the  spine,  and  causes  vertebral 
erosion;    and  behind  the  sternum  with  mediastinal  infiltration. 

Symptoms. — These  vary  with  the  part  invaded.  The  fever  is  ir- 
regular, rarelv  continuous  or  tvphoidal.  Pain  and  tenderness  are  not 
marked,  for  the  process  is  indolent  or  chronic.  Dysphagia  accom- 
panies retropharyngeal  involvement,  oedema  occurs  in  laryngeal 
localization,  and  other  local  interference  such  as  venous  obstruction  is 
frequent.  In  a  recent  case,  the  writer  observed  trismus  and  severe 
unilateral  trifacial  neuralgia  from  a  primary  focus  at  the  base  of  the 
skull;  recovery  followed  operation.  Besides  the  regional  invasion  by 
contiguity,  above  named,  hematogenous  extension  by  metastasis  may 
occur  in  this  type  as  well  as  in  the  others  to  be  described  later.  Unlike 
tuberculosis,  extension  to  the  lymphatics,  or  general  dissemination  by 
them,  is  unusual.  Hsematogenous  (really  pysemic)  deposits  may  occur 
in  the  brain,  meninges,  liver,  spleen,  kidneys,  intestines,  lungs,  muscles^ 
skin,  bones,  joints,  or  retinse,  in  which  they  may  simulate  miliary 
tubercles.    In  the  head-and-neck  form  the  mortality  is  10  per  cent. 

2.  The  lower  digestive  tract  ranks  next  (20  to  30  per  cent.)  in  fre- 
quency of  infection.  This  may  occur  anywhere  between  the  oesoph- 
agus and  rectum,  but  50  per  cent,  of  this  group  occurs  in  the  region 
of  the  ileum,  caecum  and  appendix  {'perityphlitis  actinomycotica). 
Local  pain,  tenderness,  induration  and  adhesions  frequently  follow 
the  primary  lesion  of  the  intestine.  In  rare  instances  this  lesion  is 
superficial  (enteritis  actinomycotica  super ficialis ,  Chiari),  but  small 
nodes  usually  develop  in  the  submucosa,  over  which  the  mucosa  be- 
comes somewhat  pigmented.  This  is  followed  by  central  softening  of 
"the  nodes  and  by  the  development  of  small  ulcers,  the  undermined 
edges  and  uneven  bases  of  which  make  them  resemble  tuberculous 
ulcers.  Secondary  pyogenic  infections  are  frequent.  The  ulcers  may 
cicatrize  or  fuse  into  larger  ulcerations. 

Symptoms. — -As  above  indicated,  the  signs  are  often  those  of  appen- 
dicitis; symptoms  may  be  absent,  but  colic  and  vomiting  are  often 
present,  and  constipation  is  more  frequent  than  diarrhoea  or  dysenteric 
stools.  Extension  of  the  process  is  usually  downward;  it  involves  the 
iliac  bone,  and  occasionally  the  thigh,  hip,  bladder,  ovaries,  vagina,  or 
rectum;  the  ray  fungus  is  voided  in  the  urine  and  fa?ces;  and  anter- 
iorly preperitoneal,  suprapubic,  or  muscular  infiltrations  occur,  with 
external  fistul?e.  The  process  then  extends  backward  into  the  retro- 
peritoneal cellular  tissue,  in  which  it  may  burrow  around  the  kidneys 
or  even  into  the  chest.  These  varied  localizations  may  simulate  peri- 
nephritis, peripsoitis  or  parametritis.  In  rare  cases,  freely  movable, 
and  therefore  operable,  tumors  may  develop.  Scoliosis  may  result. 
Vascular  metastases  may  occur  as  they  do  in  involvement  of  the  head 
and  neck  but  suppuration  of  the  liver  is  the  most  frequent  develop- 
ment, and  is  secondary  clinically  and  pathologically,  though  it  is 
sometimes  apparently  primary.  Forty  cases  are  reported.  In  71  per 
cent,  death  results,  usually  from  exhaustion,  from  mixed  infection, 
or  from  diffuse  amyloidosis.    Diagnosis  must  be  made  from  gross  de- 


ACTINOMYCOSIS  25& 

tection  of  the  yellow  granules  or  from  microscopic  recognition  of  the 
fungus, 

3.  Respiratory  involvement  is  still  less  frequent.  It  is  (a)  secondary 
to  extension  by  contiguity  from  the  neck  or  abdomen,  or  to  miliary 
or  larger  infarcts,  or  (6)  primary  in  the  lungs,  which  is  a  less  fre- 
quent form  (14  per  cent.).  Primary  pulmonary  actinomycosis  is 
rarely  of  the  superficial  type  (bronchitis  actinomycotica  super ficialis) . 
Canali  described  such  a  case  with  seven  years  duration.  This  form 
may  easily  escape  recognition.  A  case  of  actinomycotic  fibrinous 
bronchitis  is  reported.  More  often  it  is  deeper,  and  invades  the  alveoli. 
The  lower  lobes  are  its  usual  seat  and  they  show  a  gray  hepatization 
with  the  ordinary  actinomycotic  changes.  Fusion  of  the  foci  may  in- 
volve large  portions  of  tissue,  but  demarcation  is  usual  in  the  lung. 
The  clinical  picture  varies,  (i)  In  some  instances  cavity  formation  is 
obviously  present.  There  is  fever  of  a  hectic  or  possibly  of  a  typhoid 
type,  an  harrassing  cough,  and  malnutrition;  the  sputum  is  puriform, 
sometimes  foetid  and  stained  with  altered  blood  like  raspberry 
jelly,  or  contains  even  considerable  quantities  of  blood  and 
often  reveals  the  actinomycosis  rays,  (ii)  Induration  of  the  lower 
lobes  may  occur  from  cicatricial  development,  (iii)  Pleurisy;  (iv) 
peripleuritis;  (v)  pericarditis;  or  (vi)  mediastinitis  may  be  the  domi- 
nant finding.  There  may  be  much  luxation  of  the  intrathoracic  con- 
tents, and  involvement  of  the  heart  is  characterized  by  great  dyspnoea, 
dilatation  and  hydrops.  Penetration  may  occur  through  the  chest 
wall  with  characteristic  discharge  from  the  sinuses  which  run. along 
the  spine  and  ileopsoas  muscle,  or  into  the  abdomen.  Hsematogenous 
generalization  occurs  as  in  other  forms.  The  examination  of  the  spu- 
tum is  essential  for  diagnosis  unless  fistulee  develop.  In  25  per  cent, 
of  cases  the  ray  fungus  is  seen  and  tuberculosis  is  excluded  by  absence 
of  tubercle  bacilli  and  elastic  fibers.  Otherwise  the  resemblance  may 
be  very  close  or  differentiation  impossible.  The  course  is  usually  sub- 
chronic  (averaging  under  a  year),  less  often  chronic  (two  to  three 
years),  and  very  rarely  acute.  The  outcome  is  fatal  in  practically 
100  per  cent,  of  the  cases,  though  Schlange  reports  two  recoveries. 

4.  Other  primary  localizations  are  rare;  23  primary  skin  cases  are 
reported.  They  may  resemble  lupus  or  tubercle.  Primary  brain 
lesions  are  infrequent  (Bollinger,  Orlow,  Keller,  Grangee  and  Del- 
vaine);  they  may  simulate  brain  tumor  or  cause  cortical  epilepsy. 
Primary  genito-urinary  infection  is  possible,  though  very  few  cases 
are  recorded  (Stanton).  The  lachrymal  duct  or  middle  ear  is  very 
rarely  the  primary  focus. 

Diagnosis. — Similar  fungi  may  cause  difficulty  in  diagnosis,  but 
their  classification  is  still  a  mooted  question.  Eppinger's  cladothrix 
asteroides  may  cause  deposits  in  the  cervical  glands  or  brain,  and 
miliary  nodes  in  the  lung.  Rosenbach  noted  a  similar  growth  in 
erysipeloid,  and  Vincent  in  Madura  foot,  which  liquefies  gelatin  and 
produces  a  red  pigment.  The  leptothrix  of  the  mouth  is  a  possible 
cause  of  confusion. 


260  THE  SPECIFIC  INFECTIONS 

Treatment. — 1.  Prophylaxis. — Besides  general  measures  employed 
in  any  contagion,  care  is  necessary  in  regard  to  the  holding  of  straws 
in  the  mouth  or  picking  the  teeth  with  them.  Thorough  cooking  of 
cereals  before  eating  is  essential. 

2.  Surgical  Extirpation. — This  is  indicated,  if  possible;  or  a  sharp 
spoon  should  be  used  to  clean  accessible  foci  and  fistulee,  which  should 
then  be  packed  with  iodoform  or  sublimate  gauze.  Injections  of 
bichloride  of  mercury  (t^o  per  cent,  to  1  per  cent.)  are  used  especially 
bv  lUich  and  HocheneD-g;. 

3.  Potassium  Iodide. — In  cases  wholly  inaccessible  to  the  knife, 
potassium  iodide  is  excellent  or  even  specific,  according  to  some 
writers.  It  is  not  parasiticidal,  but  softens  the  tissues.  It  also  pre- 
pares operable  cases  for  surgical  measures;  53  per  cent,  of  bovine 
cases  recover  under  its  use.  Thomassen  and  Netter  use  six  grams 
daily  for  a  month  and  then  decrease  the  dosage.  Rydygier  injects 
large  quantities  of  a  1  per  cent,  solution  into  the  affected  tissues. 

4.  Tuberculin  Injections. — These  were  advantageous  when  used  by 
Billroth,  Kahler,  and  Socin.  Bevan  has  seen  benefit  result  from  the 
internal  use  of  copper  sulphate. 


GONORRHEAL  INFECTION. 

Lightly  spoken  of  as  "the  badge  of  virility,"  gonorrhoea  is  often 
untreated  and  neglected.  It  frequently  becomes  chronic,  and  in  its 
so-called  latent  form  may  be  conveyed  after  marriage  to  the  wife,  on 
whom  it  usually  entails  suffering,  frequently  sterility,  and  sometimes 
permanent  invalidism.     Its  other  dangers  are: 

I.  The  regional  invasion  of  the  genital  tracts  (a)  in  the  male,  of 
the  prostate,  seminal  vesicles,  and  testes;  (6)  in  the  female,  of  the 
vagina,  cervix,  uterus,  tubes,  ovaries,  and  peritoneum;  in  institutions, 
repeated  epidemics  of  vaginitis  in  children  have  occurred;  (c)  in  both 
sexes,  of  the  bladder,  pelvis,  and  kidneys,  in  which  extension,  mixed 
infection  is  an  important  factor. 


II.  Gonococcic  Septicopyeemia. 

Hsematogenous  generalization  has  already  been  discussed  under 
septic  affections.  The  fever  is  toxaemic  and  septic?emic.  Injection  of 
sterilized  cultures  produces  violent  reaction,  which  hitherto  has  bajSBed 
attempts  at  animal  immunization.  The  fever  is  intermittent,  and  is 
often  marked  by  great  variations.  The  gonococcus  has  been  found  in 
the  blood  (Amann,  Petrone,  Hewes,  Thayer,  Benmer  and  Lazear,  in 
all  1.5  times);  in  the  myocardium  fCouncilman);  in  the  pleura  (15 
cases  collected  by  Lemoine  and  Gallis,  1905);  and  in  the  joints  (v.i.), 
kidneys,  spleen,  muscular  abscess,  lymph-glands  (von  Hausteen,  Col-. 
umbine)  and  skin  (Hochmann,  Horwitz,  and  Rendue).     It  has  also 


GONOCOCCIC  SEPTICOPYEMIA  261 

been  found  in  meningo-myelitic  foci;  in  muscular  abscesses;  in 
myositis  (7  cases  collected  by  Harris  and  Haskell,  1904);  in  arteritis 
and  phlebitis  (25  cases  collected  by  Heller,  1904;  the  author  saw  one 
in  1905  with  Dr.  Cuthbertson) ;  in  purpuric,  erythematous,  dermatitic 
and  exanthematous  eruptions;  in  felons;  and  in  periostitis.  It  is 
reported  to  have  been  found  in  cases  of  pneumonia  and  of  multiple 
neuritis.  Loeb's  collection  of  62  cases  of  ulcerative  gonorrhoeal  endo- 
carditis has  been  referred  to.  This  endocarditis  may  possibly  heal. 
Septicopysemic  lesions  may  be  due  to  Neisser's  diplococcus  alone,  or 
to  mixed  infections. 

Most  cases  of  gonorrhceal  rheumatism  must  be  regarded  as  a  mild 
septicemic  form.  Occasionally  it  is  part  of  a  severe  septicopysemia. 
It  was  described  by  Selle  and  Swediaur  in  1781,  and  the  gonococcus 
was  first  found  by  Petrone  (1883),  and  Kammerer  (1884).  According 
to  Damasch  it  develops  in  2  to  3  per  cent,  of  gonorrhoeal  infections. 
If  80  per  cent,  of  males  contract  gonorrhoea,  Konig's  assertion  that  it 
is  the  most  common  disease  of  the  joints  seems  well  established. 
Eighty  per  cent,  show  an  acute  urethritis;  in  the  balance  the  urethritis 
has  subsided  or  become  chronic.  In  18  cases  reported  by  Lucas,  the 
infection  was  primarily  gonorrhoeal  conjunctivitis,  especially  in  in- 
fantile cases.  Northrup's  series  of  252  cases  of  gonorrhoeal  rheuma- 
tism gives  91  per  cent,  in  males,  though  Brun  and  Bennecke  find  62 
per  cent,  in  women,  which  is  contrary  to  common  experience.  About 
50  per  cent,  of  the  cases  occur  between  twenty  and  fifty  years  of  age. 
It  has  followed  experimental  gonorrhoea.  Too  active  treatment  and 
sexual  indulgence  during  the  florid  stage  of  gonorrhoea  are  held  to  be 
predisposing  causes. 

Symptoms. — The  symptoms  are  extremely  variable.  The  joints 
alone  may  be  involved,  or  there  may  be  more  severe  evidences  of  blood 
invasion,  such  as  endocarditis.  While  the  synovial  membrane  is  most 
often  inflamed,  gonorrhoeal  rheumatism  is  more  than  synovitis.  The 
accessory  bursse,  contiguous  tendon  sheaths,  and  the  extracapsular 
structures  are  often  involved,  whence  the  name  of  gonorrhceal  arthritis. 
It  is  often  held  that  it  affects  one  joint  (monarticular)  or  at  least  few 
joints  (oligarticular).  Though  fewer  joints  are  usually  involved  than 
in  genuine  rheumatism,  in  Northrup's  series  more  than  one  joint  was 
affected  in  78  per  cent,  of  the  cases,  and  three  or  more  joints  in  69 
per  cent.;  and  in  Gerhardt's  series  two  to  nine  or  more  joints  were 
involved  in  87  per  cent.,  and  one  joint  only  in  13  per  cent.  Gonor- 
rhoeal arthritis  frequently  involves  joints  which  are  usually  unaffected 
in  acute  articular  rheumatism,  e.g.,  the  sacro-iliac  synchondrosis, 
sternoclavicular,  temporo-maxillary,  and  intervertebral  joints.  The 
knee  is  affected  in  70  per  cent.,  the  ankle  in  27  per  cent.,  fingers  and 
toes  in  19  per  cent.,  hip  in  13  per  cent.,  wrist  in  12  per  cent.,  shoulder 
in  10  per  cent.,  and  the  elbow  in  9  per  cent.,  of  the  cases.  Within  the 
joint  serofibrin  exudes,  and  without  the  joint  there  is  oedema  and  infil- 
tration. Suppuration  is  not  frequent  but  may  occur  with  or  without 
coincident  pyogenic  infection,  especially  in  the  joints  and  tendons  of 


262  THE  SPECIFIC  INFECTIONS 

the  hand.  The  gonococci  are  found  with  variable  frequency,  the  high- 
est percentage  of  cases  being  that  of  Rindfleisch  (60  per  cent.). 

Konig's  'pathological  classification  mcXudes  (1)  simple  hydrops  of  the 
joint;  (2)  catorr^aZ  or  serofibrinous  hydrops;  (3)  py arthrosis,  send  (4) 
gonorrhoeal  phlegmon,  affecting  the  soft  parts.  A  clinical  classification 
Eoiay  be  made  as  follows:  (1)  Arthritic  form,  pain  with  exudation;  (2) 
acute  or  subacute  polyarthritis,  by  itself,  or  with  septicaemia;  (3) 
polytendosynoyitis  and  polybursitis,  often  with  periostitis, — this  is  the 
periarthritic  form;  (4)  acute  monarticular  form,  with  rather  intense  local 
reaction,  sometimes  with  suppuration;  and  (5)  the  chronic  monartic- 
ular hydrarthrosis,  especially  of  the  knee,  a  far  less  frequent  form. 
We  might  add  (6)  the  forms  in  which  simple  arthralgia  is  present  or 
the  process  locali.zed  in  the  heel. 

The  great  clinical  variations  are  explained  by  Pribram,  as  follows; 
The  joint  involvement  results  from  (1)  gonorrhoea  alone;  (2)  gonor- 
rhoeal infection  plus  mixed  infection,  with  pus  or  tuberculous  micro- 
organisms; (3)  genuine  rheumatism,  associated  with  an  accidental 
and  essentially  insignificant  gonorrhoea;  (4)  gonorrhoea  plus  a  relapse 
of  rheumatism. 

Course.— The  course  is  essentially  chronic,  is  sometimes  relapsing, 
and  is  marked  by  complications;  iritis  is  fairly  frequent;  atrophy  in 
the  contiguous  muscles  may  occur  as  in  rheumatism;  ankylosis  may 
result,  which  is  far  oftener  plastic  than  osseous.  In  exceptional  in- 
stances, sciatica,  permanent  arthritic  changes  resembling  arthritis  de- 
formans (q.  v.),  exhaustion  psychoses,  or  multiple  neuritis,  develop. 

Treatment. — Recovery  is  a  matter  of  time  and  nature,  rather  than 
of  therapy.  The  salicylates  are  almost  wholly  inert  and  the  iodides 
highly  unsatisfactory.  In  the  acute  stage,  immobilization  by  plaster 
casts  or  splints,  and  in  the  chronic  stage,  blisters,  Pacquelin  cautery, 
massage,  passive  movements,  and  extension,  to  overcome  residual 
exudation  and  contractures,  are  useful.  Some  cases  are  helped  by 
Roentgen  rays  and  by  superheated  air  (See  Arthritis  Deformans). 
Surgical  incision  and  simple  irrigation  are  indicated  after  a  reason- 
able lapse  of  time  and  after  the  failure  of  expectant  treatment.  In 
some  intractable  cases,  however,  there  is  no  fluid  to  drain. 


SYPHILIS    (POX,  LUES  VENEREA). 

Syphilis  is  evidently  an  ancient  disease  as  is  indicated  by  probably 
syphilitic  bones  belonging  to  the  stone  age  and  found  in  Japan.  The 
first  clear  outbreak  occurred  in  1494  among  the  troops  of  Charles 
VIII,  who  was  then  investing  Naples.  A  full  account  of  this  disease 
will  be  given  because  of  its  colossal  importance. 

Definition. — A  specific  chronic  infection,  found  in  man  only,  either 
hereditary  or  acquired  by  inoculation,  in  the  seat  of  which  a  primary 
lesion  (hard  chancre)  develops.  This  is  followed  in  two  or  three 
months  by  secondary  lesions  in  the  skin  and  mucosse.    Still  later  (after 


ACQUIRED  SYPHILIS  26^ 

months  or  years)  tertiary  lesions  (gummata)  develop  in  the  viscera, 
bones,  and  skin,  and  these  are  finally  followed  in  some  instances  by 
meta-  or  parasyphilitic  manifestations,  as  tabes  dorsalis,  dementia, 
and  perhaps  aneurysm.  This  division  of  Ricord  is  most  convenient 
but  does  not  invariably  hold, — e.  g.,  in  hereditary  syphilis  and  some- 
times in  the  (malignant)  acquired  variety,  where  the  stages  overlap. 
Virchow  finds  a  close  histological  resemblance  between  the  secondary 
and  tertiary  lesions. 

Stages  According  to  Ricord. — The  Primary  Stage. — (1)  Incubation 
lasts  until  the  chancre  appears,  when  the  disease  is  already,  according 
to  most  writers,  a  general  disease;  (2)  the  chancre  develops,  the  lymph- 
vessels  and  adjacent  glands  enlarge,  and  there  is  a  period  of  latency, 
sometimes  called  the  "second  incubation." 

The  Secondary  Stage. — (1)  Symptoms  prodromal  to  the  eruption, 
as  fever  or  anaemia,  develop  and  then  (2)  the  eruption  appears  on  the 
skin  and  mucosae,  with  headache,  "rheumatism,"  iritis,  or  sometimes 
jaundice,  albuminuria,  and  splenic  tumor. 

The  Tertiary  Stage — This  may  follow  very  closely  upon  the  second- 
aries or  appear  with  them  (syphilis  maligna),  but  usually  is  not  mani- 
fest for  at  least  two  years  (even  fifty  or  sixty).  Tumor-like  gummata 
occur  in  the  skin  and  viscera,  especially  in  the  liver,  scrotum,  brain 
and  cord.  Unlike  secondary  manifestations,  they  are  asymmetrical, 
non-contagious,  and  respond  to  different  therapeutic  agents. 

The  parasyphilitic  manifestations  of  Fournier,  Sigmund,  Lancer- 
eaux  and  Baiimler  are  not  included  in  Ricord's  division. 


Acquired  Syphilis. 

Etiology. — 1.  Transmission  by  sexual  intercourse  (contact  syphilis) 
causes  the  great  majority  of  cases,  but  the  term  lues  venerea  is  often 
incorrect  and  unjust  since  syphilis  may  occur  in  the  innocent  (syphilis 
insontium).  Lustgarten's  bacillus  3  to  4  //  in  length,  found  by  him 
in  round  cells  of  primary  and  tertiary  lesions,  is  not  generally  recog- 
nized and  may  be  confused  with  the  smegma  organism.  Schaudinn 
and  Hoffmann  describe  a  spirochcete  pallida,  so  named  because  of  the 
difficulty  in  staining  it:  it  is  thread-like,  refractile,  actively  mobile, 
pointed  at  its  ends,  and  twisted  like  a  corkscrew;  it  measures  4  to  20 ft 
in  length;  it  rather  resembles  the  spirochsete  of  relapsing  fever  but 
is  a  flagellated  protozoon.  Though  it  is  clearly  present  in  nearly  all 
cases,  it  is  not  positively  known  whether  it  is  the  cause  of  syphilis  or 
only  a  concomitant  infection.  It  is  found  in  the  chancre,  in  the  papules, 
blood,  viscera  and  in  inoculated  apes  and  mice.  Siegel's  staining 
technique;  an  old,  "well-ripened"  solution  of  1  part  methylene  blue 
with  2.5  parts  borax  and  100  parts  distilled  water  gives  clear,  well- 
defined  views  of  the  parasites  after  ten  minutes  contact  with  the  sec- 
tions, followed  by  simple  rinsing  under  a  strong  stream  of  water. 
This  stains  the  red  corpuscles  well,  but  leaves  the  blood  plasma  color- 


264  THE  SPECIFIC  INFECTIONS 

less,  in  which  the  parasites  stand  out  distinctly.  It  is  not  necessary 
to  examine  sections  of  the  organs,  as  the  parasites  are  found  equally 
well  in  the  blood,  which  is  much  more  convenient  for  examination. 
Siegel  found  the  parasites  constantly  in  the  blood  at  the  time  of  the 
exanthem.  The  parasites  vanished  from  the  blood  in  the  third  week 
of  inunction  treatment. 

The  sound  skin  and  mucosae  resist  infection,  and  hence  a  raw  sur- 
face, erosion,  wound,  or  hypersemia  is  necessary  for  infection.  Syphilis 
not  only  has  a  certain  choice  of  place  in  its  inoculation,  but  persists 
with  peculiar  obstinacy  in  certain  localities,  notably  in  the  genitalia, 
under  the  breasts,  in  the  axilla,  in  the  navel,  between  the  toes,  in  the 
angles  of  the  mouth,  on  the  tongue,  iris,  palate  or  tonsils,  because  of 
(a)  irritation  caused  by  the  sweat,  sebum,  saliva  or  urine;  (b)  pressure 
on  the  parts  by  clothing;  (c)  trauma  to  the  skin,  or  (d)  irritation  from 
smoking,  from  other  skin  lesions,  and  from  various  causes.  These 
foci  are  of  great  moment  in  the  awakening  or  reproduction  of  the  dis- 
ease. Syphilis  is  sometimes  called  a  disease  of  cities;  though  more 
common  in  the  city  than  in  the  country,  syphilis  very  frequently 
escapes  recognition  in  the  country. 

2.  Accidental  infection  occurs  in  surgical  or  obstetrical  practice,  in 
skin-grafting,  by  postmortem  infection  (two  cases  of  personal  obser- 
vation), in  ritual  circumcision,  in  nursing,  vaccination,  kissing,  from 
use  of  pipes,  in  shaving,  by  scratches,  from  instruments  used  in  glass- 
blowing,  or  from  catheters.  A  few  instances  are  known  of  transmis- 
sion through  a  third  healthy  person. 

Symptoms. — 1.  Primary  Stage. — After  an  incubation  of  two  to 
three  weeks  (ten  to  seventy  days),  the  initial  lesion  occurs  (the  ulcus 
durum,  Hunterian  chancre,  or  initial  sclerosis).  Multiple  lesions  are 
rare.  The  induration  may  be  irregular  or  flat,  but  is  usually  oval. 
It  is  always  sharply  localized,  is  of  variable  or  even  cartilaginous  hard- 
ness, is  freely  movable,  and  is  usually  red  and  papular.  Hardness  is 
its  most  constant  characteristic;  it  may  last  a  long  time,  and  heals 
only  when  the  hardness  disappears.  It  cannot  be  diagnosticated  before 
the  sixteenth,  and  is  most  characteristic  on  the  twenty-first  day  or  in 
the  fourth  week,  when  the  glands  become  somewhat  enlarged.  Such 
retrogressive  changes  as  ulceration,  loss  of  epithelium,  or  necrosis  are 
frequent.  The  ulcer  varies  in  size,  is  round,  elliptical,  slit-like,  or 
irregular;  it  is  hard,  with  even  surface,  seldom  with  elevations  or  ex- 
cavations; it  has  no  areola,  but  a  smooth,  glistening  base  and  there 
is  some  thin  secretion.  The  color  varies.  It  is  gray  when  the  exudate 
is  removed,  red,  blue,  or  even  gangrenous.  On  the  skin  the  chancre 
may  appear  as  an  erosion.  Contact  ulcers  around  the  corona  are  hard. 
The  sclerosis  may  resemble  herpes,  but  there  is  no  itching.  It  has  a 
copper  hue.  An  herpetiform  sclerosis  becomes  indurated  in  about  six- 
teen days,  while  simple  herpes  lasts  but  three  or  four  days.  Herpes 
may  be  the  atrium  for  syphilitic  inoculation.  If  the  sclerosis  occur 
on  a  mucous  surface  there  is  little  elevation;  maceration  and  bleed- 
ing readily  occur,     (a)  The  genital  sclerosis  in  men   occurs   on    the 


ACQUIRED  SYPHILIS  265 

urethral  orifice;  in  the  fossa  navicularis,  possibly  producing  some 
stenosis  or  ulceration,  with  a  thin,  "meat  juice"  secretion;  on  the 
glans,  often,,  as  an  erosion,  usually  not  extensive,  and  difficult  to  diag- 
nosticate because  of  the  hardness  of  the  glans;  on  the  corona,  circular 
and  hard;  on  the  (broken)  frenulum  or  on  the  sulcus  coronarius, 
usually  with  ulceration  and  much  induration,  giving  the  "split  pea" 
appearance,  one-half  lying  on  the  glans  and  the  other  half  on  the  pre- 
puce; on  the  prepuce,  often  with  phimosis;  on  the  dorsum.  (6)  The 
genital  sclerosis  in  women  occurs  mostly  on  the  labia;  in  the  labia 
majora,  as  large,  readily  ulcerating  contact  ulcers  with  inflammatory 
oedema;  in  the  labia  minora  as  small,  hard  and  circumscribed  nodes; 
on  the  prepuce  as  hard  fissures;  in  the  urethral  orifice  with  widening 
and  induration  which  is  felt  from  the  vagina;  on  the  posterior  com- 
missure, as  erosions,  which  are  especially  prone  to  infect  during  coitus; 
on  the  hymen  relics,  as  fissures,  or  large  hard  ulcers  reaching  into  the 
vagina;  rarely  in  the  vagina,  because  of  its  paucity  in  glands  and  the 
thick  epithelium,  although  sclerosis  may  develop  on  gonorrhoea]  ero- 
sions; in  the  vaginal  portion  of  the  cervix,  usually  in  women  who  have 
been  pregnant,  in  which  location  it  produces  chancres  on  the  male 
meatus  and  is  diSicult  to  differentiate  from  simple  and  gonorrhoeal 
erosions,  (c)  The  perigenital  sclerosis  occurs  on  the  scrotum,  on  the 
mons  veneris,  or  on  the  inner  thigh,  (c^)  Extragenital  scleroses  (3  to 
4  per  cent.;  5.5  per  cent.,  Montgomery  and  Bulkley;  6.3  per  cent., 
Fournier)  are  especially  dangerous  in  midwives,  physicians,  and  wet- 
nurses.  They  occur  on  the  scalp,  conjunctiva,  nose,  eyelids,  lips, 
tongue  and  tonsils  (from  sexual  perversion),  cheeks,  fingers,  arms,  and 
mammae.  In  rare  cases  of  accidental  syphilis  the  chancre  may  not  be 
found.  Among  9,058  extragenital  chancres,  1,863  occurred  from  A^ac- 
cination,  745  from  cupping  or  phlebotomy,  179  from  circumcision, 
and  82  from  tattooing  (Bulkley). 

The  primary  sclerosis  is  always  inoculated  from  a  chancre  or  from 
an  individual  with  secondary  syphilis,  and,  in  very  rare  cases  only, 
from  tertiary  syphilis;  Delbanchs  reports  five  infections  from  gum- 
mata  chiefly  of  the  genitalia.  When  the  sclerosis  is  recognized,  the 
blood  is  already  infected. 

Histology  of  the  Sclerosis. — The  round  cells  about  the  vessel 
walls  increase  their  thickness  ten-  or  twentyfold,  and  the  vessel  lumen 
is  narrowed  from  external  pressure  and  endothelial  proliferation,  even 
to  obliteration,  when  retrogressive  change,  as  ulceration,  ensues.  The 
lymph  vessels  and  glands  are  involved  later.  The  nerve  fibers  are 
altered.  Epithelioid  and  giant  cells,  and  proliferation  of  the  connective 
tissue  in  and  about  the  vessels,  are  noted.  The  spirocha?te  pallida  is 
almost  invariably  present. 

Course. — Retrogression  usually  occurs  and  the  induration  dis- 
appears in  thirty  to  ninety  days,  generally  without  scar  formation. 
In  exceptional  cases  (1)  the  sclerosis  lasts  longer,  especially  on  the 
corona  or  prepuce,  and  relics  may  be  found  after  years  (even  50)  due 
to  permanent  vascular  injury;    (2)  acute  or  (3)  phagedenic  inflamma- 


266 


THE  SPECIFIC  LYFECTIOXS 


tion  sometimes  intervenes.  Recently  anthropoid  apes  have  been  inoc- 
ulated by  Metschnikoff  and  Nicolle;  they  developed  typical  chancres 
but  usually  died  in  the  secondary  stage  of  the  disease.  Siegel  states 
that  he  has  succeeded  in  inoculating  rabbits  and  white  mice. 


Dl^gnosis  (According  to  Neujiann). 
Chaxcre  or  Sclerosis — vs. — Venereal  Ulcer  or  Chancroid. 


Incubation:     two  to  three  weeks. 

Form:  erosion,  xilcer,  nodule,  papule, 
aU  indurated. 

Number:  single,  rarely  multiple  at 
first,  also  rarely  successively  inocu- 
lated. 

Depth:  erosion  is  superficial,  flat,  with 
little  elevation,  rarely  deep  excava- 
tions. 

Border:     gradual  descent. 

Surface:  red,  livid,  sometimes  pseudo- 
membranous, thick,  yellow-white 
covering  or  crusts. 

Induration :  marked,  cartilaginous, 
sharply  outlined,  movable,  sometimes 
thin,  lasting  weeks,  perhaps  months. 

Secretion:  scanty,  serous,  autoinocula- 
tion  difficult. 

Pain:    little. 

Destruction:  rarely  phagedenic  (and 
then  circumscribed). 

Re-infection:    extremely  rare. 

Lymph-vessels :  inflamed  frequently, 
hard  and  wide. 

Lymph-glands :  regional,  indolent, 
swelling  hard,  painless,  movable; 
rarely  pus  formation. 

Nature  of  the  disease:  constitutional 
sjTnptoms  foUow,  usually  inside  of 
eight  weeks. 


Three  days. 

Pustule,  ulcer,  etc.,  without  induration. 


Often  multiple  at  beginning  or  succes- 
sively inoculated. 


Through     entire     cutis    or     mucosa; 
"punched-out "  appearance. 

Abrupt,  sharp,  indented,  undermined. 
White,  gray. 


No  basal  induration;  not  sharply  out- 
lined; merges  gradually  into  adjacent 
tissue;    short  duration. 

Rich,  purulent,  auto-inoculation  easy. 


Much. 

More  often  phagedentic;    diffuse. 

Frequent. 

Painful;    cylindrical. 


Often  absent  or  acute  inflammatory 
swelling;  often  pus  formation,  capa- 
ble of  autoinoculation. 

A  local  infection,  or  involving  at  most 
contiguous  lymph-glands. 


Mixed  infection  may  occur,  whence  the  now  abandoned  idea  of  the 
unity  of  all  venereal  ulcers.  The  real  practical  lesson  from  this  doc- 
trine is  diagnostic  reservation,  which  is  often  imperative  for  some 
time  in  doubtful  cases. 

Lymphangitis  syphilitica  is  marked  in  70  per  cent,  of  cases.  The 
lymph  vessels  may  become  as  thick  as  a  lead  pencil,  bulging  at  the 
site  of  the  valves  ("bubonulus");  they  become  hard,  are  mostly  pain- 
less, reddened,  and  are  narrowed  in  their  lumen  from  endothelial  pro- 


ACQUIRED  SYPHILIS  267 

liferation,  and  from  pressure  inward  of  their  infiltrated  walls.  The 
inflammation  is  best  seen  on  the  dorsum  penis,  extending  toward  the 
symphysis  pubis;  it  is  usually  not  over  6  to  8  centimeters  in  length, 
but  may  reach  the  glands.  Resorption  occurs  in  three  to  eight  months. 
(Edema  in  women  is  particularly  suggestive  when  the  lymphatic  sys- 
tem is  involved  and  the  initial  lesion  cannot  be  found.  Local  lymph- 
adenitis (indolent  buboes)  is  present  in  97.3  per  cent,  of  cases,  and 
appears  in  three  weeks  if  there  be  much,  or  in  four  weeks  if  little  secre- 
tion from  the  chancre;  and  in  six  weeks  reaches  the  contralateral  inguinal 
glands  and  the  iliac  and  lumbar  group,  and  in  seven  weeks,  the  cubital 
glands.  Just  before  the  eruption  of  the  secondary  stage,  the  cer\dcal 
and  other  groups  are  involved. 

II.  Secondary  Stage. — Secondary  symptoms  usually  appear  toward 
the  end  of  the  eighth  week  (sixth  to  twelfth  week).  1.  Evidences  of 
general  infection  occur.  Fever  is  spoken  of  by  the  oldest  writers,  but 
is  less  frequent  at  the  present  time  (20  to  33  per  cent.).  It  may  be 
low.  It  is  far  less  common  in  tertiary  than  in  secondary  syphilis 
("fever  of  syphilitic  invasion").  It  often  develops  just  before  the 
eruption,  and  occurs  mostly  in  the  pustular  variety.  It  may  be 
continuous,  remittent,  or  intermittent.  Solution  by  crisis  has  been 
observed  by  Gunz.  Fournier  described  a  typhoidal  type.  Janeway 
reports  instances  resembling  tuberculosis  pulmonalis.  It  may  occur 
with  chills,  suggesting  malaria.  Sudden  ancemia,  vasomotor  symp- 
toms, psychical  depression,  (frontal)  headache,  vertigo,  neuralgias, 
palpitation,  night-sw^eats,  boulimia,  polydipsia,  digestive  disorders, 
nocturnal  boneaches,  synovitis,  increased  reflexes,  icterus,  sw^ollen  liver, 
albuminuria,  or  swollen  spleen,  may  also  occur  as  prodromata. 

2.  The  exanthem  is  polymorphous ,  sharply  marked,  frequently 
grouped  in  a  circular  arrangement  and  is  without  pain  or  itching;  it 
is  highly  infective,  is  not  reddish  as  in  other  eruptions  but  copper- 
colored,  a  fact  recognized  in  the  fifth  century;  it  appears  where  other 
eruptions  are  rare,  as  on  the  forehead  or  nasolabial  fold;  crusts  may 
develop  on  an  infiltrated  basis.  It  is  recurrent  and  responds  to  anti- 
syphilitic  treatment.  The  most  frequent  form  is  the  m^acide  or  roseola, 
next  the  papular  syphilide,  and  then  the  forms  resembling  pustules, 
varicella,  pemphigus  or  impetigo.  In  the  folds  or  damp  parts  of  the 
skin  the  so-called  mucous  patches  appear,  as  at  the  angles  of  the  mouth, 
the  groin,  or  the  perineum. 

3.  The  enanthem  on  the  mucous  membranes  is  observed  on  the 
tongue,  lips  and  cheeks  (mucous  patches),  and  is  often  accompanied 
by  pharyngitis. 

4.  The  lymphatic  enlargement  becomes  general,  although  in  some 
cases  it  may  remain  more  or  less  localized.  Syphilitic  rheumatism 
and  iritis  are  frequent. 

III.  The  Tertiary  Stage. —  This  is  characterized  by  the  gumma 
which  occurs  in  many  tissues.  Its  specific  symptomatology  will  be 
described  below.  The  gumma  may  be  microscopic,  or  an  inch  or 
more  in  diameter.    On  section  it  is  usually  hard,  grayish-yellow,  homo- 


268  THE  SPECIFIC  IXFECTIOXS 

geneous,  centrally  caseous  and  peripherallr  fibrous.  Baiimler  first 
remarked  that  tertiary  syphilis,  particularly  of  the  ^dscera  (liver,  etc.), 
may  be  attended  by  fever.  It  must  be  borne  in  mind  that  in  20  to  40 
per  cent,  of  the  cases  of  tertiary  syphilis,  no  evidence  of  earlier  lesions 
can  be  found.  The  author  believes  that  this  explains  many  instances 
of  the  so-called  mendacia  syphilitica,  since  there  is  no  good  reason 
why  a  patient  should  admit  having  gonorrhoea  and  lie  about  a 
chancre. 

Special  Symptomatology  of  Syphilis. — {A).  Blood. — Oligocythaemia 
and  olio-ochromgemia  occur  earlv  and  mav  be  most  marked  when  the 
glands  are  widely  involved  (Virchow).  The  anaemia  disappears  under 
administration  of  mercury  to  reappear  if  too  much  be  given.  A  count 
as  low  as  1,700,000  may  be  observed.  The  "Justus  test"  is  based 
on  the  loss  of  red  cells  after  mercurialization;  its  value  is  still 
undecided.  The  haemoglobin  is  reduced  15  to  30  per  cent,  and  the 
loss  may  exceed  that  of  the  red  cells.  The  white  cells  are  increased, 
especially  the  lymphocytes;  the  eosinophiles,  as  in  other  skin  diseases, 
are  increased,  but  not  constantly.  The  blood  contains,  especially  dur- 
ing the  secondaries,  the  syphilis  ^-irus,  which  is,  however,  not  always 
inoculable;  it  has  been  held  that  the  germ  is  a  tissue  rather  than  a 
blood  parasite  but  recent  studies  have  shown  that  the  spirochaete  is 
usuallv  present  in  the  blood.  Pernicious  anaemia  and  leukaemia  may 
sometimes  follow  syphilis. 

(B).  The  Skin.— The  macular  (roseolous)  syphilide  is  the  most  fre- 
quent secondary  eruption.  It  develops  rapidly,  lasts  eight  to  ten  days, 
varies  in  size  from  that  of  a  lentil  to  that  of  a  dime,  is  at  first  red,  then 
li^-id,  and  pressure  leaves  it  yellow.  It  comes  out  more  clearly  by  chil- 
lino-  the  skin,  and  sometimes  after  administration  of  mercury.  It  occurs 
mostlv  on  the  trunk.  The  face,  hands,  and  feet  are  usually  free  except 
in  severe  cases.  It  is  symmetrical,  appears  mostly  on  the  flexor  sur- 
faces, is  circumscribed,  recurs  more  frequently  than  does  any  other 
variety,  and  is  prognostically  favorable.  It  is  recognized  with  difficulty 
when  sweat  or  other  secretions  cause  maceration.  On  the  scalp  focal 
fallino-  of  the  hair  results.  Annular  or  gvrate  forms  mav  occur.  Some 
pigmentation  is  left. 

The  papular  syphilide  presents  various  forms:  (a)  The  small  mil- 
iary papule  Qichen  syphiliticus),  usually  develops  on  the  forehead, 
chin,  nose,  shoulders,  buttocks,  back,  and  extensor  surfaces  of  the 
extremities  and  usually  corresponds  to  the  glands  of  the  skin.  Ir- 
regularly distributed,  it  may  appear  in  rings  or  circles.  At  first  red, 
it  rapidly  becomes  brownish-red.  It  may  occur  with  the  roseola  or 
with  acne  in  weak  or  alcoholic  subjects.  Fine  scales  or  crusts  may 
form,  which,  on  faUing,  leave  a  lacquered  appearance;  vesicles  may 
form.  Recurrences  are  infrequent.  It  must  be  differentiated  from 
psoriasis,  the  development  of  which  on  the  scalp,  ear,  and  extensor 
surfaces  is  not  observed  in  syphilis,  where  the  scales  are  smaller  and 
less  glistening;  the  hemorrhage  on  their  removal  is  parenchymatous 
and  not  punctate;  the  glands  are  swollen;  and  the  hair  thinned.    On 


ACQUIRED  SYPHILIS  269 

the  palms  of  the  hands  and  soles  of  the  feet  differentiation  may  be 
difficult,  but  in  syphilis  the  centre  of  the  papule  is  likely  to  be  sunken. 
(6)  The  large  papular  syphilide  is  often  associated  with  fever,  constitu- 
tional disturbance,  or  rheumatism,  and  may  occur  on  all  parts  of  the 
body,  as  the  corona  veneris  on  the  upper  forehead,  around  the  nose,  or 
in  the  furrows  of  the  chin  and  neck.  Though  infrequent  on  the  palm, 
it  is  often  seen  on  the  dorsum  of  the  hand.  This  variety  occurs  most 
frequently  at  the  junction  of  the  skin  and  mucosa  and  its  polymorph- 
ism is  pronounced,  as  psoriasis  palmaris,  rhagades,  onychia,  or  verru- 
cose  forms,  (c)  The  condylomata  latum  (moist  papule)  is  the  papule 
altered  by  secretions  or  excretions,  and  is  found  about  the  genito-anal 
regions,  axillse,  etc.  It  is  the  most  important  syphilide,  and  plays  an 
important  role  in  the  propagation  of  syphilis  by  its  occurrence  on  the 
lips,  breast,  and  genitalia;  it  is  flat,  elevated,  dirty,  ill-smelling,  and 
secretes  a  highly  infective  secretion,  (d)  The  pustular  syphilide  in- 
cludes the  acne  form,  the  varioloid,  varicelliform,  impetiginous,  and 
other  forms. 

Gummata  of  the  skin  are  asymmetrically  disposed;  are  cutaneous 
or  subcutaneous,  involving  deeper  structures;  are  non-infective  com- 
pared with  the  secondary  eruptions;  are  prone  to  develop  at  the  site 
of  secondary  involvements;  occur  in  the  skin  more  than  in  all  other 
localities  combined;  follow  incomplete  mercurial  treatment;  are  pro- 
moted by  vicious  habits  and  constitutional  diseases;  and  are  seen  in 
6  to  13  per  cent,  of  cases,  most  frequently  in  the  third  year  after  infec- 
tion. Small  gummata  may  resorb  by  fatty  degeneration,  but  the  larger 
ones  caseate,  ulcerate,  suffer  secondary  infection,  and  leave  a  scar 
with  deformation.  The  ulcers  may  remain  open  and  resemble 
lupus.  Gummata  are  differentiated  from  malignant  ulcerations  by 
the  absence  of  lymph  nodes,  by  their  slow  growth,  painlessness,  and 
multiplicity,  and  by  the  results  of  therapy.  In  gumma,  ulceration  is 
more  rapid  than  in  lupus;  it  is  deeper,  less  sharply  marked,  redder, 
and  less  symmetrical;  recurrence  after  cicatrization  is  less  frequent, 
the  scars  are  less  flat  and  smooth,  and  the  bacteriological  findings 
of  lupus  are  absent. 

Leukoderma  syphiliticum  is  observed  in  recent,  but  rarely  in  late, 
syphilis — e.g.,  after  macular  or  lenticular  syphilides — as  white  spots 
with  peripheral  brown  pigmentation,  appearing  mostly  on  the  face 
and  neck.  Leukoderma  usually  disappears  in  from  two  to  twelve 
years,  is  rarely  seen  in  either  extreme  of  life,  and  occurs  in  4  per  cent, 
of  syphilitic  men  and  45  per  cent,  of  syphilitic  women  (Neisser). 

The  hair  falls  out  except  from  the  crown  of  the  head.  This  occurs 
most  frequently  during  the  secondary  stage,  and  is  proportionate  to 
the  intensity  of  the  eruption.  It  sometimes  happens  during  the  ter- 
tiary stage;  is  greater  in  poorly  nourished  cases,  and  its  regrowth  is 
often  imperfect. 

The  nails  are  sometimes  affected.  Onychia  syphilitica  occurs  par- 
ticularly in  women,  in  whom  it  may  be  the  only  secondary  symptom 
(Jullien).    The  nails  may  hypertrophy,  fall  out,  or  fail  to  grow.    Peri- 


270  THE  SPECIFIC  IXFECTIOXS 

or  paronychia  rarely  occurs  without  other  specific  signs  and  rarely 
causes  pain,  ulceration  or  suppuration. 

(C).  Lymph  Glands. — The  inguinal  glands  are  first  enlarged  because 
thev  are  nearest  to  the  most  common  erenital  chancre.  Some  glands 
are  more  involved  than  others,  yet  adenopathy  in  secondary  syphilis 
of  any  particular  group,  as  the  epitrochlear,  is  not  pathognomonic. 
The  posterior  cervical  glands  are  involved  more  than  the  anterior. 
Next  in  frequency  are  the  axillary,  epitrochlear,  and  those  along  the 
pectoralis.  Inflammation  and  pain  are  rare,  and  suppuration  occurs 
in  but  3  per  cent.  Secondary  infection  sometimes  causes  painful  in- 
guinal swelling.  In  extragenital  sclerosis,  other  glands  are  enlarged 
first, — e.  g.,  the  anterior  cervical,  from  chancre  of  the  lip.  The  glands 
are  freely  movable;  may  remain  swollen  for  years;  and  are  not  usually 
larger  than  a  hazelnut,  but  occasionally  become  massive  from  trauma, 
scrofula,  or  gumma  formation,  and  then  may  resemble  Hodgkins'  dis- 
ease. Virchow  describes  three  stages:  (1)  irritative;  (2)  medullary, 
with  leukocytosis,  chlorosis,  and  increase  in  the  stroma  and  lymph- 
adenoid  tissue;  (3)  caseous,  from  loss  of  water  and  fatty  retrogression, 
and  much  resembling  gummatous  formation. 

(D).  Gastro-intestinal  Tract. — On  mucous  membranes  the  eruption 
(enanthem)  is  not  necessarily  characteristic,  is  less  frequent  and  is  less 
polymorphous  than  on  the  skin,  T\^th  which  it  occurs  synchronously. 

Mouth. — This  is  more  involved  than  any  other  part  except  the  skin. 
Mechanical,  thermal,  chemical,  and  bacterial  irritation  promote  erup- 
tions. Recurrence  is  very  frequent.  The  eruption  sometimes  occurs 
earlier  than  that  in  the  skin. 

1.  Erythema  may  occur  as  diffuse  or  circumscribed  maculae,  which 
are  dark  red  ^dth  slight  swelling  and  elevation,  especially  in  the  cheek, 
pharynx,  uvula,  palate  and  tonsils — the  acute  syphilitic  angina;  it 
rarely  passes  in  front  of  the  border  of  the  soft  and  hard  palate,  and  it 
often  escapes  recognition  in  women,  in  drinkers,  and  in  smokers. 
Desquamation,  infiltration,  fissures,  with  a  slightly  granulated  and 
vesicular  appearance,  may  develop.  Erosions  may  last  long  in  users 
of  tobacco  and  of  alcohol. 

2.  Mucous  patches  develop  just  before  or  with  the  exanthem,  and 
are  seen  mostly  on  the  tonsils,  cheeks  and  lips.  They  are  single  or 
multiple,  disseminated,  round,  elliptical  or  irregular,  flat  or  slightly 
elevated  patches  which  are  circumscribed  and  of  variable  color,  white, . 
milky,  or  red.  On  the  lips  they  may  measure  6  to  17  millimeters. 
The  desquamated  epithelium  may  be  renewed  when  little  irritation 
exists,  but  the  course  is  usually  chronic;  the  patches  swell,  become 
granular,  ecchymotic,  and  often  ulcerated.  On  the  tonsils,  for  instance, 
they  may  simulate  diphtheritic  patches,  and  in  smokers  a  cure  cannot 
be  effected  until  the  habit  is  stopped.  Cauterization  leaves  scars. 
They  are  the  most  important  syphilide  because  so  highly  contagious. 

3.  Chronic  angina  occurs  in  addition  to  the  syphilitic  patches.  It  is 
of  a  light  red,  granular  appearance,  and  is  accompanied  by  hyper- 
aemia,  some  oedema,  and  erosion,  a  gray  coating  on  the  swollen  ton- 


ACQUIRED  SYPHILIS  271 

sils,  and  the  general  appearance  of  pharyngitis  granulosa.  Psoriasis 
linguae  is  usually  central,  with  round  or  elliptical  bright  red,  flat  spots, 
with  thread-like  coating;  fissures  are  frequent  on  the  edges  of  the 
tongue,  and  result  especially  from  the  use  of  tobacco  and  from  bad 
teeth. 

4.  Pachyderma,  ichthyosis,  and  leukoplakia  occur  on  the  mucosa  of 
the  cheeks,  and  on  the  angles  of  the  mouth,  lips,  and  tongue,  and  are 
not  always  syphilitic,  as  Kaposi  maintained.  They  are  swellings  with 
fissures,  are  gray  in  color,  irregular,  they  vary  in  shape  and  size,  and 
are  thick  and  scar-like.  They  may  occur  early  or  late,  especially  in 
users  of  tobacco  and  of  alcohol,  and  rarely  in  women.  They  may 
become  carcinomatous.  Leukoplakia  in  tobacco  users  usually  occurs 
on  the  tongue,  or  under  the  lip  or  palate,  while  in  syphilis  it  is  mostly 
on  the  cheek. 

5.  Gummata  of  the  oral  cavity  are  tertiary.  They  appear  on  the 
lips,  when  the  face  is  involved,  as  ulcers,  nodes,  or  deformations.  In 
general  they  are  rare  and  without  glandular  swelling,  and  occur  chiefly 
in  smokers.  Gummata  of  the  tongue  are  most  frequent,  occurring  (a) 
as  a  diffuse  glossitis  or  diffuse  infiltration  and  later  as  a  cirrhotic 
shrinkage  or  (6)  as  circumscribed  gummata  on  the  dorsum  or  edges 
of  the  tongue,  with  nodes,  swelling,  or  ulceration,  and  without  pain  or 
glandular  involvement.  Gummata  of  the  palate  or  pharynx  are  mostly 
multiple,  and  ulceration  may  reach  the  nose,  spine,  base  of  the  brain, 
Eustachian  tube,  or  the  large  vessels.  They  are  dangerous  because 
they  are  frequently  diffuse,  deep,  or  phagedenic;  they  destroy  the 
uvula,  produce  adhesions,  obliterate  the  posterior  nares  or  Eustachian 
tube,  stenose  the  pharynx  or  draw  the  tongue  back,  thus  stenosing  the 
respiratory  passage.  In  the  tonsils  they  are  very  deep  and  may  erode 
the  carotid  or  palatine  artery.  Differentiation  is  required  from  tuber- 
culosis and  epithelioma,  in  which  the  glands  are  usually  but  not  always 
involved.  The  diagnosis  ex  juvantihus  is  important.  Carcinomatous 
or  tuberculous  change  in  oral  gummata  is  infrequent. 

(Esophagus. — Strictures  result  from  deep  gummata,  from  ulcera- 
tions in  the  larynx,  or  by  extension  from  the  bronchial  or  other  glands. 
Differentiation  is  required  from  turriors  of  the  mediastinum,  from  an- 
eurysm, carcinoma,  round  ulcer,  and  nervous  dysphagia.  Diverticula 
may  result  as  in  other  stenoses. 

Stomach. — 1.  Acute  catarrhal  gastritis  occurs  in  the  secondary 
stage  with  dyspeptic  disturbances  and  sometimes  with  great  thirst. 
It  is  usually  toxemic,  and  is  rarely  due  to  early  organic  changes  in  the 
liver,  and  other  organs. 

2.  Chronic  gastritis  is  more  common,  in  part  explaining  the  syph- 
ilitic anaemia  and  tertiary  malnutrition:  it  may  result  from  early 
changes  in  the  liver  or  pancreas.  It  differs  in  no  wise  from  the  vulgar 
chronic  gastritis  except  in  the  influence  of  treatment.  Amyloid  change 
and  glandular  wasting  are  infrequent. 

3.  Ulcers  of  the  stomach  are  not  as  infrequent  as  is  usually  stated. 
Some  round  ulcers  are  syphilitic  and  result  from  syphilitic  arteritis; 


272  THE  SPECIFIC  INFECTIONS 

Rosanow  described  an  ulcer  of  eight  years  standing,  with  nocturnal 
exacerbations,  which  was  cured  by  inunctions.  Lafleur  recently  diag- 
nosed an  ulcer  before  operation.  Lang's  contention  that  20  per  cent, 
of  gastric  ulcers  are  specific  is  certainly  overdrawn.  Flexner  has  col- 
lected 16  definite  cases. 

4.  Gummata,  described  by  Wagner,  Lancereaux,  Klebs,  Cornil, 
Chiari,  B.  Hirsch,  Galliard,  Andral,  and  Weichselbaum,  are  rare. 
They  begin  in  the  submucosa,  are  usually  multiple,  leave  radiate 
scars,  and  differ  from  the  ordinary  round  ulcer  in  that  the  latter  is 
funnel-shaped  and  broader  toward  the  mucous  membrane,  while  the 
ulcer  of  gumma  has  undermined  edges  and  is  broader  at  its  base. 

5.  Hemorrhages  from  the  stomach  are  most  rare,  and  Hayem's 
case  is  almost  unique.  They  may  also  result  from  cardiac,  splenic, 
hepatic,  or  renal  lesions. 

Intestines. — Except  for  the  rectal  involvement,  little  is  known  of 
intestinal  syphilis  in  the  adult. 

1.  Acute  catarrhal  enteritis  occurs  with  gastric  catarrh,  and  pro- 
duces icterus  when  the  duodenum  is  involved;  it  resists  treatment 
other  than  specific. 

2.  Chronic  enteritis  results  from  stasis  or  from  acute  enteritis.  In 
the  syphilitic  new-born,  enteritis  is  manifested  by  the  viscid  meconium. 
It  may  occur  with  gummata,  and  disappears  only  with  antisyphilitic 
treatment.  Obstinate  diarrhoea  and  stenosis  may  follow  (Cullerier, 
Pillon,  Mueller,  Rieder). 

3.  Ulcerations  may  result  from  enteritis  in  secondary  syphilis,  from 
gummatous  and  diphtheroid  changes  in  the  tertiary,  and  from 
amyloid  disease  in  the  tertiary  or  quatenary  stages.  Meschede  col- 
lected 54  cases  of  ulcer  in  the  small  intestines.  They  occur  around  the 
axis  of  the  intestine,  and  are  characterized  by  productive  inflammation 
about  the  ulcer,  which  prevents  perforation  but  leads  to  stenosis.  They 
are  not  frequent  in  the  jejunum  or  ileum  but  may  reach  the  colon. 

4.  Intestinal  amyloid  disease  is  associated  with  amyloid  of  the 
liver,  spleen  and  kidneys.  The  gut  is  pale,  smooth,  waxy,  thick,  and 
rigid,  and  there  are  atrophic  folds,  amyloid  ulcers,  obstinate  diar- 
rhoea, stinking  stools,  and  hydrops.  It  is  most  frequent  in  the  small 
intestine  and  is  an  essentially  vascular  change.  Amyloidosis  in  general 
occurs  in  67  per  cent,  of  tuberculosis,  and  in  21  per  cent,  of  syphilis 
(Hoffmann). 

Rectum. — Ulceration  occurs  in  papules  near  the  anus,  or  results 
from  fissures  (Johnson).  Rectal  disease  is  usually  secondary  by  con- 
tiguity, except  in  cases  of  infection  from  unnatural  coitus,  (a)  The 
presence  of  irritative  'proctitis  in  primary  cases  is  not  clearly  proved, 
as  it  is  secondary  to  fissure,  catarrh,  papules,  or  ulcerations.  It  is 
more  frequently  chronic  than  acute,  is  attended  by  evacuations  of 
pus,  which  are  voided  alone  or  with  the  fseces,  by  itching,  tenesmus, 
and  external  excoriations,  by  a  long  course,  and  occasionally  by  secon- 
dary tuberculous  infection.  (6)  Syphilitic  idcers  of  the  rectum  are 
generally  tertiary.    They  occur  high  up,  extend  to  the  colon,  and  often 


ACQUIRED  SYPHILIS  273 

produce  stenosis.  In  14  per  cent,  of  cases  there  are  plaques  in  the 
rectum  (Lang).  The  occurrence  of  strictures  without  previous  ulcera- 
tions is  rarCj,  although  Fournier  declares  it  possible.  Perforation  is 
rare.  The  periproctal  tissues  are  invaded.  Fistulse  may  develop,  but 
the  symptoms  are  less  marked  than  in  cancer  or  tuberculosis.  They 
may  increase  when  the  ulceration  is  low,  or  when  it  is  complicated 
with  fissures.  The  fseces  are  covered  with  mucus  and  blood.  Diar- 
rhoea from  catarrh  of  the  colon,  myositis  of  the  sphincter  with  involun- 
tary evacuations,  burrowing  of  pus,  and  sepsis,  necessitate  at  best 
a  long  course.  Tuberculous  ulcers  rarely  occur  in  the  rectum  alone, 
and  are  marked  by  the  tubercle  bacillus.  In  dysentery  the  involve- 
ment is  higher  up,  colic  is  more  frequent,  diarrhoea  is  more  profuse, 
and  the  resulting  stenosis  is  higher  in  the  intestine.  In  carcinoma,  age, 
cachexia  and  local  appearances  are  suggestive,  but  not  positive  criteria. 
Stricture  is  lower  in  syphilis,  higher  in  carcinoma,  and  adhesions — 
e.g.,  to  the  uterus — are  more  commonly  carcinomatous. 

Pancreas. — Acute  syphilitic  pancreatitis  was  first  noted  by  Rokitan- 
sky.  The  interstitial  inflammation  and  sclerosis  causing  parenchy- 
matous atrophy  is  rarer  in  acquired  (22  per  cent.,  Hecker)  than  in 
hereditary  syphilis.  The  peritoneum  sometimes  participates  in  syphili- 
tic disease  of  the  organs  which  it  envelops,  while  it  is  extremely  rare 
as  an  independent  disease;  Lancereaux,  Aufrecht  and  Laurenzi  have 
observed  gummatous  peritonitis.  Seropurulent,  serous  or  localized 
adhesive  peritonitis  may  occur,  as  perisplenitis,  perihepatitis,  peri 
nephritis,  or  perityphlitis.  Perimetritis,  salpingitis,  and  ovaritis  are 
very  rare. 

(E).  Spleen. — 1.  Acute  splenitis,  first  described  by  Walter  (1821) 
occurs  in  31  per  cent,  of  acquired  and  61  per  cent,  of  congenital  syph- 
ilis. (2)  Interstitial  splenitis  occurs  less  frequently  alone  than  with 
syphilitic  liver  and  renal  disease.  The  organ  is  much  increased  in 
size  and  is  hard,  tender,  and  painful  from  perisplenitis.  (3)  Gumma- 
tous splenitis  is  very  rare,  and  cannot  be  diagnosticated  intra  vitam. 
(4)  Amyloidosis  occurs  very  frequently  as  the  "sago"  spleen  which 
is  not  necessarily  very  much  enlarged;  or  as  the  diffuse  ainyloid  spleen, 
which  causes  considerable  swelling. 

(F).  Liver. — Syphilis  of  the  liver  occurs  in  two  forms,  interstitial  and 
gummatous,  which  are  often  associated  with  perihepatitis,  amyloid  or 
fatty  change,  and  sometimes  also  with  such  parenchymatous  changes 
as  acute  yellow  atrophy.  (1)  Interstitial  hepatitis  (syphilitic  indura- 
tion of  the  liver,  syphilitic  cirrhosis,  or  granulated  liver)  is  more  fre- 
quent in  congenital  (in  65  per  cent.)  than  in  acquired  syphilis.  The 
volume  of  the  liver  is  increased  in  children,  and  sometimes  decreased 
in  adults.  The  surface  is  sometimes  even,  but  is  more  frequently 
uneven,  with  furrows  or  nodules;  the  edge  is  thin,  indented,  and  fairly 
sharp,  whereas  in  other  cirrhoses  it  is  rounded.  Perihepatic  adhesions 
to  the  colon,  the  abdominal  wall,  etc.,  are  frequent,  and  are  clinically 
evidenced  by  lessened  respiratory  excursion.  The  connective  tissue 
forms  in  Glisson's  capsule,  follows  the  branches  of  the  portal  vein 

18 


274  THE  SPECIFIC  INFECTIOXS 

into  the  liver  (peripylephlebitis),  and  shows  as  bands  of  grayish  tissue, 
the  protruding  granules  representing  normal  tissue.  The  liver  cells 
are  degenerated,  or  even  destroyed  by  the  connective  tissue,  or  by 
obliterating  endarteritis  of  the  small  vessels.  The  atrophy  is  most 
marked  in  the  anterior  border  of  the  liver  and  in  the  left  lobe.  The 
connective  tissue  is  not  only  perilobular,  but  reaches  into  the  lobes 
more  than  it  does  in  alcoholic  cirrhosis.  In  acquired  syphilis  the  liver 
is  not  equally  nor  completely  diseased,  whence  protrusions  of  the 
sound  tissue  are  noted.  New  bloodvessels  develop  in  the  connective 
tissue  from  the  hepatic  artery,  the  hepatic  veins  are  dilated,  and  throm- 
bosis may  occur  in  the  portal  vein  and  its  radicles  (pylephlebitis). 

Symptoms. — The  clinical  development  is  latent  or  insidious, — e.  g., 
without  pain,  ascites  or  oedema.  The  abdominal  veins  may  be  dis- 
tended ;  the  urine  is  often  dark,  possibly  icteric,  with  heavy  sediment, 
and  often  with  albuminuria.  The  concomitant  splenic  tumor  results 
from  hyperplasia,  stasis,  or  amyloid  degeneration.  Ascites  is  less  fre- 
quent and  develops  late,  herein  differing  from  the  vulgar  cirrhoses. 
It  usually  increases  gradually.  Icterus  is  less  frequent  (33  per  cent. 
Leube).  More  bile  is  present  in  the  stools  than  in  vulgar  cirrhosis. 
Gastro-intestinal  dyspepsia  and  vomiting  of  blood  are  not  infrequent. 
This  form  develops  more  often  in  men  than  in  women ;  is  promoted  by 
alcoholism;  has  a  chronic  course;  and  its  prognosis  is  rather  better 
than  in  non-syphilitic  cirrhosis,  since  relative  recovery  is  possible. 
When  the  liver  is  small,  recovery  is  impossible.  Death  is  more  com- 
mon from  intercurrent  pneumonia,  from  pleurisy,  from  cholsemia  or 
hemorrhagic  diathesis. 

2.  Gummatous  hepatitis  (syphilitic  hepatitis  par  excellence)  is  more 
frequent  than  the  first  form,  and  occurs  oftener  in  acquired  than  in 
congenital  syphilis.  The  gummata  are  either  miliary  or  large  nodes. 
The  surface  of  the  liver  is  smooth  or  warty,  thickened,  or  adherent  to 
the  diaphragm,  or  colon.  The  nodes  vary  from  one  to  over  fifty,  and 
may  be  superficial  or  deep.  The  liver  is  distorted,  mammillated  or 
lohulated  (hepar  lobatum).  Deep,  irregular,  radiating  furrows  are  fre- 
quent, resulting  from  absorbed  gummata,  affecting  either  lobe,  and 
occurring  mostlv  on  the  anterior  surface  near  the  suspensory  ligament 
(Virchow)  or  on  the  edge.  In  congenital  syphilis  gummata  are  often 
observed  at  the  hilum,  in  the  wall  of  the  portal  vein,  or  near  the  bile 
vessels. 

Symptoms. — Gummata  are  frecjuently  latent — i.e.,  are  discovered 
only  at  postmortem.  Considerable  pain  in  the  shoulder  or  over  the 
liver  often  results,  as  well  as  pain  on  motion  or  tenderness  on  pressure 
in  the  epigastrium  or  hypochondrium.  Pain  is  due  mostly  to  peri- 
hepatitis; a  friction  rub  is  heard  when  the  inflammation  is  fresh; 
adhesions  and  loss  of  respiratory  excursion  result,  in  older  cases. 
Icterus  is  infrequent  and  results  from  accidental  gummatous  compres- 
sion of  the  bile  duct  (Virchow),  from  perihepatitis  (Lancereaux),  or 
from  cicatrices.  When  icterus  exists  the  affection  is  often  mistaken 
for  cancer.    The  liver  mav  be  smaller,  but  usuallv  shows  furrows  and 


ACQUIRED  SYPHILIS  275 

nodules.  Early  enlargement  is  more  frequent  than  in  alcoholic  cir- 
rhosis but  a  final  shrinkage  has  been  observed.  Ascites  is  rare  except 
from  coincident  cirrhosis,  amyloid  liver,  or  cardiac  insufficiency.  When 
present,  ascites  is  usually  terminal,  independent  of  the  size  of  the  liver, 
and  is  often  associated  with  albuminuria.  Splenic  tumor  is  infrequent, 
except  from  gummata  or  amyloid  degeneration  in  the  spleen,  from 
coincident  liver  cirrhosis,  from  gummata  at  the  porta  hepatis,  or  from 
splenic  vein  compression.  Functional  dyspeptic  disturbances,  bronzed 
skin  (Lancereaux),  hemorrhages,  and  inflammations  of  the  serous 
membranes,  rather  infrequently  complicate  liver  gummata. 

Diagnosis. — This  depends  upon  other  evidences  of  syphilis,  and, 
while  sometimes  easy,  it  is  often  difficult  or  impossible.  All  forms 
of  syphilis  of  the  liver  may  remain  stationary  for  a  time  (Bamberger), 
and  in  general  a  longer  course  is  expected  than  in  alcoholic  cirrhosis. 
Oppolzer  and  Bachdalek  mistook  gummata  for  cancer,  and  the  re- 
ported cases  of  cure  of  cancer  by  the  earlier  writers  are  clearly  con- 
fusions with  syphilis.  Age  is  only  a  relative  criterion,  since  cancer 
may  occur  under  thirty  years,  yet  most  cases  of  syphilis  of  the  liver 
occur  under  the  fortieth  year.  Ascites,  icterus,  enlarged  liver,  and 
cachexia,  may  occur  in  both  diseases,  occasioning  doubt  and  confusion. 
The  nodules  of  syphilis  are  usually  small  but  may  be  larger  than  those 
of  cancer.  Rapid  growth  is  an  indication  of  cancer;  more  constant 
size,  of  syphilis.  According  to  Bamberger  and  Peiser,  albuminuria 
and  splenic  tumor  are  more  common  in  syphilitic  liver.  The  best 
clinicians  have  confused  syphilis  with  cancer,  and  the  safest  rule  is 
always  to  think  of  syphilis  when  cancer  seems  the  obvious  diagnosis. 
Coincident  amyloid  disease  renders  the  diagnosis  difficult.  The  lungs 
are  compressed  in  cancer  more  than  they  are  in  syphilis.  The  smooth 
edge  of  the  liver,  lack  of  respiratory  excursion,  or  signs  of  fresh  hepa- 
titis, indicate  syphilis  (Lancereaux  and  Riedel).  Riedel  found  similar 
symptoms  in  syphilis  and  gall-stones,  such  as  pain,  fever,  and  tender- 
ness. Fever  is  not  uncommon  in  hepatic  syphilis,  which  may  then  be 
easily  confused  with  liver  abscess  (q.v.).  Final  differentiation  may  be 
made  ex  juvantibus.  (See  Differential  Table  of  Diseases  of  the 
Liver.) 

Prognosis. — This  is  more  favorable  than  in  the  vulgar  cirrhosis, 
for  the  disease  lasts  several  years.  Spontaneous  recovery  from  gum- 
mata may  result  without  specific  treatment.  Rupture  into  the  peri- 
toneal cavity  is  rare.    Death  from  cachexia  and  amyloidosis  may  occur. 

Amyloid  liver  (q.v.)  may  occur  in  the  congenital  type  (Rokitansky), 
but  is  most  frequent  in  tertiary  acquired  syphilis  or  as  a  parasyphilitic 
manifestation.     Amyloidosis  rarely  occurs  in  the  liver  alone. 

Syphilitic  pylethrombosis  (See  Pylephlebitis). 

Icterus,  especially  investigated  by  French  writers,  has  been  attri- 
buted to  an  intestinal  enanthem,  to  swelling  of  the  portal  lymphatics, 
early  hepatitis,  cholangitis,  injury  to  the  liver  cells,  or  to  gastroduodenal 
catarrh.  Its  connection  with  syphilis  is  likely,  according  to  Neumann, 
when  no  gastric  symptoms  precede  the  icterus;  when  the  icterus  de- 


276  THE  SPECIFIC  INFECTIONS 

velops  synchronously  with  the  exanthem;  when  the  exanthem  recurs 
with  the  recurrence  of  icterus;  and  when  antisyphihtic  remedies  re- 
move the  icterus. 

((r).  Kidneys. — 1.  ^/fewmmwria  occurs  in  cases  of  recent  syphilis  or 
in  the  later  ulceration.  It  is  usually  transitory  and  its  connection  with 
syphilis  is  not  precisely  known.  It  is  thought  to  result  from  toxaemia 
or  vascular  changes.  Its  prognosis  is  usually  good,  since  nephritis 
rarely  follows  it,  but  the  later  in  the  disease  that  albuminuria  appears, 
the  poorer  is  the  prognosis.  The  use  of  small  quantities  of  mercury 
probably  does  not  cause  it  (Lang),  though  energetic  mercurialization 
may  produce  albuminuria,  cylindruria  and  even  calcification  of  the 
convoluted  tubules  (Prevost  and  Saikowsky). 

2.  Paroxysmal  hcBmoglobinuria  occurs  relatively  often,  especially 
after  mercurial  therapy.  The  prognosis  is  better  than  in  non-syphilitic 
cases. 

3.  Acute  'parenchymatous  nephritis  is  focal  and  cortical.  It  occurs 
with  the  eruption,  is  toxsemic,  and  is  distinctly  rare  (although  some 
estimate  its  frequency  at  nearly  4  per  cent,  of  the  cases).  When  it 
develops  late,  from  ulceration,  the  prognosis  is  unfavorable.  There 
may  be  no  symptoms;  ansemia,  vomiting,  or  other  symptoms  of  any 
acute  nephritis  may  be  present,  but  ureemia  is  rare,  since  it  is  a  focal 
disease  (Bamberger),  and  the  greatest  danger  is  from  oedema  of  the 
glottis  and  intercurrent  inflammation. 

4.  Chronic  parenchymatous  nephritis  may  follow  syphilis.  Its  actual 
relation  to  the  disease  and  its  percentage  are  difficult  to  estimate 
(0.5  per  cent.). 

5.  Chronic  interstitial  nephritis  differs  from  the  ordinary  form  only 
in  its  multiple  disseminated  focal  involvement,  which  leaves  scars. 
Polyuria  is  rarely  great,  casts  and  albumin  are  often  present  in  greater 
amount,  and  the  course  is  more  rapid  than  the  ordinary  course  of 
from  three  to  seven  years,  because  of  marasmus,  amyloid,  fatty,  and 
other  visceral  changes.  It  often  occurs  from  the  twenty-seventh  to 
the  thirty-seventh  year,  when  arteriosclerosis  is  rare.  There  is  said 
to  be  no  hypertrophy  of  the  heart.  Bamberger  found  syphilis  in  3 
per  cent,  of  cases  of  ordinary  contracted  kidney,  but  the  exact  relation 
is  difficult  to  determine. 

6.  Gummata,  in  sizes  varying  from  miliary  to  large  forms,  which 
are  found  in  the  cortex  and  sometimes  in  the  medulla,  are  usually 
multiple  (20  to  80)  and  generally  unilateral.  The  renal  tissue  is 
partly  destroyed.  They  occur  especially  with  liver  gummata,  amyloid 
kidney,  and  chronic  parenchymatous  nephritis.  The  symptoms  are 
not  well  defined. 

7.  Amyloid  kidney  may  occur  alone,  or  is  much  more  frequently 
accompanied  by  other  renal  lesions,  especially  contracted  kidney 
(Rosenstein).  It  always  occurs  in  the  advanced  stages  with  cachexia 
and  amyloidosis  in  other  organs.  The  specific  gravity  of  the  urine  is 
higher  than  in  the  non-syphilitic  amyloid  kidney  (Bartels).  The  al- 
bumin is  due  to  vascular  amyloid  change,  but  may  be  entirely  absent 


ACQUIRED  SYPHILIS  277 

(Ebstein).  Globulin  may  occur  in  large  quantities  (Senator).  The 
course  is  chronic. 

8.  According  to  Frerichs,  Cantani,  and  others,  syphilis  is  an  etio- 
logical factor  in  glycosuria.  Mercurial  treatment  is  sometimes  held 
causative.  The  suprarenals  are  rarely  involved,  except  in  congenital 
syphilis;  swelling,  hypersemia,  fatty  degeneration,  gummata,  inter- 
stitial inflammation,  and  amyloid  changes  have  been  recorded. 
Gummata  have  been  observed  in  Addison's  disease.  Amyloid  occurs 
especially  in  the  Malpighian  bodies. 

(H).  Circulation. — The  heart  was  found  involved  but  six  times  in 
100,000  autopsies  (Mracek).  Involvement  of  the  heart-muscle  and 
brain-vessels  is  frequently  associated  with  sudden  death. 

1.  Independent  syphilitic  pericarditis  is  unknown;  it  is  invariably 
a  complication  of  myocardial  syphilis,  occurring  over  the  large  vessels 
or  anterior  surface  of  the  heart,  as  serofibrinous  pericarditis  or  com- 
plete concretion.  Gummatous  pericarditis  is  always  combined  with 
the  serofibrinous  form,  and  sometimes  with  aneurysms  of  the  coro- 
nary arteries.  The  symptoms  are  those  of  disordered  compensation 
or  of  myocarditis,  its  invariable  associate. 

2.  Syphilitic  myocarditis  is  coronary  arteritis;  foci  of  interstitial 
involvement  occur,  as  infiltration  along  the  small  vessels,  which  is 
especially  marked  in  congenital  syphilis,  and  which  spreads  into  the 
intermuscular  septa.  Microscopically,  the  general  picture  of  myo- 
carditis prevails.  It  involves  the  front  surface  or  apex  of  the  left  ven- 
tricle or  the  intermuscular  septum.  In  congenital  syphilis  it  occurs 
in  the  right  more  than  in  the  left  heart.  Resulting  changes  are  cardiac 
hypertrophy,  aneurysm  of  the  heart,  and  Dittrich's  true  heart  stenosis 
(conus  stenosis).  Gummatous  myocarditis  seldom  occurs  alone,  and 
is  usually  observed  with  a  diffuse  myocarditis.  Only  97  (62  perfectly 
clear)  cases  of  myocardial  gummata  are  recorded  (Stockmann,  Gold- 
frank).  Gummata  may  attain  great  dimensions  in  the  interventricular 
septum.  The  disease  is  often  latent  until,  in  50  per  cent,  of  the  cases, 
sudden  death  results,  wherein  it  differs  from  myocarditis  of  other 
origin.  Most  fatalities  occur  in  persons  between  thirty  and  forty 
years  of  age.  The  heart  action  may  be  incompetent  or  irregular,  and 
there  may  be  dyspnoea,  asthma,  angina  pectoris,  or  cerebral  embolism. 
Hydrops  is  rare.  Amyloid  of  the  heart  is  occasionally  associated  with 
gummatous  myocarditis.     Heart  rupture  is  recorded. 

3.  Syphilitic  endocarditis  rarely  develops.  The  nodules  on  the 
valves  rarely  retract,  as  they  do  in  rheumatism,  and  therefore  consecu- 
tive valvular  disease  is  rare.  Mural  plaques  complicate  myocardial 
gummata.     Endocardial  gummata  may  occur. 

Bloodvessels. — Endarteritis  Syphilitica. — (a)  In  the  fibrous  form, 
the  wall  is  thick,  and  opaque,  and  the  intima  and  elastic  tissue  are 
hyperplastic,  and  the  lumen  is  eccentric.  When  the  muscular  coat 
is  not  involved,  thromboses  occur;  when  both  the  muscular  and 
elastic  coats  are  diseased,  aneurysms  result;  this  type  is  known  as 
the  obliterating  endarteritis  of  Heubner  (see  Syphilis  of  the  Brain). 


278  THE  SPECIFIC  INFECTIONS 

(b)  Gummatous  arteritis  or  periarteritis,  occurring  with  Form  a  is 
very  rare,  (c)  General  arteriosclerosis  involves  the  vessels  more  widely 
than  does  the  syphilitic  arteritis  which  is  largely  localized  in  the  aorta 
and  brain-vessels  and  exceptionally  in  the  other  vessels.  Coronary 
involvement  is  held  by  some  writers  to  be  more  frequent  than  brain 
involvement.     It  may  begin  in  the  first  year  after  infection. 

Aorta. — Syphilitic  aortitis  (Heiberg,  1877)  is  oftenest  seen  in  the 
ascending  aorta  and  its  arch  and  thoracic  segment.  It  begins  in  the 
adventitia  or  intima  and  ultimately  involves  all  the  walls,  though  in 
varying  degrees.  The  early  stages  show  gray,  transparent,  gelatinous 
patches  of  productive  inflammation  in  the  intima;  older  foci  are  gray- 
white,  round  or  oval,  elevated  and  stellate  plaques.  The  process 
sometimes  becomes  deep  and  calcification  occurs  in  the  intima  with 
thrombosis.  It  may  extend  down  into  the  aortic  valves.  Its  origin 
may  be  (a)  in  the  intima,  (6)  in  the  adventitia  and  media  together,  or 

(c)  in  the  intima  and  adventitia.  The  resulting  loss  of  elasticity  and 
resistance  promotes  aneurysm.  Welch  held  that  50  per  cent,  of  aneur- 
ysms were  syphilitic;  personally,  the  author  believes  80  to  90  per  cent, 
is  a  more  accurate  estimation.  Syphilitic  aneurysms  develop  more 
rapidly  than  those  due  to  other  causes.  They  may  be  single  or  multiple 
and  usually  occur  in  the  arch  of  the  aorta,  and  sometimes  also  in  the 
abdominal  aorta  or  its  branches  (see  Aneurysm).  Straub  found  this 
aortitis  in  98  per  cent,  of  cases  of  paretic  dementia,  and  Chiari  in  50 
per  cent,  of  syphilitics.  Benda  describes  gummata  (of  which  only  six 
cases  are  on  record). 

Pulmonary  Artery. — Valvular  gumma  is  very  rare,  as  are  occlu- 
sions of  the  pulmonary  trunk,  or  its  compression  by  scars.  According 
to  Neumann,  syphilitic  dilatation  or  aneurysm  of  the  pulmonary  artery 
has  not  yet  been  observed. 

Vein  Syphilis. — Thirty-three  cases  of  phlebitis  were  collected  by 
Roussy  in  1903.  Schuppel  has  described  a  periphlebitis  originating 
in  the  adventitia  and  seen  especially  in  hereditary  syphilis.  Gummata 
sometimes  exist  in  the  veins  or  involve  them  secondarily. 

(/).  Respiratory  Tract. — Nose. — 1.  An  initial  nasal  lesion  is  most 
rare,  only  95  cases  being  recorded. 

2.  Acute  rhinitis  is  much  rarer  in  adults  than  in  the  new-born 
but  is  often  not  recoOTized.  It  is  characterized  bv  being;  less  diffuse 
than  an  ordinary  rhinitis,  by  its  persistence,  by  erythematous  and 
papular  foci,  by  hemorrhagic  erosions  with  persistent  bleeding,  by 
fetor,  sometimes  by  acute  sinus  inflammation,  and  by  hyperplastic 
rhinitis. 

3.  Rhinitis  atrophicans  in  syphilis  is  the  result  of  hyperplastic 
rhinitis. 

4.  Gummata  usually  develop  late,  though  they  have  been  seen  in 
the  seventh  month  (Mauriac) ;  they  occur  on  the  floor  and  septum  of 
the  nose,  and  also  in  the  periosteum,  bone,  and  secondarily  in  the 
cartilage.  They  occur  with  diffuse  necrosis  or  with  circumscribed 
gummata  in  the  skin,  and  involve  the  cartilaginous  and  membranous 


ACQUIRED  SYPHILIS  279 

septum  and  cartilages  of  the  alse;  sequestra  may  be  blown  from  the 
nose.  Septal  perforation  may  develop  and  a  long  course  is  usual, 
with  discharge  of  pus  and  crusts;  the  bone  is  often  denuded.  The 
deformed  "saddle-back"  nose  is  due  to  loss  of  the  triangular  cartilage 
and  vomer,  and  sometimes  to  simple  atrophy.  Difficulty  in  swallow- 
ing, meningitis,  or  disease  of  the  antrum,  are  occasional  sequences. 
Differentiation  from  noma,  tuberculosis,  carcinoma,  and  the  ordinary 
perforating  ulcer  of  Zuckerkandl  (beginning  as  a  hemorrhage  and  due 
to  streptococcic  and  staphylococcic  infection)  must  be  considered. 
The  diagnosis  ex  juvantibus  is  the  best  test. 

Larnyx. — 1.  Catarrhal  laryngitis  occurs  with  the  eruption,  and  at 
times  is  accompanied  by  swelling  of  the  tonsils  and  by  pharyngitis.  The 
larynx  is  red  and  swollen,  with  a  diffuse,  thin  secretion,  which  is  at 
first  thready  and  later  purulent.  Coughing  and  hoarseness  are  com- 
mon. 

2.  In  papular  and  submucous  laryngitis  the  papules  often  ulcerate 
like  ordinary  catarrhal  ulcers  and  are  often  associated  with  diffuse 
infiltration  and  nodes.  The  epiglottis  is  also  involved.  Deforming 
ulcers  are  neither  so  acute  nor  inflammatory  as  the  non-syphilitic 
variety.  Stenosis  of  the  glottis  results  if  ulcers  invade  the  submucous 
tissue. 

3.  Gummata  of  the  larynx  (2  per  cent.)  are  usually  multiple,  and 
vary  from  the  miliary  size  to  that  of  a  pigeon's  egg,  though  sometimes 
they  are  simply  a  diffuse  infiltration.  They  may  soften,  ulcerate,  and 
produce  dysphonia,  dysphagia,  dyspnoea,  hemorrhage,  or  suffocation. 
They  always  leave  adhesions,  stenosis,  scars,  or  deformity. 

Diagnosis. — In  cancer  the  glands  are  usually,  but  not  always, 
enlarged;  the  growth  is  harder  than  in  syphilis;  and  the  microscopic 
examination  may  be  of  value,  but  is  often  unsatisfactory.  Syphilis 
and  tuberculosis  may  occur  together.  Though  the  round  form  of 
syphilitic  ulcer  is  not  of  absolute  diagnostic  value,  it  usually  begins 
near  the  epiglottis,  is  rounder  and  larger,  and  has  sharper  edges,  a 
more  reddened  border,  and  a  whitish-yellow  coating  of  its  deeper 
base,  while  the  tuberculous  ulcer  is  less  red,  less  infiltrated,  less  deep 
and  less  insidious  in  its  development.  . 

4.  Perichondritis  may  affect  any  cartilage,  the  involvement  usually 
being  secondary.  The  cartilage  is  discolored  and  excoriated,  and 
may  be  surrounded  by  oedema,  and  there  may  be  submucous  necrosis, 
or  difficulty  in  respiration  and  deglutition.  The  progliosis  is  always 
grave.  The  lower  the  necrosis  develops,  the  worse  is  the  prognosis, 
for  deformity  and  stenosis  occur.  Syphilis  causes  13  per  cent,  of  cases 
of  glottis  oedema;   tuberculosis,  9  per  cent. 

5.  Cicatricial  stenosis  of  the  larynx,  described  in  the  prelaryngo- 
scopic  days  by  Oppolzer  and  Tiirck,  occurs  mostly  at  the  true  cords, 
usually  with  adhesions  between  the  cords  anteriorly,  and  sometimes 
leads  to  absolute  occlusion. 

6.  Syphilitic  vegetations  are  rare,  and  histologically  resemble  other 
vegetations.     They  are  due  to  irritating  secretions ;  occur  in  the  larynx. 


280  THE  SPECIFIC  INFECTIONS 

epiglottis,  and  anterior  parts  of  the  cords;  appear  sessile  or  peduncu- 
lated; and  cause  dysphonia  or  even  suffocation. 

Trachea. — The  trachea  is  irritated  {e.g.,  by  secretions  from  the 
larynx)  mostly  in  its  middle  third,  and  next  in  its  lower  third.  Only 
two  instances  of  condylomata  have  been  recognized.  There  may  be 
chronic  inflammation  in  the  submucous  tissue.  The  trachea  is  red, 
swollen,  and  sometimes  ulcerated  and  distorted.  Tracheal  stenosis, 
resulting  from  healing  gummata,  is  usually  angular  (Mauriac);  is 
rarely  diaphragmatic,  and  involves  mostly  the  middle  third.  The 
symptoms  are  a  burning  sense  of  constriction;  dyspnoea  at  night,  on 
exertion,  or  on  lying  down;  a  cough  resembling  that  of  pertussis, 
with  sanguineo-purulent  sputum,  which  may  contain  fragments  of 
cartilage;  and  cyanosis  or  lobular  pneumonia.  The  diagnosis  may  be 
made  by  the  laryngoscope. 

Bronchi. — 1.  Acute  bronchitis  is  observed,  especially  in  tubercu- 
lous, cachectic  and  alcoholic  subjects,  and  w^as  held  by  Stokes  to  be 
an  enanthem.  It  is  frequent  with  the  secondary  symptoms  but  may 
last  months. 

2.  Chronic  bronchitis  often  accompanies  laryngeal,  tracheal,  or 
bronchial  affections.  When  there  is  much  secretion,  bronchiolitis  or 
pneumonia  may  result  with  signs  resembling  phthisis.  The  breathing 
is  disproportionately  disturbed  (jMorton),  which  is  caused  by  irri- 
tation of  the  vagus  from  enlargement  of  the  bronchial  glands;  dys- 
pnoea, fever,  pain,  and  a  thin,  green,  nummular,  sometimes  bloody, 
sputum,  may  be  noted. 

3.  Kidney-shaped  ulcers  may  cause  stenosis  and  sometimes  per- 
foration into  the  pulmonary  artery,  mediastinum,  or  oesophagus.  L. 
A.  Conner,  of  New  York,  collected  128  cases  of  bronchial  and  tracheal 
syphilis;   in  56  per  cent,  the  trachea  alone  was  affected. 

Lungs. — S}"philis  of  the  lungs,  as  first  recognized  by  Morton  (eigh- 
teenth century),  may  cause  symptoms  like  those  of  pulmonary  tuber- 
culosis, and,  according  to  Sims,  every  case  with  tuberculous  signs 
should  be  searched  for  syphilis. 

1.  The  white  pneumonia  of  hereditary  syphilis  may  be  described 
here  although  it  presents  no  clinical  symptoms.  The  lung  is  firm, 
heavy,  airless,  and  grayish-white.  This  condition  was  called  white 
hepatization  by  Virchow,  the  chief  change  being  in  the  thickened  and 
infiltrated  alveolar  walls.  In  the  air  cells,  desquamation  and  swollen 
epithelium  are  found,  with  scattered  miliary  foci  about  the  arteries. 

2.  Diffuse  infiliration  differs  from  tuberculosis  in  that  it  occurs  in  the 
centre  of  the  lung,  on  one  or  on  both  sides,  and  exceptionally  in  the  apex 
(Fournier).  It  usually  travels  downward  rather  than  upward.  In  the 
beginning  the  lung  is  red,  hard,  large,  airless,  and  smooth  on  section, 
and  later  becomes  gray,  uneven,  and  nodulated;  the  alveoli  are  filled 
with  fibrin,  epithelium,  and  blood-cells.  Infiltration  of  the  connective 
tissue  occurs,  particularly  about  the  vessels  impinging  upon  the  air- 
cells.  The  bronchi  are  thick,  narrowed  by  connective  tissue,  or  else 
dilated.     The  origin  of  this  infiltration  is  disputed.     It  occurs  either 


ACQUIRED  SYPHILIS  281 

from  desquamative  pneumonia,  from  the  alveolar  connective  tissue, 
from  the  bloodvessels,  from  the  peribronchial  connective  tissue,  or 
from  the  Ijmph-vessels.  Necrosis,  fatty  change,  and  caseation,  may 
result  from  occlusion  of  the  vessels,  which  later  may  result  in  the  forma- 
tion of  cavities  or  pneumothorax.  Disproportionate  dyspnoea  is  pres- 
ent.    Temperature  may  occur  with  or  without  ulceration. 

3.  Gummatous  pneumonia  may  occur  alone  or  with  diffuse  infiltra- 
tion. Gummata  may  be  found  everywhere,  but  largely  in  the  lower 
lobes  near  the  hilum,  whence  they  spread  to  the  pleura  (dry  pleurisy). 
Differentiation  from  tuberculosis  is  often  difficult;  the  two  lesions  may 
occur  together.  Dulness  and  other  signs  of  consolidation  or  cavity 
formation  often  result.  The  sputum  is  mucous,  purulent,  profuse, 
bloody,  stinking,  and  contains  masses  of  tissue  but  no  tubercle  bacilli. 
The  course  is  usually  chronic,  and  advanced  cases  may  heal  with 
appropriate  treatment.  Diagnosis  is  most  difficult  if  the  foci  are  small. 
Tuberculosis  occurs  more  often  on  the  left,  and  syphilis  on  the  right 
side.  Tuberculosis  occurs  more  frequently  in  the  upper,  syphilis  more 
often  in  the  lower  or  middle  lobes.  The  history  alone  may  be  mis- 
leading. Rise  of  temperature  is  more  frequent  in  tuberculosis.  In 
syphilis,  hemorrhage  is  rare,  as  the  vessels  are  obliterated,  and  night 
sweats  are  infrequent.  In  caseous  tuberculous  pneumonia,  localiza- 
tion is  of  no  diagnostic  value. 

4.  Syphilitic  interstitial  pneumonia  rarely  occurs  alone,  but  usually 
with  the  above  affections.  The  lung  may  be  lobulated  like  the  lobu- 
lated  liver,  and  adhesions  may  occur  at  the  base;  there  is  marked 
induration  in  the  middle  portions  of  the  lung,  as  irregular  branching 
bands,  which  dilate  or  distort  the  bronchi;   diagnosis  is  impossible. 

5.  Syphilitic  disease  of  the  pleura  is  rare.  It  may  occur  with  lesions 
of  the  lung  alone  or  with  pleural  gummata. 

(J).  Nervous  System. — The  changes  are  partly  toxsemic,  partly  ana- 
tomical. Syphilis  of  the  nervous  system  occurs  in  men  more  frequently 
than  in  women  (8  to  1),  mostly  between  the  ages  of  twenty-five  and 
forty,  in  neuropathic  subjects,  and  after  trauma;  in  brain  workers  or 
those  debilitated  by  worry,  excesses,  or  from  lead  or  nicotine;  and  in 
cases  of  acquired  syphilis,  or  in  children  as  perhaps  the  first  symptom 
of  parental  disease. 

The  primary  lesion  often  escapes  recognition.  In  20  per  cent,  of 
cases,  there  is  no  history  of  chancre.  It  occurs  where  the  secondaries 
have  been  light  and  have  had  ineffectual  or  no  treatment.  Syphilis 
is  said  to  occur  in  the  brain  in  16.5  per  cent,  of  syphilitics,  more,  in- 
deed, than  in  other  viscera,  excepting  the  liver.  (Again,  it  has  been 
held  that  only  10  to  15  per  cent,  of  syphilitics  have  visceral,  and  only 
3  per  cent,  brain,  complications.) 

Fifty  per  cent,  of  brain  syphilis  occurs  within  three  years  after  infec- 
tion. Formerly  described  as  occurring  many  years  after  infection, 
instances  are  recorded  where  cerebrospinal  syphilis  developed  even  as 
early  as  five  weeks  after  infection.  Nervous  symptoms  may  occur  soon 
after  an  infection  in  those  advanced  in  years  (Kuh).     Earlv  nervous 


282  THE  SPECIFIC  IXFECTIONS 

symptoms,  as  headache,  neuralgia,  spinal  pain,  increased  reflexes,  or 
fleeting  paralyses,  may  occur  in  the  secondary  stage  and  are  probably 
chiefly  toxsemic. 

In  general,  the  symptoms  are  marked  by — (a)  variability,  undulation, 
inconsistency  and  inconstancy,  due  to  the  characteristic  growths  and 
vessel  changes  which  regress  and  recur;  (b)  incompleteness,  as  partial 
paralysis  or  partial  disturbance  of  consciousness;  (c)  the  symptoms 
are  partly  tumor-like,  partly  vascular,  or  partly  inflammatory;  they  are 
partly  meningeal,  partly  basal  or  cortical,  and  rarely  occur  in  the  centre 
of  the  brain  except  from  secondary  vessel  lesions  and  gummata.  The 
disease  may  begin  with  diffuse  neurasthenic,  meningeal,  psychopathic 
or  focal  symptoms.  As  Wunderlich  stated,  syphilis  produces  no 
symptom  not  produced  by  other  disease;  therefore,  no  typical  picture 
obtains. 

Types. — 1.  Basal  gummatous  meningitis,  the  most  studied  type, 
and,  after  arterial  disease,  the  most  frequent  form,  begins  in  the  dura, 
especially  along  the  chiasma  opticum,  in  the  interpeduncular  spaces,  or 
along  the  cavernous  sinus;  less  frequently  in  the  fossa  of  Sylvius  and 
the  cortex;  pathologically  it  consists  of  fibrinous  exudate,  granula- 
tion tissue,  cicatrices  and  gummata. 

General  Symptoms. — Headache  (in  66  to  75  per  cent,  of  the  cases) 
is  the  most  important,  constant,  and  early  symptom.  It  is  paroxysmal, 
or,  if  persistent,  is  increased  at  night,  is  sharp,  boring  or  dull,  is  super- 
ficial, or  deep-seated  (Fournier)  and  but  rarely  circumscribed.  Other 
symptoms  are  neuralgias,  cerebral  (projectile)  vomiting,  vertigo,  and 
changes  in  mentality  (somnolence,  semi-intoxication,  or  impulsive, 
motiveless  activity  and  loss  of  the  aesthetic  sense).  Again,  the  brain 
may  be  normal,  except  during  the  attacks, — e.g-,  coma  may  occur 
from  which  spontaneous  recovery  is  possible.  Persistent  sleep  has 
been  observed,  lasting  for  weeks  or  months  and  is  usually  ominous. 
The  brain  activity  may  be  tardy  or  excited,  while  nocturnal  automa- 
tism (Wood)  or  dementia,  may  develop,  alternating  with  delirium,  epi- 
leptic attacks,  or  paralytic  seizures.  The  brain  symptoms  may,  on 
rare  occasions,  resemble  those  of  ureemia,  meningitis  or  typhoid.  Epi- 
lepsy may  be  typical  or  unilateral,  frequent  or  violent;  tetanic  or 
cataleptic  seizures  may  occur.  Polyuria  or  polydipsia  (33  per  cent,  of 
cases),  diabetes  insipidus  (probably  resulting  from  disease  in  the  third 
ventricle),  or  diabetes  mellitus  (of  which  Oppenheim  has  collected  20 
cases)  may  occur.  Fever  may  be  present;  it  is  irregular,  and  usually 
accompanies  the  secondary  manifestations. 

The  cerebral  nerves  are  often  affected,  especially  the  second  and  third. 
Involvement  of  the  nerve  trunks  or  branches  successively  is  most 
characteristic  (85  per  cent.,  Uhthoff);  80  to  90  per  cent,  of  cases  of 
nerve  involvement  results  from  syphilis  of  the  brain,  tabes,  or  less  fre- 
quently, from  general  paralysis  and  brain  tumor,  (a)  The  third  nerve 
is  involved  most  frequently — 50  to  80  per  cent,  of  the  cases,  "the  sign 
of  syphilis"  (Ricord).  (b)  Disease  of  the  optic  nerve  occurs  anatomic- 
ally in  82  per  cent,  and  clinically  in  40  per  cent,  of  cases.     Choked 


ACQUIRED  SYPHILIS  283 

disk  (10  per  cent.)  is  almost  always  bilateral.  (See  Retinal  Plates 
under  Miliary  Tuberculosis.)  Neuritis  is  unilateral  in  4.6  per 
cent.;  simple  atrophy,  with  complete  blindness  (in  6.6  per  cent.),  is 
most  frequent  in  tabes  and  next  most  frequent  in  brain  syphilis  and 
general  paralysis.  Involvement  of  the  opticus  rarely  occurs  as  an 
independent  syphilitic  lesion.  Amaurosis  is  common  and  often  uni- 
lateral. Hemianopsia  is  homonymous.  Temporal  heteronymous  hemi- 
anopsia is  very  often  syphilitic  while  the  nasal  form  is  rarely  so.  In 
5  per  cent,  of  cases  the  field  of  vision  is  constricted.  The  eye  changes^ 
due  to  meningitis,  bone  disease,  or  gumma,  are  susceptible  to  treat- 
ment, (c)  The  fourth  nerve,  (d)  the  sixth,  and  (e)  the  fifth  nerve  are 
next  in  frequency  of  involvement.  The  fifth  is  unilaterally  affected, 
and  more  in  its  sensory  than  in  its  motor  branches.  The  olfactory 
nerve  is  rarely  involved.  The  facial  nerve  may  be  paralyzed,  nearly 
always  unilaterally  and  peripherally.  The  eighth  nerve  is  sometimes 
involved,  and  the  Meniere  symptom-complex  results,  which,  accord- 
ing to  Fournier,  is  ominous.  The  lower  nerves,  such  as  the  vagus,  or 
hypoglossus,  may  be  affected.  Together  with  the  above  changes 
gummata  may  grow  into  the  pons,  crus,  or  medulla,  and  may  cause 
hemiplegia  and  crossed  paralyses,  as  hemiplegia  plus  oculomotor 
paralysis  (Weber's  paralysis) ;  plus  facial  paralysis  (Gubler's  paralysis) 
or  plus  abducens  and  trigeminus  paralysis  (Leyden's  paralysis).  In 
basal  meningitis,  arterial  phenomena  are  often  noted;  in  the  cortical 
region  they  are  evidenced  by  syncope  or  apoplectiform  attacks  from 
sudden  variation  in  the  blood  pressure;  toward  the  base  (central 
ganglia)  they  produce  encephalomalacia,  hemiplegia,  hemiansesthesia, 
and  hemianopsia.  These,  however,  are  usually  later  symptoms  than 
meningitis  and  neuritis.  The  course  of  syphilitic  meningitis  is  rarely 
acute  or  chronic,  the  typical  type  being  subacute  with  remissions  and 
exacerbations,  and  lasts  rarely  more  than  a  half  a  year,  unless  treat- 
ment has  been  given.  Headache,  convulsions,  sopor,  coma,  delirium 
and  neuritis  are  followed  by  irritative  and  paralytic  symptoms  with 
remissions,  then  with  renewal  of  older,  or  advent  of  new,  symptoms. 

Differential  Diagnosis. — Carcinoma  and  sarcoma  at  the  base  of  the 
brain,  which  involve  the  meninges,  run  a  continuous  progressive  course, 
with  definite  localization  and  with  few  changes  in  the  vessels,  while 
in  syphilis  the  course  is  intermittent  or  remittent,  localization  varies 
and  changes  in  the  vessels  may  be  marked.  Tuberculous  meningitis 
may  exceptionally  give  identical  symptoms,  but  there  is  less  develop- 
ment of  connective  tissue,  vascular  changes  are  rarer,  the  nerves  less 
frequently  involved,  the  course  more  acute,  febrile,  and  progressive, 
and  remissions  less  frequent  and  less  marked;  stift'  neck  and  general 
muscular  rigidity  occur,  which  are  rare  except  in  the  congenital  type 
of  syphilis.  Mental  obscurity  is  more  marked  and  sudden,  while  it 
intermits  in  syphilis.  The  irritation,  in  the  initial  stage,  is  followed 
by  paralysis  later,  while  paralysis  may  occur  at  once  in  syphilis. 
Tuberculous  meningitis  is  a  disease  of  the  first,  second  or  third  decen- 
nium,  while  syphilis  usually  occurs  after  twenty  years  of  age.     Other 


284  THE  SPECIFIC  INFECTIONS 

syphilitic  or  tuberculous  foci  and  the  results  of  therapy  determine  the 
differentiation.  The  two  affections  rarely  co-exist.  Differentiation 
from  Quincke's  serous  meningitis  may  be  difficult,  but  the  variations 
in  the  syphilitic  variety  and  the  results  of  the  therapy  are  the  final 
tests.  Differentiation  must  be  made  from  primary  syphilitic  neuritis 
and  from  multiple  syphilitic  root  neuritis.  It  is  questionable  whether 
primary  involvement  of  the  second  and  third  nerves  may  occur  in 
syphilis.  It  is  rare  at  the  base  of  the  brain  and  these  cases  are  generally 
caused  by  an  anatomical  meningitis  with  but  few  symptoms.  The 
multiple  nerve  root  affections  of  Kahler,  involving  the  seventh  and 
third  cerebral  and  the  cervical  and  dorsal  nerve  roots,  were  observed 
without  symptoms  of  meningitis  or  tumor,  and  caused  neuralgia,  and 
paralysis.  Optic  neuritis  requires  differentiation  from  similar  changes 
due  to  tumor,  alcohol,  nephritis,  diabetes  and  acute  infections. 
Periodic  paralysis  of  the  third  nerve  is  rhythmic  in  its  attacks,  usually 
involves  the  entire  nerve,  occurs  in  young  children  especially,  and  with 
attacks  of  migraine. 

2.  Syphilis  of  the  convexity  may  occur  as  circumscript  or  diffuse 
meningitis  or  meningo-encephalitis,  with  symptoms  like  those  of  cor- 
tical tumor  or  with  diffuse  manifestations. 

General  Symptoms. — Headache  is  usually  the  first  and  most  com- 
mon, though  convulsions  may  be  the  first,  manifestation.  Mental 
symptoms  may  occur  independently  of  the  localization.  Focal  symp- 
toms are  the  Jacksonian  attacks  or  epilepsy,  which  occurs  with  mono- 
or  hemiplegia,  sometimes  with  local  tenderness,  develops  by  starts  or 
"installments"  and  occurs  without  an  aura.  Ninety -per  cent,  of  con- 
vulsions occurring  in  those  over  thirty  years  of  age,  not  ursemic  or 
alcoholic,  are  syphilitic  (Fournier).  The  symptoms  are  more  diffuse 
than  in  vulgar  epilepsy.  The  convulsions  may  even  number  400  in 
twenty-four  hours.  Pain,  or  parsesthesia  occur,  but  anaesthesia  is 
uncommon.  Aphasia  is  frequent  and  is  usually  of  the  transitory  motor 
type  at  first,  word  deafness  being  relatively  rare;  aphasia  occurs  less 
often  from  gumma  than  from  vascular  disease.  Alexia  and  agraphia 
have  been  observed.  When  the  process  is  diffuse  it  may  be  manifested 
clinically  as  an  acute  psychosis  which  can  be  cured  only  with  anti- 
syphilitic  therapy;  dementia  is  the  most  frequent  type.  Both  the 
diffuse  and  gummatous  forms  recover  more  frequently  than  do  other 
forms. 

3.  Syphilitic  arterial  disease  occurs  alone  or  with  the  other  varie- 
ties of  brain  syphilis.  It  is  the  most  frequent  form  and  (aside  from 
paralysis  of  the  nerves),  is  the  most  frequent  cause  of  syphilitic  par- 
alysis. There  are  prodromal  disturbances;  headache  is  usual  but  less 
constant  than  in  meningeal  syphilis;  vomiting,  vertigo,  dulness,  psy- 
chical changes,  dementia,  convulsions,  intermittent  hemianopsia,  and 
aphasia  may  occur;  choked  disk  is  rare;  thrombosis  and  obliteration 
of  the  vessels  is  gradual  in  onset  and  is  intermittent, — e.g.,  it  may 
involve  the  leg  and,  in  a  few  hours  or  days,  the  arm.  These  changes 
are  due  to  obliteration  of  the  vessels  and  multiple  softening  which 


ACQUIRED  SYPHILIS  285 

(in  95  per  cent,  of  cases)  occurs  in  the  Arteria  Fossae  Sylvii;  pseudo- 
bulbar paralysis  may  rarely  result  from  involvement  of  the  bulbar 
vessels. 

Course. — The  first  attacks  are  mild  and  short;  the  later  ones  are 
more  severe,  and  occur  with  marked  somnolence,  very  frequently  with 
bilateral,  alternating,  or  crossed  paralysis,  with  general  or  unilateral 
convulsions,  which  are  rarely  Jacksonian  in  character,  or  with  partial 
or  mixed  aphasia,  mental  changes,  and  progressive  bulbar  phenom- 
ena, such  as  dysphagia.  They  result  from  arterial  disease  or  hemor- 
rhage, the  latter  of  which  is  most  rare  except  from  rupture  of  a  cerebral 
aneurysm. 

It  may  be  difficult  to  diagnosticate  primary  syphilitic  disease  from 
the  ordinary  arteriosclerosis;  the  latter  in  over  90  per  cent,  of  cases 
occurs  in  late  life,  its  progress  is  slower,  the  changes  are  more  dis- 
seminated, all  coats  of  the  vessels  are  involved,  the  more  frequent 
fatty  and  calcareous  changes  lead  more  often  to  widening  than  to 
obliteration,  psychical  changes  and  convulsions  are  less  frequent  and 
hemorrhage  is  more  characteristic  than  softening;  whereas  in  syphilis, 
encephalomalacia  occurs  at  a  younger  age  (See  Brain  Embolism,  Dif- 
ferential Table),  the  changes  chiefly  affect  the  aorta  and  brain  vessels, 
the  intima  is  chiefly  involved  (the  entire  artery  and  tissue  about  the 
artery  are  exceptionally  implicated),  calcareous  and  fatty  changes  are 
rare  and  obliteration  is  usual.  Syphilitic  endarteritis  is  more  acute  in 
development  and  the  headache  is  more  severe  and  is  nocturnal.  There 
are  such  characteristic  psychical  changes  as  somnolence  or  apathy; 
the  hemiplegia  occurs  by  "epochs"  or  "installments,"  is  associated 
with  meningitis,  dementia,  or  delirium;  finally  the  symptoms  are  more 
diffuse  than  in  senile  arteriosclerosis.  Syphilitic  endarteritis  some- 
times occurs  without  softening.  This  type  may  occur  with  spinal 
syphilis  or  may  produce  the  pseudo-apoplectic  attacks  in  tabes  (Minor, 
Kuh,  Heubner,  Dinkier).  Without  treatment,  the  average  duration 
is  one  to  three  months  (Oppenheim), 

Dieulafoy  has  carefully  described  aneurysms  in  the  basilar,  the 
Sylvian,  and  carotid  trunks;  they  are  not  necessarily  tertiary  but  may 
occur  eight  months  after  infection.  Their  rupture  produces  symptoms 
of  apoplexy  or  meningeal  hemorrhage.  Otherwise  hemorrhage  is  rare 
in  brain  syphilis.    They  are  often  multiple.     (See  illustrations  under 

AXEURYSM.) 

While  softening  is  usually  ischsemic  and  not  inflammatory,  we  some- 
times encounter  foci  of  encephalitis  syphilitica  as  (a)  disseminated 
foci  in  the  brain  and  cord;  (6)  indurated  sclerosis;  (c)  softening 
occurring  apart  from  disease  of  the  vessels,  and  very  rarely  observed 
in  secondary  syphilis. 

4.  GuMMATA  are  the  least  frequent  variety;  they  may  occur  in  any 
part  of  the  brain,  usually  in  the  meninges,  although  sometimes  in  the 
medullary  substance,  central  ganglia,  cerebellum,  pons  or  crus.  If 
they  occur  alone  the  symptoms  are  the  same  as  in  brain  tumor,  except 
that  there  is  often  regression,  which  is  either  spontaneous  or  results 


286  THE  SPECIFIC  INFECTIONS 

from  antisyphilitic  treatment.  Cortical  gummata,  producing  cortical 
epilepsy  and  monoplegia,  require  differentiation  from  other  tumors 
as  tubercle  or  glioma;  in  cortical  tumor  the  headache  is  duller  and 
deeper;  the  pressure  symptoms,  mental  depression,  and  slow  pulse  are 
more  marked ;  the  disk  changes  follow  focal  symptoms  and  the  process 
advances  less  by  epochs;  while  in  syphilis  the  headache  is  frequently 
local  and  the  pressure  symptoms  are  more  diffuse,  being  those  of  more 
rapid  extensive  involvement;  the  disk,  as  a  rule,  is  involved  only  when 
coincident  basal  meningitis  occurs.  Cortical  paralysis  may  develop, 
and  is  often  associated  with  Jacksonian  epilepsy  {v.s.).  The  symp- 
toms are  more  undulatory,  and  finally  success  in  treatment  is  per- 
manent (though  slight  temporary  improvement  may  follow  antisyphilitic 
treatment  in  cases  of  genuine  tumors). 

5.  Cerebrospinal  syphilis  produces  no  characteristic  spinal  symp- 
toms; suggestive,  however,  are  (a)  their  asymmetry,  (ft)  their  less  pro- 
nounced character,  (c)  their  variability,  {d)  meningeal  and  nerve  root 
symptoms,  and  (e)  response  to  mercury  and  iodides.  Syphilis  is  never 
a  system-disease  (Gowers).  Syphilis  of  the  cord  is  five  to  six  times 
less  frequent  than  brain  syphilis. 

The  most  frequent  and  characteristic  form  is  cerebrospinal  men- 
ingo-encephalitis,  which  is  observed  in  both  acquired  and  congenital 
syphilis.  While  the  symptoms  may  be  strictly  spinal  (spastic  spinal 
paralysis,  myelitis  and  meningitis),  anatomical  brain  changes,  such  as 
gummatous  meningitis  or  meningo-encephalitis  are  frequently  found. 
Of  the  three  sets  of  spinal  bloodvessels,  the  peripheral  are  most  in- 
volved and  Heubner's  findings  (considered  by  some  characteristic  of 
arterial  brain  syphilis),  are  not  noted  in  them.  Brain  changes  usually 
occur  first  and  may  conceal  the  spinal  symptoms,  so  that  doubt  often 
exists  whether  some  symptoms  are  spinal  or  cerebral.  The  meninges 
are  most  involved  in  the  cervical  and  upper  dorsal  region,  as  evi- 
denced })y  pain,  stiffness,  or  girdle  sensation;  while  the  cord  itself  is 
mostly  affected  in  the  lower  dorsal  region,  and  therefore  involves 
chiefly  the  lower  extremities,  and  causes  weakness  in  the  legs,  par- 
sesthesia,  sphincter  disturbance,  and  decubitus.  Intercostal  neuralgia, 
pains  in  the  extremities  (often  most  severe  at  night),  spastic  parapar- 
esis, hemiparaplegia,  triplegia,  Brown-Sequard's  syndrome,  anterior 
poliomyelitis  or  amyotrophic  lateral  sclerosis,  increased  (varying) 
reflexes,  involvement  of  the  bladder  and  rectum,  and  general  or  selec- 
tive sensory  disturbances,  are  some  of  the  symptoms  of  cerebrospinal 
syphilis.     Erb  has  laid  special  stress  on  the  spastic  paraplegic  type. 

Varieties. — (a)  Gummata  of  the  bones.  These  are  exceptional,  as 
are  also  exostoses  and  caries. 

Q})  Gummatous  meningitis.  This  is  most  frequent,  and  includes 
pachymeningitis  (see  p.  hypertrophica  cervicalis  of  Charcot). 

(c)  Meningo-myelitis.  This  is  myelitis  secondary  to  meningitis, 
with  connective  tissue  and  vascular  changes.  It  is  now  maintained 
that  the  so-called  syphilitic  myelitis  is  only  softening — /.  e.,  myelomal- 
acia. 


ACQUIRED  SYPHILIS  287 

(d)  Gummata  of  the  cord.    These  are  relatively  infrequent. 

(e)  Vascular  disease.  Softening  is  rare  and  involves  small  areas 
only. 

(/)  Perineuritis  gummosa  of  the  sensory  or  motor  nerve  roots. 

Differentiation  from  combined  system-disease  is  often  difficult. 
Some  cases  of  ascending  paralysis  are  considered  syphilitic,  and  some 
have  certainly  been  helped  by  mercury.  In  cerebrospinal  syphilis  and 
parasyphilitic  tabes  or  dementia,  the  lymphocytes  predominate  in  the 
fluid  withdrawn  by  lumbar  puncture. 

Steady  progression  and  constancy  of  symptoms  characterize  mul- 
tiple sarcomatosis  of  the  brain  and  cord. 

Prognosis  of  Brain  Syphilis. — According  to  Naunyn,  only  48  per 
cent,  of  the  cases  recover.  The  later  the  disease,  the  worse  is  the 
prognosis.  The  prognosis  is  more  favorable  in  meningeal  (i.e.,  extra- 
cerebral) involvement,  when  nerve  symptoms  are  dominant,  when 
epilepsy  and  other  symptoms  of  peripheral  brain  irritation  occur,  or 
when  early  treatment  is  instituted.  The  prognosis  is  less  favorable  in 
specific  arterial  disease  (paralysis  from  softening),  in  bulbar  forms,  in 
diffuse  involvement,  in  great  psychical  alteration,  and  in  proportion 
as  the  primary  and  secondary  lesions  were  poorly  developed;  also  in 
extragenital  infections,  in  hereditary  syphilis,  and  in  complicating 
trauma,  tuberculosis  or  alcoholism.  Eighty-two  to  88  per  cent,  of 
cases  of  syphilis  receive  insufficient  mercurialization  (Hjelman). 
Recovery  is  rarely  complete  and  recurrence  may  be  observed.  The 
prognosis  is  relatively  poor  in  spinal  lesions. 

6.  Syphilis  of  the  peripheral  nerves  may  cause  facial  and 
trigeminal  paralysis,  even  in  the  secondary  stage.  The  most  frequently 
affected  spinal  nerves  are  the  occipital  and  auriculotemporal.  Other 
nerves  are  infrequently  involved,  as  the  crural  or  popliteal.  Peri- 
pheral (multiple)  neuritis  is  rare,  yet  isolated  perineuritis  and  neuritis 
gummosa  (nodosa)  are  recorded. 

(A").  Eye  and  Ear. — Syphilis  comprises  2  to  3  per  cent,  of  all  eye 
diseases  and  at  least  3  per  cent,  of  all  syphilitics  have  eye  disease.  Any 
part  may  be  involved,  except  the  lens,  which  suffers  only  from  arterial 
disease  in  the  uveal  tract.  The  uveal  tract  is  most  involved;  next  in 
frequency  come  the  retina,  optic  nerve  and  eye-muscles.  Suppuration 
or  inflammation  may  occur  in  the  lachrymal  duct;  the  gland  is  prac- 
tically immune.  The  lids  are  not  often  involved;  chancre,  condyloma, 
and  gumma,  may  occur,  and  are  easily  confused  with  chalazion. 

Conjunctiva. — Twenty-two  scleroses  (Guzeit)  have  been  observed, 
as  well  as  a  few  gummata;  catarrh  occurs  usually  in  the  secondary 
stage. 

Cornea. — The  cornea  is  frequently  involved:  (a)  as  parenchy- 
matous keratitis,  which  is  mostly  observed  in  congenital  syphilis,  and 
occurs  even  in  the  third  generation,  while  in  acquired  syphilis  it  occurs 
in  but  2  per  cent,  of  cases.  "  Hutchinson's  triad  "  in  congenital  syphilis 
consists  of  keratitis,  notched  teeth,  and  congenital  or  early  acquired 
deafness.     The  cornea  is  diffusely  clouded  and  milky,  and  on  close 


288  THE  SPECIFIC  INFECTIONS 

examination  shows  patches  or  streaks  of  inflammation  and  sometimes 
new-formed  vessels;  (h)  as  keratitis  parenchYmatosa,the  circumscribed 
or  the  punctate  variety;  (c)  as  gumma^  which  is  infrequent;  {d)  as 
keratoma! acia,  which  is  observed  in  the  congenital  variety.  The  sclera 
is  involved  secondarily  to  disease  in  adjacent  parts. 

Zeis. — Of  all  inflammations  of  the  iris,  23  per  cent.  (Cohn)  to  75 
per  cent.  (Mauthner)  or  90  per  cent.  (Klein)  are  syphilitic.  The 
symptoms  are  those  of  other  varieties  of  iritis — ciliary  injection  with 
discoloration,  narrowed  pupil,  slow  reaction,  and  synechia  or  occlu- 
sion of  the  pupil.  It  is  usually  plastic,  or  exudative  with  tiny  papules 
(Fuchs),  and  is  rarely  purulent;  gummatous  iritis  with  nodules,  if  it 
is  not  the  result  of  trauma,  is  strongly  indicative  of  syphilis  (in  12  to 
30  per  cent,  of  such  cases,  Klein).  Iritis  is  usually  secondary  and 
rarely  tertiary,  or  if  so,  it  occurs  in  foci  of  an  old  iritis.  Without  cyclitis 
it  is  rare  in  congenital  syphilis.  As  it  rarely  heals  completely,  atropine 
should  be  administered  early  while  mercury  is  being  given,  for  expec- 
tant treatment  results  in  severe  lesions  and  inflammation  tends  to 
recur.  Serous  iritis  may  occur  in  the  form  of  fine  brown  spots  on  the 
posterior  surface  of  the  cornea.  They  are  often  triangular  in  arrange- 
ment, with  injection,  disturbance  of  sight,  and  a  few  synechia?.  Ciliary 
involvement  is  usually  secondary,  rarely  tertiary  and  may  be  the  sole 
symptom  of  syphilis.  Injection  and  exquisite  tenderness  to  touch  are 
characteristic.  Because  of  their  intimate  vascular  connection,  cyclitis 
is  often  associated  T^dth  iritis.  Gummata  usually  heal;  recurrence  is 
not  infrequent. 

The  Choeoid  is  involved  late  in  the  secondary  period;  it  may  be 
involved  secondarily  to  iritis  or  cyclitis.  There  are  several  forms  but 
all  terminate  with  much  the  same  appearances — e.g.,  the  exudative 
choroiditis  ^dth  bright  yellowish,  bluish,  or  even  rose-colored  spots, 
which  are  small,  oval,  or  irregular,  and  are  usually  peripherally 
pigmented.  The  pigmented  type  is  without  spots.  Both  the  spots 
and  pigment  lie  behind  the  retinal  vessels,  which  branch  over  them  in 
the  ophthalmoscopic  picture.  (See  Retinal  Plates  under  Miliary 
TuBEECULOSis.)  Disseminated  choroiditis  consists  of  spots  of  pig- 
ment, especially  in  the  peripheral  eye  ground,  and  is  usually  an  indica- 
tion of  syphilis.  Choroiditis  may  occur  suddenly,  with  great  pain  and 
reduction  in  the  tension  of  the  eye,  and  with  synechia  and  disturbed 
vision.  When  occurring  with  inflammation  of  the  retina  and  choroid 
(choroiditis  totalis)  the  prognosis  is  usually  bad,  as  blindness  may  result 
from  recurrent  attacks.  Though  no  objective  signs  positively  point 
to  a  syphilitic  origin,  syphihs  is  always  suspected.  The  vitreous  humor 
is  frequently  involved  after  other  lesions,  especially  those  of  the  uvea, 
and  is  rarely  involved  alone.  As  it  usually  occurs  late,  it  results  merely 
in  opacities  or  dust-like  bodies;  in  the  absence  of  myopia  and  hemor- 
rhage, it  rattier  indicates  syphilis. 

The  Retixa  is  involved  chiefly  in  its  anterior  layers,  becoming 
cloudy  about  the  disk,  with  opacity  of  the  nerve  and  blurring  of  the 
disk  outlines.     The  course  of  the  arteries  is  lost  or  broken  and  the 


ACQUIRED  SYPHILIS  289 

veins  are  tortuous  and  engorged.  Hemorrhages  are  not  common. 
Most  idiopathic  cases  of  retinitis  are  syphilitic,  although  no  unique 
morphological  characters  exist.  Nodules,  either  papules  or  gummata, 
constitute  the  specific  retinitis.  This  is  usually  late  or  tertiary  and 
its  prognosis  is  usually  good.  Central  recurring  retinitis  (v.  Graefe), 
commencing  at  the  macula,  is  of  great  importance.  Retinitis  with 
pigment  formation  occurs  mostly  in  congenital  syphilis.  The  optic 
nerve  is  usually  involved  with  the  retina.  It  may  be  involved  any- 
where from  its  central  origin  to  the  disk.  It  is  involved  less  fre- 
quently than  is  the  uveal  tract.  So-called  rheumatic  neuritis  is  often 
syphilitic.  Sometimes  the  change  is  simple  blue  atrophy;  again  the 
appearance  is  nearly  normal,  or  again  choked  disk  occurs.  The 
causative  lesions  are  gumma  in  the  brain,  basal  disease  or  independent 
syphilitic  inflammation  of  the  intracranial  portion  of  the  tract.  Neither 
its  syphilitic  nature  nor  its  location  can  be  diagnosticated  by  the  oph- 
thalmoscope. The  nerve  alone  may  be  involved — e.  g.,  atrophy  may 
occur,  as  it  does  in  tabes  or  progressive  paralysis.  Amblyopia  or  amau- 
rosis may  result  from  transitory,  circulatory,  or  permanent,  organic 
changes.  Hemianopsia  is  often  central,  results  from  lesion  in  the 
optic  tract,  and,  in  most  cases,  is  transitory. 

The  Eye  Muscles  are  involved  as  frequently  as  is  the  iris.  Syph- 
ilis is  a  more  common  cause  than  is  usually  recognized,  explaining 
many  so-called  rheumatic  cases.  More  than  half  the  paralyses  of  the 
eye  muscles  are  syphilitic.  Ocular  paralyses  may  be  (a)  peripheral; 
(6)  intracranial  as  at  the  base  of  the  brain;  or  (c)  central,  comprising 
nuclear,  fasicular  and  cortical  localization.  Anatomically  the  following 
lesions  occur:  diffuse  syphilitic  basal  meningitis,  basal  gummata  and 
periostitis,  cellulitis  of  the  orbit,  diffuse  arterial  disease  of  Huebner, 
nuclear  disease,  poliencephalitis,  gummata  of  the  hemispheres  or  cor- 
tex, and  rarely  hemorrhage.  Other  causes,  as  tabes,  general  paralysis, 
tumor,  tuberculosis  and  cancer  must  be  considered.  Thirty-six  to  50 
per  cent,  of  nuclear  paralyses  are  syphilitic.  According  to  Gowers, 
syphilis  frequently  produces  progressive  paralysis  of  all  the  muscles 
of  both  eyes.  The  oculomotor  is  involved  in  at  least  65  per  cent,  of  the 
cases  (Alexander,  Uhthoff).  Total  paralysis  is  rare;  if  it  occurs,  the 
lesion  is  usually  at  the  base,  is  rarely  orbital,  or  may  be  nuclear  with 
localization  in  the  third  ventricle,  especially  if  one  twig  after  another 
become  involved.  If  it  is  partial,  it  is  usually  nuclear,  rarely  neural  or 
muscular.  Ptosis  occurs  very  frequently,  and  is  highly  suggestive  of 
syphilis.  Abducens  and  trochlear  paralysis  may  occur.  Ophthalmo- 
plegia interna,  involving  the  sphincter  iridis  and  the  ciliary  muscle, 
produces  mydriasis  and  paresis  of  accommodation,  and  is  sometimes 
an  unfavorable  symptom.  Thirty-six  per  cent,  of  all  mydriases  are 
syphilitic  (Alexander).  Its  origin  is  purely  nuclear  (Mauthner). 
Ophthalmoplegia  externa  may  occur  with  facial  paralysis,  involving 
the  orbicularis  palpebrarum,  or  with  trigeminal  paralysis  involving  the 
sensorv  filaments  of  the  eye  (in  25  per  cent,  of  cases  of  brain  syphilis, 
Uhthoff). 

19 


290  THE  SPECIFIC  IXFECTIOXS 

Orbit. — Cellulitis  and  periostitis  occur  frequently.  Periostitis  is 
indicated  by  deep  pain  on  pressure  over  the  eyeball,  or  over  the  edge 
of  the  orbit,  which  is  sometimes  prominent;  by  pain  on  movement 
of  the  eye ;  more  rarely  by  blindness,  exophthalmos,  and  thrombosis. 
Periosteal  gummata  may  often  be  mistaken  for  tumors. 

Ear. — Four  instances  of  primary  sclerosis  on  the  external  ear  have 
been  noted  (Politzer).  The  ear  in  general  is  involved  in  0.6  per  cent, 
in  acquired  syphilis;  33  per  cent,  of  children  with  hereditary  syphilis 
are  deaf.  Secondary  eruptions,  as  maculae  or  condylomata,  mastoid 
periostitis  or  gumma,  sclerosis  or  gumma  of  the  Eustachian  tube,  sup- 
purative otitis  media,  sclerosing  otitis  media  and  labjTinthine  disease 
(rapid  deafness,  vertigo,  and  tinnitus),  may  be  observed. 

(L).  Gentalia. — Some  primary  lesions  occur  in  the  urethra.  Secon- 
dary manifestations  are  infrequent,  though  gummata  have  been  oc- 
casionally observed  in  the  urethra  and  bladder. 

Penis. — Gummata  may  occur  at  the  site  of  the  primary  lesion  or 
elsewhere,  and  have  often  been  confused  ^vith  the  primary  ulcer, 
chancroids,  pustules,  or  carcinoma. 

Testes. — (a)  The  diffuse  interstitial  form  (orchitis  fibrosa  syph- 
ilitica) occurs  with  great  enlargement;  the  swelling  is  oval  or  pyri- 
form,  mth  flattening  of  the  epididymis;  it  is  more  often  nodular  than 
smooth,  and  is  due  to  periorchitis  (the  albuginitis  syphilitica  of  Ricord), 
or  sometimes  to  gummata.  Serous  effusion  and  partial  or  total  syne- 
chia occur.  Recovery  by  absorption  of  this  sarcocele  syphilitica  may 
result.  Some  changes  may  occur  in  the  epididymis  or  spermatic  cord. 
The  connective  tissue  is  increased  and  the  canals  are  compressed, 
separated,  sparse,  fatty,  pigmented,  and  infiltrated- with  round  cells. 
(b)  Gummatous  orchitis  is  less  frequent,  and  usually  involves  one  testis, 
and  also  the  epididymis  and  cord,  more  than  the  first  form.  Great 
swelling  may  occur,  may  be  symmetrical  or  irregular,  and  frequently 
involves  the  entire  organ,  which  is  elastic,  firm,  and  studded  with 
miliary  or  giant  gummata,  has  thick  bloodvessels,  and  shows  per- 
foration with  fungus-like  granulations,  or  suppuration.  It  is  often 
mistaken  for  sarcoma.  The  testes  atrophy  and  sclerose.  The  symp- 
toms begin  gradually,  or  develop  after  strain  or  trauma.  The 
anterior  portion  of  the  testis  is  most  involved,  with  single  or  multiple, 
hard,  irregular  nodules,  which  are  usually  not  painful.  The  veins  are 
dilated  and  adhesions  occur.  The  scrotum  is  infiltrated  and  nodular, 
and  red  or  violet  in  color.  Perforation  is  frequent,  with  a  crater-like 
opening  and  irregular  edges.  Oligospermia,  azoospermia  or  impoten- 
tia  may  occur,  though  this  is  not  always  the  case,  because  islets  of 
functionating  tissue  frequently  remain.  Differentiation  is  required 
from  gonorrhoea!  orchitis,  which  is  more  rapid,  painful,  and  which  in- 
volves the  epididymis  first.  Plastic  orchitis,  resulting  from  stricture, 
traumatic  orchitis,  and  mumps  orchitis,  must  be  considered;  also  tuber- 
culous disease,  which  is  often  bilateral,  or  which  at  least  occurs  in 
several  foci,  and  frequently  involves  the  cord,  vesicles,  epididymis  and 
often  causes  perforation  with  pain,  fever,  and  prostration,  in  which 


ACQUIRED  SYPHILIS  291 

case  tubercle  bacilli  may  be  detected.  Differentiation  is  also  necessary 
from  sarcoma,  which  is  harder,  develops  more  rapidly,  is  more  nodular, 
produces  lancinating  pains,  and  frequently  affects  the  epididymis  and 
cord,  which  are  less  often  involved  in  syphilis.  Sarcoma  also  invades 
the  glands,  and,  when  perforation  results,  is  more  rapid  and  painful, 
and  occurs  with  fever,  necrosis,  hemorrhage,  and  cachexia.  Car- 
cinoma, which  is  often  difficult  to  differentiate  from  the  interstitial 
form  of  syphilis,  does  not  respond  to  specific  treatment. 

Vas  Deferens. — This  is  rarely  involved,  and  is  seldom  affected 
alone,  though  gummata  may  form.  Syphilis  of  the  seminal  vesicles 
may  convey  the  disease  to  the  mother  and  child.  Prostatic  involve- 
ment is  rare. 

Vagina. — In  the  vagina,  primary  infections  are  relatively  rare,  be- 
cause of  its  thick  epithelium  and  the  paucity  of  glands;  secondary 
eruptions  are  rarely  observed.  Condylomata  occur  which  may  be  con- 
fused with  colpitis  granulosa.  They  must  disappear  under  mercury 
to  make  certain  the  diagnosis.  Gummata  rarely  occur  alone  and  sel- 
dom affect  the  whole  circumference. 

Vulva. — The  vulva  is  very  frequently  the  seat  of  secondary  lesions, 
upon  which  tertiary  lesions  develop  from  microscopic  residua  of  secon- 
dary eruptions.  These  may  extend  to  the  urethra  or  bladder.  Enor- 
mous swelling,  sometimes  resembling  blisters,  is  a  common  result  of 
lymphatic  involvement.  Phagedenic  ulcerations  or  strictures  may 
occur.  Gummata  are  readily  differentiated  from  carcinoma  and 
tuberculosis. 

Cervix. — Chancre  occurs  in  5^  per  cent,  of  the  cases  (Fournier, 
Mracek  and  Neumann).  Scars  may  result  with  stenosis,  and  sterility. 
Chancre  in  this  location  is  promoted  by  erosions  and  by  a  low  posi- 
tion of  the  uterus.  Tertiary  lesions  may  occur  and  recur.  Diagnosis 
may  be  difficult. 

Syphilitic  endometritis  is  frequent;  its  symptoms  are  the  same  as 
those  of  the  non-syphilitic  type.  Previous  endometritis  may  be  in- 
creased by  syphilis;  metrorrhagia  may  respond  only  to  mercury. 
Virchow  describes  a  papular  and  a  tuberous  variety.  Endometritis 
may  produce  sterility.  Metritis  syphilitica  has  been  less  studied,  but 
some  clear  cases  are  recorded,  in  which  large  tumors  have  disappeared 
on  administration  of  iodide.  Specific  perimetritis  or  simple  perime- 
tritis is  secondary  to  rectal  disease,  and  is  frequently  located  in  the 
pouch  of  Douglas,  with  gummata,  adhesions,  dislocations  or  with 
sterility. 

Effect  on  Pregnancy. — The  ovum  may  be  infected  without  infection 
of  the  mother,  if  abortion  occurs  in  the  first  two  months,  before  de- 
velopment of  the  placental  circulation.  Later  the  child  infects  the 
healthy  mother  in  direct  ratio  to  the  advance  of  gestation.  The  child 
may  escape  infection,  only  to  become  infected  later  by  preexisting  or 
post-conceptional  syphilis  of  the  mother.  Fraentzel  has  found  peri- 
and  endarteritis  in  the  placental  villi  with  infarction  and  necrosis  from 
occlusion  of  the  vessels.    Thrombosis  in  the  umbilical  vessels  results 


292  THE  SPECIFIC  IXFECTIOXS 

in  the  death  of  the  child,  and  in  abortion.  Adhesions  mar  occur,  so 
that  only  part  of  the  placenta  is  expelled,  and  these  are,  according  to 
Neumann,  the  foci  of  the  specific  disease.  ^Miliary  gummata  have 
been  found  in  the  maternal  portion  of  the  placenta. 

Tubes  and  Ovaeies. — Salpingitis  gummosa  has  occurred.  Oophor- 
itis syphilitica  has  been  described  and  also  gummata,  Avhich  disappear 
on  administration  of  iodide. 

(Jf).  Bones,  Joints,  and  Muscles. — Secondary  periostitis  produces 
pain,  tenderness,  and  considerable  swelling,  vrhich  is  hard  at  first, 
and  later  is  elastic  even  to  fluctuation.  It  occurs  especially  on  parts 
subjected  to  trauma  as  on  the  forehead,  temporal  bone,  sternum,  ribs, 
tibia,  or  clavicle.  Osteophytes  develop  in  the  cambrium  layer,  which 
later  becomes  adherent.  Fugitive  pain  may  occur  with  the  secondary 
eruption.  The  pain  of  periostitis  is  fixed;  it  may  radiate  but  rarely 
migrates,  is  increased  by  pressure,  is  largely  boring  in  character, 
appears  at  night — the  dolores  nocturncE — and  disappears  at  one  or 
two  o'clock  in  the  morning  with  sweating,  but  otherwise  resembles 
other  varieties  of  periostitis.  In  28  per  cent,  of  cases  it  occurs  in 
the  frontal  or  temporal  bones,  and  forms  circumscribed,  smooth, 
elastic,  and  immovable  tumors.  It  may  also  occur  on  the  ribs,  caus- 
ing pain  on  coughing,  neuralgia  over  the  sternum,  or  possibly 
dyspnoea.  Tibial  nodes  occur  in  16  per  cent,  of  cases.  Periosteal 
changes  last  for  five  or  six  weeks  and  are  sometimes  associated  with 
arthritis.  Gummata  of  the  bones  were  the  first  well-studied  form 
of  gummata.  They  occur  on  the  exposed  parts  largely  as :  (a)  Diffuse 
subperiosteal  infiltration,  which  causes  molecular  destruction  of  the 
bone,  and  possibly  reaches  the  marrow  or  meninges  (perforating  type). 
Osteophytes  develop,  and  are  the  result  of  an  effort  of  nature  toward 
regeneration.  The  bone  mav  rarefv  or  show  foci  of  sclerosis;  mul- 
tiple  areas  exist  in  the  pernicious  forms  of  gummata.  In  large  bones 
sequestra  may  form,  especially  in  the  femur;  osteophytes  may  develop 
in  the  diaphysis,  and  sometimes  resemble  arthritis  deformans.  (6) 
Circumscribed  gummata,  the  most  important  form,  develop  chiefly  in 
the  periosteum;  they  form  elastic,  immobile  tumors  which  are  not 
especiahy  tender,  and  which  afterward  soften  and,  at  a  very  late  stage, 
may  develop  connective  tissue  and  calcification. 

Symptoms. — Gummata  of  the  cranium  are  single  or  multiple;  are 
attended  by  duh  pain,  especially  at  night;  have  a  slow  growth;  are 
at  first  soft,  and  later  become  hard  and  have  a  wall-like,  hard  edge. 
They  rarely  ulcerate  and  often  disappear  spontaneously,  lea^•ing  a 
somewhat  elevated  periphers'  and  a  deep  centre.  They  last  for  a 
month  or  two,  and  are  very  often  mistaken  for  supra  orbital 
neuralgia,  or  migraine.  Tuberculous  ulcers  rarely  occur  in  this 
location.  Pyogenic  infection  may  produce  ulceration;  or  menin- 
geal symptoms  such  as  epilepsy,  coma,  paralysis,  or  dementia,  may 
develop.  Gummata  may  occur  at  the  base,  where  periostitis  is  ob- 
served infrequently;  they  occur  chiefly  in  the  middle  fossa  and  involve 
the  nerves  or  bloodvessels.     Diffuse  gummatous  infiltration  develops 


ACQUIRED  SYPHILIS  293 

very  slowly,  with  little  pain,  possibly  with  ulceration  and  exposure  of 
the  bone  and  is  diagnosticated  with  difficulty.  The  spine  is  rarely 
the  seat  of  gummata;  but  when  it  is  involved,  the  affection  is  largely 
cervical,  rarely  dorsal,  very  rarely  lumbar,  and  includes  the  bodies  of 
the  vertebrse  less  than  their  processes  and  arches,  in  contradistinction 
to  tuberculosis.  Pain  and  immobility  are  observed.  The  head  is 
held  in  the  hands,  if  the  atlas  is  involved;  recovery  is  possible,  but 
death  may  result  from  ulceration,  pressure  on  the  medulla,  or  lux- 
ation. Paralysis  of  the  upper  extremities  has  been  observed.  The 
humerus,  radius,  and  carpus,  are  less  frequently  involved.  The  pha- 
langes may  be  involved,  but  this  usually  affects  one  finger  only,  the 
spina  ventosa,  the  parts  being  swollen,  but  soft,  with  periosteal 
thickening,  shining  appearance,  and  rarely  pain  or  ulceration.  The 
clavicle,  from  its  slight  protection  and  its  exposure  to  trauma,  is  very 
frequently  involved;  the  course  is  slow,  often  without  pain.  Ulcer- 
ation of  the  sternum  is  frequent;  that  of  the  ileum  and  sacrum  is 
rare.  Involvement  of  the  tibia,  patella,  femur,  tarsus,  or  toes, 
may  occur. 

Joints. — (a)  Acute  synovitis,  of  recent  syphilis,  occurs  alone  or  with 
bone  changes  at  the  time  of  the  eruption ;  pain  alone  may  be  observed 
or  the  swelling  may  be  multiple,  constituting  the  pseudorheumatism 
of  Fournier,  with  tenderness,  nocturnal  pain,  immobility,  temperature, 
fluctuation  and  involvement  of  the  periarticular  structures,  as  the 
muscles  and  tendons.  The  acute  form  is  polyarticular,  while  the  sub- 
acute variety  is  oftener  monarticular.  The  knees  are  most  frequently 
involved,  and,  according  to  Fournier,  more  than  three  joints  are  never 
affected.  The  affection  may  last  for  weeks  or  months,  does  not  lead 
to  cardiac  complications,  and  responds  to  mercury  and  iodide,  and 
rarely  to  salicylates,  (b)  Chronic  synovitis  or  arthritis  is  usually 
monarticular,  indolent,  with  little  or  no  pain  or  fever,  and  affects 
chiefly  the  knee  and  elbow,  with  slow  loss  of  function  and  fluctuation. 
It  responds  to  antisyphilitic  treatment,  (c)  Joint  disease  of  late  syph- 
ilis originates  in  the  bone  or  cartilages  (tumor  albus  syphilitique  of 
Richet),  and  affects  chiefly  the  knee  and  elbow  and  next  in  frequency 
the  ankle.  The  central  portion  of  the  cartilage  is  involved,  and  not 
its  edge,  as  is  the  case  in  arthritis  deformans.  This  is  probably  due 
to  gummata  originating  in  the  bone  and  is  most  frequently  seen  in 
congenital  syphilis.  The  symptoms  begin  slowly  with  moderate  pain, 
swelling  and  localized  tumors;  no  temperature  is  observed,  the  symp- 
toms vary,  and  contracture  may  result.  There  may  be  a  close  resem- 
blance to  tuberculous  lesions,  diagnosis  from  which  depends  upon 
other  stigmata  of  syphilis  or  tuberculosis;  while  tuberculosis  is  usually 
inflammatory,  incipient  syphilitic  lesions  are  non-inflammatory;  in 
syphilis,  sequestration  and  ulceration  are  infrequent;  therapy  is  the 
flnal  test. 

Muscles. — Early  involvement  may  occur,  even  before  the  eruption, 
from  (a)  toxcemia,  or  (6)  myositis.  The  latter  is  either  a  diffuse  or 
circumscribed  infiltration,  which  possibly  results  in  muscular  contrac- 


294  THE  SPECIFIC  INFECTIONS 

tures  and  limited  motion,  especially  in  the  biceps,  arm  flexors,  finger 
flexors,  sphincter  ani,  masseters,  deltoid,  and  sternocleidomastoid. 
The  course  is  subacute  or  chronic,  depending  on  treatment.  The 
affection  is  most  often  observed  from  two  to  twelve  months  after 
infection.  Diagnosis  from  muscular  rheumatism  may  be  necessary. 
Gummata  of  the  muscles  are  important  because  of  confusion  with 
neoplasms,  especially  when  they  occur  in  the  arms  and  neck;  they 
may  be  as  large  as  the  fist,  single  or  multiple,  usually  with  a  firm  con- 
nective-tissue capsule;  they  involve  the  long  muscles,  especially  at 
their  attachments.  The  course  is  long,  and  regression  may  occur  with 
induration.  Myositis  ossificans  is  rare.  Syphilitic  atrophy  of  the  muscles 
may  follow  arterial  disease  and,  less  frequently,  central  nervous  lesions. 
The  tendons  may  be  involved,  partly  from  changes  in  the  bones  or 
muscles,  (a)  The  irritative  form,  occurring  early  as  acute  bursitis, 
or  as  tendosynovitis  (Fournier),  is  sometimes  confused  with  rheuma- 
tism. There  is  more  tension  than  pain.  It  occurs  most  frequently  in 
sewing  women  and  washerwomen,  and  the  exudate  is  usually  absorbed. 
(b)  The  gummatous  form,  occurring  in  the  flexor  tendons,  is  character- 
ized by  slow  growth,  little  pain,  rarely  by  diffuse  infiltration,  and 
usually  a  favorable  prognosis. 

(N).  Mamma. — The  mammae  may  be  involved  (a)  by  diffuse  infil- 
tration, by  syphilitic  mastitis,  with  increased  size,  and  possibly  by 
tumor  formation.  The  affection  occurs  largely  in  the  secondary  stage, 
and  often  resorbs  spontaneously,  (b)  Gummatous  mastitis  is  deep- 
seated  and  is  not  very  sensitive.  Rapid  growth  may  be  observed 
with  central  necrosis,  fluctuation,  or  even  external  ulceration.  It 
requires  differentiation  from  adenoma,  fibroma,  and  carcinoma;  no 
glands  are  involved,  it  occurs  frequently  on  both  sides,  without 
cachexia,  but  possibly  with  gummata  elsewhere,  and  it  responds  to 
antisyphilitic  treatment,  (c)  206  cases  of  mammary  chancre  are 
recorded  (Dimey). 

Abnormal  Course  of  Syphilis.— Of  special  importance  is  malignant 
syphilis,  (syphilis  precox,  acute  syphilis,  or  galloping  syphilis,  which 
are  synonymous  with  early  development  of  tertiary  syphilis).  The 
cause  may  be  increased  virulence  of  the  virus,  or  decreased  physio- 
logical resistance,  as  in  cases  of  tuberculosis,  alcoholism  and  other 
cachexise.  Early  ulceration,  grave  general  symptoms  and  hemorrhage 
are  noted. 

Relation  to  Physiological  and  Pathological  Conditions. — The  mor- 
tality is  great  in  congenital  syphilis  (v.i.);  tuberculosis,  retarded 
development,  idiocy,  and  epilepsy,  may  result  later.  On  pregnancy  the 
disease  has  a  bad  influence  and  mercury  is  less  universally  successful. 
Exanthematous  diseases  may  cause  syphilis  to  disappear  but  their 
curative  influence  is  short.  The  effect  of  coincident  measles  and 
smallpox  is  unfavorable.  Chronic  diseases,  as  tuberculosis,  are  un- 
favorable and  often  induce  the  ulcerative  form  with  early  tertiary 
symptoms.  Syphilitic  cachexia  may  be  complicated  by  tuberculosis; 
glaucoma  may  become  aggravated,  and  syphilitic  psoriasis  may  become 


HEREDITARY  SYPHILIS  295 

carcinomatous.  Trauma  is  an  important  and  well-studied  subject. 
In  the  treatment  of  fractures  in  syphilis,  mercury  is  indicated.  Pyaemia 
is  seldom  observed  after  operations  in  syphilis.  Syphilis  is  important 
in  plastic  operations.  Wounds  may  become  the  seat  of  specific  ulcera- 
tion. In  life  assurance,  the  outlook  is  uncertain;  it  has  been  estimated 
that  11  per  cent,  die  before  their  expectancy. 


Hereditary  Syphilis. 

That  syphilis  descends  only  to  the  first  generation  is  the  general 
belief.  Fournier  (1905)  finds  115  cases  recorded  in  the  second  gen- 
eration, of  which  many  are  very  doubtful. 

If  both  parents  are  diseased  the  child  mortality  is  68  per  cent,  and 
the  morbidity  is  92  per  cent. 

1.  Sjrphilis  of  the  Child  Acquired  from  the  Father  at  the  Time  of 
Conception. — The  possibility  of  purely  spermatic  (paternal)  infection 
is  established.  It  is  the  simplest  and  most  frequent  variety,  in  that 
97  per  cent,  of  cases  of  syphilis  occurs  in  men  (Fournier),  although  a 
larger  ratio  occurs  in  women  of  the  lower  classes.  It  rarely  occurs 
after  the  second  year  of  infection  has  passed.  The  explanation  is 
difficult,  except  on  the  theory  that  the  otherwise  non-infective  sperma 
is  infective  for  the  ovum  only.  This  form  of  transmission  is  more 
probable,  the  more  recent  the  paternal  disease.  The  effects  are  shown 
by  abortion,  premature  birth,  less  frequently  by  syphilitic  children  at 
full  term,  or  all  of  the  above  successively  (the  virulence  of  paternal 
syphilis  decreasing  with  time).  The  child  mortality  is  28  per  cent, 
and  the  morbidity  37  per  cent.,  this  being  the  most  frequent  and  the 
most  favorable  form.    The  mother  may  remain  uninfected. 

2.  Syphilis  of  Child  from  Mother,  Sjrphilitic  at  the  Time  of  Con- 
ception.— Infection  is  most  dangerous  in  the  first  year  of  the  disease, 
and  generally  persists  longer  than  in  man.  Abortions  occur  first,  then 
premature  deliveries,  and  finally,  dead  or  diseased  children  at  term. 
The  mortality  is  60  per  cent,  and  the  morbidity  84  per  cent. 

3.  Infection  of  the  Mother  and  Conception  Occurring  Simultan- 
eously.— This  form  is  dangerous  to  the  child,  though  early  treatment 
may  modify  the  result.  According  to  Neumann,  in  29  per  cent,  of 
cases,  the  children  are  not  viable,  and  39  per  cent,  die  soon  after  birth 
(i.  e.,  68  per  cent.  die). 

4.  Postconceptional  Syphilis. — The  child  is  less  liable  to  contract 
the  disease,  the  later  the  infection  of  the  mother;  it  may  even  escape 
direct  infection  and  only  suffer  inanition.  The  virus  may  pass  through 
the  placenta  to  the  child,  although  there  is  a  theory  that  the  placenta, 
if  not  diseased,  may  protect  the  child  from  infection. 

Influence  upon  the  Sound  Mother  of  the  Child  Infected  by  the 
Father. — Colle's  (or  Baume's)  law  is  as  follows:  The  child  is  held  to 
make  the  mother  immune  to  infection;  she  cannot  be  infected  from 
her  infected  child;   she  can  nurse  her  syphilitic  child  without  danger. 


296  THE  SPECIFIC  INFECTIONS 

Some  exceptions  exist  and  30  cases  are  reported  in  which  the  mother 
was  infected  after  the  birth  of  a  syphiHtic  child.  Caspary  and  Neu- 
mann have  widened  the  appHcation  of  Colle's  law  to  the  statement 
that  the  mother  cannot  even  be  infected  by  inoculation  from  an  initial 
sclerosis.  In  such  cases  it  is  not  true,  as  Fournier  held,  that  the  mother 
is  already  syphilitic.  Sound  children  of  syphilitic  parents  have  appar- 
ently some  immunity  against  syphilis  because  of  action  of  toxins 
(Profeta's  law, — i.e.,  the  syphilitic  mother  is  said  not  to  infect  the 
sound  child,  which  theory  has  many  exceptions).  If  the  children 
acquire  syphilis,  it  is  said  to  run  a  mild  course.  It  is,  nevertheless,  a 
fact  (Grunfeld)  that  the  sound  child  may  become  infected  intra  partum. 

Influence  on  the  Child. — Abortions  and  miscarriages  have  been 
overestimated  as  evidences  of  syphilis.  They  are  frequent  in  animals. 
Abortion,  atrophy,  maceration,  retarded  development,  congenital  syph- 
ilis or  evidences  of  the  disease  after  birth,  are  frequent.  Many  chil- 
dren, born  first  after  infection,  die,  though  those  born  later  may  be 
sound.  A  difference  exists  between  the  congenital  syphilis  with  signs 
at  birth,  and  the  hereditary  type,  which  develops  later  (possibly  very 
late,  syphilis  hereditaria  tarda).  Even  when  specific  lesions  are  absent, 
pathological  cell  degeneration,  rhachitis,  scrofulosis,  slow  intelligence, 
neuroses,  psychoses,  and  a  high  percentage  of  mortality  to  all  diseases, 
may  result. 

Symptomatology. — The  primary,  secondary  and  tertiary  stages  are 
not  usually  present  and  lymphatic  infection  does  not  precede  that  of 
the  entire  organism.  Secondary  and  tertiary  manifestations  may  occur 
in  the  most  intimate  and  synchronous  connection.  The  symptoms  are 
usually  recognizable  at  birth  or  soon  afterward,  usually  after  a  few 
days  or  weeks,  and  almost  always  within  the  first  three  months. 

Appearance .^ — -The  atrophic  child  presents  a  characteristic  appear- 
ance, with  relaxed  yellow-gray  skin,  poorly  developed  hair  and  bent 
or  undeveloped  nails  (onychia).  The  palms  of  the  hands  and  soles 
of  the  feet  are  lacquered,  the  voice  and  muscles  are  weak,  and  the 
child  does  not  nurse  well.  Such  children,  especially  when  several  are 
born  in  succession,  are  suggestive  of  syphilis,  even  when  no  lesions 
are  found.  Other  suggestive  symptoms  include  the  heavy  placenta 
whose  weight  compared  with  that  of  the  syphilitic  child  is  1  to  5,  4,  or 
3  (normally  1  to  6) ;  increasing  loss  of  weight  for  one  to  two  weeks 
(normally  three  days),  which  may  amount  to  13  ounces;  and  enlarge- 
ment of  the  spleen. 

Pathognomonic  Symptoms. — The  exanthem,  as  in  adults,  is  poly- 
morphous, but  varieties  occur  which  are  absent  or  infrequent  in  the 
adult,  such  as  pemphigus,  hemorrhages,  furuncles,  and  diffuse  infiltra- 
tion of  the  skin.  There  is  a  general  tendency  to  severe  forms.  The 
maculae  are  dirty,  brown-red,  and  often  confluent,  and  occur  on  the 
face,  body,  extremities  and  in  the  genital  region.  The  papules  occur 
principally  in  the  folds  of  the  joints,  in  the  axillre,  groin  and  gluteal 
region  and  they  tend  to  recur;  papules  of  various  ages  co-exist  with 
desquamation,  though  never  with  condyloma,  which  is  always  a  sign 


HEREDITARY  SYPHILIS  297 

of  acquired  syphilis.  They  tend  to  ulcerate.  Psoriasis  of  the  hands 
and  soles  of  the  feet  with  desquamation  is  common.  Pustular  lesions 
occur  in  severe  syphilis  and  are  prognostically  unfavorable.  They 
occur  not  only  in  the  new-born  but  also  in  the  immature  foetus;  pem- 
phigus is  a  subtype  of  the  pustule;  gangrene  and  necrosis  may  occur. 
The  copper-colored  syphilitic  infiltration  especially  on  the  nates  and 
lower  extremities,  may  often  be  mistaken  for  erysipelas.  Coryza 
("snuffles")  is  very  characteristic  and  almost  invariable,  the  secretion 
being  bloody  and  purulent,  with  crust  formation.  Fissures  occur 
about  the  mouth,  with  an  infiltrated  base  and  cicatrix  formation. 
Papular  eruptions  (erosions)  occur  in  the  mouth,  especially  on  the 
tongue  and  the  palate,  and  the  tendency  is  toward  necrosis  of  the  bones. 
Sequels  result  from  secretion  reaching  the  larynx,  lungs  or  intestines. 
Eruptions  and  rhagades  occur  about  the  genital  and  anal  regions. 

Teeth. — Erosions  may  occur  upon  the  surface  and  furrows  of  the 
teeth  and  notches  may  develop.  The  teeth  are  small,  often  irregular 
and  poorly  developed.  Hutchinson  held  that  the  semilunar  covering  on 
the  free  edge  of  the  upper  middle  incisors  was  pathognomonic  of  tardy 
hereditary  syphilis,  but  Hutchinson's  teeth  occur  in  other  affections, 
such  as  scrofula  and  rickets;  they  are  therefore  expressions  of  con- 
stitutional derangement  and  not  necessarily  syphilitic,  though  they  are 
suggestive  of  it. 

Fig.  19. 


Notched  teeth.     Malformation  of  permanent  teeth  found  in  hereditary  syphilis. 
(Jonathan  Hutchinson.) 

Bones. — ^The  bones,  as  in  adults,  may  present  characteristic  findings. 
There  may  be  periostitis,  tophi  or  perforated  palate.  Osteochondritis 
occurs  in  various  bones  but  especially  in  the  lower  end  of  the  femur; 
the  diaphysis  and  epiphysis  may  be  separated.  There  is  (a)  over- 
growth of  the  cartilage  of  the  diaphysis  which  produces  the  wavy  line 
of  white  cartilage  cells;  (6)  the  line  of  cartilage  cells  becomes  thick 
and  foci  of  decalcification  occur;  (c)  the  cartilage  is  as  prominent  as 
it  is  in  rickets,  the  part  nearest  the  bone  being  soft.  The  immobility 
of  the  leg  may  be  suggestive  of  paralysis. 

Viscera. — The  changes  are  vascular  or  gummatous.  There  are 
characteristic  changes  in  certain  organs  which  are  rarely  involved  in 
acquired  syphilis; — e.g.,  in  the  thymus,  umbilical  cord,  pancreas, 
lungs,  intestines  and  adrenals.  To  avoid  repetition  and  to  conserve 
the  classification,  these  changes  have  been  described  under  acquired 
syphilis  (Special  Symptomatology).  Vascular  changes  are  especially 
marked,  as  in  the  umbilical  vessels,  and  the  tendency  is  toward  hem- 
orrhage— syphilis  hcemorrhagica  neonatorum.  Hemorrhages  may  occur 
in  the  skin,  mucous  membranes  and  viscera.  They  may  be  profuse, 
especially  in  the  liver  and  the  lungs,  where  the  circulation  is  precipit- 
ately altered  after  birth.    Some  vessels  may  be  thickened  or  infiltrated 


298  THE  SPECIFIC  INFECTIONS 

(disease  of  the  vasa  vasorum).  There  is  often  deficient  brain  develop- 
ment and  the  posterior  cerebral  fossa  is  especially  involved;  the  head 
may  be  retracted,  and  there  are  other  signs  of  meningitis. 

Acquired  Syphilis  in  Children —vs. Hereditary. 

Less  mortality  and  less  malnutrition.  Marked. 

After  third  month  (are  exceptions).  Before  third  month. 

A  primary  lesion  occurs.  Absent. 

Secondary  lesions,  then  tertiary.  Secondary  and  tertiary  together. 

Lymph  glands  enlarged.  Absent  (except  from  accidental  causes 

or  suppuration). 

Usual  sequence  of  primary,  secondary         SnufHes,  ansemia,  diffuse  pigmentation, 
and  tertiary  symptoms.  pemphigus,  involvement  of  soles  and 

palms,  epiphyseal  changes,   etc. 

Syphilis  hereditaria  tarda  develops  its  first  symptoms  in  later  years, 
as  for  instance,  at  puberty.  This  variety  is  recognized  by  some  writers 
such  as  Neumann,  if  (a)  the  parents  are  syphilitic,  and  if  (6)  the  indi- 
vidual has  presented  no  previous  signs  of  syphilis.  Most  cases  begin 
between  the  tenth  and  eighteenth  years  (rarely  before  the  tenth  and 
even  after  the  fortieth  year).  Most  cases  are  seen  in  private  practice. 
The  symptoms  are  mostly  those  of  infantilism,  in  regard  to  puberty, 
bone  development,  teeth,  and  brain. 

Syphilis  usually  confers  immunity,  but  this  is  neither  absolute  nor 
life-long,  because  (1)  reinfection  may  occur  (53  instances,  Koebner) ; 
(2)  in  hereditary  syphilis,  a  later  infection  may  be  acquired  (27  cases 
known)  and  (3)  a  sound  child  of  syphilitic  parentage  may  acquire 
syphilis  (29  cases  reported). 

Treatment  of  Syphilis. 

Prophylaxis. — The  disease  prevails  in  spite  of  the  numerous  oppor- 
tunities for  free  treatment,  for  the  sexual  instinct  is  even  stronger 
than  that  of  self-preservation.  Irregular  intercourse  is  possible 
because  of  class  differences,  lack  of  barriers  among  the  ignorant  and 
destitute,  and  is  promoted  by  the  struggle  for  existence  which  often 
makes  early  marriage  impossible.  Prostitution,  hidden  or  open,  is 
the  basis  of  syphilis.  Sixty-nine  per  cent,  of  women  in  open  houses 
have  the  disease  for  months  before  treatment  is  instituted,  while  hidden 
prostitution  among  waitresses,  for  example,  is  much  more  dangerous. 
In  prostitutes,  condylomata  last  as  long  as  seven  years  and  repeatedly 
recur  about  the  genitalia.  Continence  and  enforced  medical  inspection 
with  control  are  the  sole  prophylactic  measures.  American  sentiment 
is  against  licensed  prostitution,  which,  besides,  is  incomplete  because 
it  does  not  regulate  men  nor  unlicensed  hidden  prostitution.     Many 


TREATMENT  OF  SYPHILIS  299 

infections  are  acquired  under  the  influence  of  liquor.  Where  ethical 
considerations  fail,  an  appeal  to  fear  may  be  effectual. 

The  importance  of  the  disease  lies  in  its  long  course,  in  the  involve- 
ment of  vital  viscera,  in  its  transmission  to  the  wife  and  oft'spring 
whose  mortality  and  morbidity  are  enormous,  in  its  wide  dissemination 
(13  per  cent,  of  the  population  acquire  the  disease,  and  1,650,000 
persons  are  infected  annually),  and  finally  in  our  possession  of  specific 
remedies. 

Marriage  should  be  forbidden  for  at  least  two,  or,  better,  for 
three  years.  Coitus  must  be  avoided  when  there  are  recurrences. 
In  cases  of  doubtful  infection  of  the  wife  or  husband,  both  should 
be  treated.  Inunctions  should  be  given  the  pregnant  mother,  whether 
she  be  infected  in  the  first  or  second  part  of  pregnancy.  If  the 
child  be  diseased  and  the  mother  healthy,  the  facts  should  be  laid 
before  her  and  some  would  then  allow  her  to  choose  whether  she  would 
nurse  her  child.  Mercury  should  be  given  her.  The  physician  should 
never  countenance  employing  a  healthy  wet-nurse  for  the  syphilitic 
child.     Circumscision  is  thought  to  lessen  chances  of  infection. 

I.  Initial  Lesion. — Extirpation  is  inefficient.  The  early  use  of  mer- 
cury does  not  prevent  the  secondaries  nor  the  recurrence  of  the  dis- 
ease; it  may  lessen  secondary  manifestations,  but  it  is  thought  that 
the  tertiaries  are  more  apt  to  follow  weak  secondary  development.  We 
may  err  in  the  diagnosis  of  hard  chancre,  if  we  employ  treatment  in 
the  initial  stage.  Patients  may  become  immune  to  mercury  when 
results  are  most  needed — e.g.,  late  in  the  course  of  the  disease. 
Nevertheless,  the  writer  believes  early  treatment  is  often  indicated 
when  the  diagnosis  is  certain.  Local  treatment  includes  the  use  of 
antiseptics,  iodoform,  aristol,  mercurial  plasters,  iodoform  in  supposi- 
tory in  rectum  or  vagina,  bichloride  washes  for  mouth,  and  calomel  for 
condylomata  (calomel  6  parts,  boric  acid  3,  and  salicylic  acid  1  part). 

II.  Seconday  Stage. — In  the  secondary  stage  mercury  is  a  specific. 
It  must  always  be  used  with  care;  the  teeth  should  be  cleaned  first, 
and  bad  teeth  should  be  filled.  Calomel  acts  especially  on  the  lesions 
of  the  mouth,  and  is  prone  to  produce  salivation.  Mercury  is  indicated 
for  all  of  the  irritative  (i.e.,  secondary)  phenomena  of  syphilis,  and 
Gowers  always  uses  it  with  the  iodides,  even  in  the  tertiary  stage, 
especially  in  nervous  lesions.  Mercury  may  produce  bad  effects  (v.i.) 
in  tuberculous,  cachectic,  alcoholic,  malarial,  or  anaemic  subjects,  in 
bleeders,  and  in  cases  of  galloping  syphilis,  in  which  latter,  iodides  are 
considered  by  some  better  than  mercury.  Mercury  must  be  used  with 
great  care  in  nephritic  subjects. 

Methods  of  Administration. — 1.  By  Mouth. — Ninety-five  per 
cent,  of  cases  are  treated  by  this  method  in  this  country:  (a)  Calomel 
(Hydrargyri  chloridum  mite)  is  especially  adapted  to  children  with 
hereditary  syphilis,  who  are  rarely  salivated  under  three  years  of  age; 
gr.  \  to  h  t.  i.  d.  plus  opium  p.  r.  n.  It  is  insoluble,  and  is  probably  con- 
verted by  the  alkaline  carbonates  in  the  intestines  into  the  gray  oxide 
which  is  absorbed  with  the  fats.     (6)  Blue  mass  (Massa  hydrargyri), 


300  THE  SPECIFIC  INFECTIONS 

gr.  ^  to  1,  is  milder  than  calomel  and  less  irritant  to  the  stomach,  but 
produces  salivation  oftener  than  any  other  mercurial.  Women  are 
less  subject  to  ptyalism  than  men.  (c)  Hydrargyrum  tannicum  oxy- 
dulatum  (Lustgarten)  contains  50  per  cent,  mercury,  is  non-irritant, 
does  not  salivate,  produces  less  diarrhoea  and  is  easily  assimilated;  gr. 
1  to  1^  plus  pulv.  opii  gr.  A;  {d) — 

Hydrargyri  protiodidi gr.  xv. 

Extr.  opii gr.  v. 

Extr.  gentianse q.  s. 

M.  et  ft.  piiulae  no.  60 
S. — One  after  meals. 

The  Hydrarg.  iodidum  flavum  or  protiodide  is  mild  and  analogous 
to  calomel,  (e)  The  bichloride  of  mercury  is  irritating  (Hydrarg. 
chloridum  corrosivum) ;  it  is  not  prone  to  salivation,  is  absorbed  by 
the  intestine,  and  stimulates  the  liver.  Mercury,  administered  inter- 
nally, produces  more  irritation  and  is  less  likely  to  be  absorbed.  It 
is  used  especially  in  children  and  in  lighter  forms  of  the  disease. 

2.  Inunctions. — These  must  be  thorough  and  should  be  given  where 
the  skin  is  soft  and  free  from  hair  (flexor  surfaces,  and  never  in  the 
axillffi,  the  English  method).  The  mercury  is  rubbed  into  the  seba- 
ceous or  sweat-glands  and  is  probably  absorbed  by  the  lymph-vessels. 
The  skin  must  be  cared  for  by  daily  baths.  A  simple  diet  and  mild 
laxatives  should  be  given,  though,  as  a  rule,  mercury  somewhat  loosens 
the  bowels.  The  rubbing  should  continue  for  twenty  to  thirty  minutes. 
Hairy  regions,  the  navel,  the  nipple,  and  areas  of  accidental  eczema, 
abscess,  psoriasis,  or  furuncle,  are  to  be  avoided.  On  the  first  day  the 
inunction  should  be  given  on  the  abdomen,  on  the  second  day  on  the 
chest,  on  the  third  on  the  calf,  then  on  the  thigh,  forearm,  arm,  etc. 
If  an  attendant  gives  the  rubbing,  his  hand  should  be  protected  by  a 
rubber  glove.  Written  instructions  should  always  be  given  to  the 
patient. 

The  number  of  inunctions  necessarily  varies  with  the  case;  twenty 
to  thirty  should  be  given  for  the  macular  and  papular  types;  more 
than  thirty,  for  all  pustular  or  ulcerating  eruptions,  but  not  more 
than  thirty  should  be  given  continuously.  Inunctions  must  be  inter- 
rupted for  ulceration,  diarrhoea,  or  stomatitis.  Salivation  is  not  de- 
sirable, nor  is  it  a  sign  that  enough  mercury  has  been  given.  The 
unguentum  contains  50  per  cent,  of  mercury,  and  the  more  elegant 
oleatum  but  20  per  cent.,  which  should  be  considered,  as  about  3ss 
of  mercury  should  be  incorporated  daily. 

I^  _  . 

Unguent,  hydrarg o  iv. 

Div.  in  dos.  sequal.  no xxx 

Dent,  ad  cartara  cerat 

S. — One  as  directed  daily. 

In  children,  mercurial  ointment  may  be  applied  on  a  binder  (West- 
lander)  and  allowed  to  remain  for  many  days.    The  ointment  is  some 


TREATMENT  OF  SYPHILIS  HOl 

times  also  applied  to  the  feet,  and  the  friction  of  walking  rubs  the  mer- 
cury in.  The  advantages  of  inunctions  are  as  follows:  they  cause 
almost  no  digestive  disturbance;  they  are  especially  good  in  children; 
they  are  the  most  rapid  method,  and  are  attended  by  the  least  general 
bad  effects.  The  disadvantages  are  publicity,  troublesomeness,  and 
dirtiness,  all  of  which,  however,  are  but  relative  objections. 

3.  Injections. — A  great  diversity  of  opinion  exists  as  to  the  value 
of  injections.  Other  methods  should  at  least  be  used  first.  Their 
advantages  are  prompt  action  and  exact  dosage.  Intravenous  injec- 
tions may  be  imperative  in  cases  with  coma  and  other  urgent  symp- 
toms. The  disadvantages  are  the  risk  of  embolism,  suppuration, 
sloughing,  and  pain;  once  given,  their  action  cannot  be  regulated 
or  decreased.     The  soluble  salts  are  best: 

Hydrarg,  chlorid.  corrosivi 1.00 

Sodii  chloridi 10.00 

Aqusedist 100.00 

One  c.c.  daily  equals  0.01  gm.  or  gr.  ^  of  HgCU;  five  to  forty  injec- 
tions are  usually  necessary. 

4.  Baths. —  5ij  to  iij.  of  HgCU  to  a  full  bath  is  useful  for  skin  lesions, 
such  as  syphilitic  psoriasis. 

5.  Fumigations. — Four  ounces  of  calomel  should  be  vaporized,  and 
the  fumes  held  to  the  exposed  body  by  heavy  coverings.  The  method 
is  impracticable. 

Mercury  is  incompatible  with  nearly  everything.  Coincident  anaemia 
is  treated  by  iron,  strychnia,  sarsaparilla,  and  arsenic.  Syphilitics  tol- 
erate mercury  well,  in  large  doses,  and  for  a  remarkable  period.  In- 
deed, they  sometimes  seem  to  develop  an  immunity  to  its  action.  It 
is  not  out  of  place,  however,  to  consider  briefly  the  general  action  of 
the  drug;  in  the  smallest  doses  it  is  tonic,  for  it  increases  the  number 
of  red  cells.  In  small  doses  there  develops  a  symptom-complex 
known  as  salivation,  of  which  peculiar  foetor  is  first  noted;  then  sore 
teeth,  metallic  taste,  red  gums  which  are  swollen,  spongy,  and  bleed 
easily,  and  increased  saliva,  follow.  The  drug  is  never  given  beyond 
this  point.  In  larger  doses  the  tongue  becomes  swollen,  the  gums 
inflamed  with  a  red  line  and  great  vascularity;  the  teeth  become  loose; 
the  saliva  is  increased  greatly,  is  viscid  and  stringy;  the  salivary  glands 
become  intumescent;  there  is  low  fever;  fugaceous  eruptions  appear, 
resembling  those  of  eczema,  scarlatina,  measles,  and  more  rarely,  pur- 
pura and  pemphigus.  Severe  salivation  results  in  loss  of  teeth,  great 
stomatitis,  necrosis  of  jaw,  ulceration  of  the  mouth  and  contiguous 
parts,  marked  changes  in  the  blood,  and  profound  exhaustion.  The 
treatment  consists  of  potassium  chlorate  as  an  antiseptic  mouth  wash, 
and  such  astringents  as  tr.  myrrh  and  tannic  acid. 

III.  Tertiary  Stage. — Iodides  are  specific  in  this  stage.  They  are 
sometimes  used  in  the  secondary  stage  {v.  s.)  especially  in  febrile 
cases,  in  secondary  osseous  and  nervous  manifestations,  and  in  weakly 
persons  with  a  marked  macular  eruption.     Iodides  do  not  operate 


302  THE  SPECIFIC  INFECTIONS 

very  specifically  in  the  tertiary  stage  when  no  mercury  has  been  given 
during  the  secondaries.  It  acts  more  slowly  than  mercury;  it  acts 
not  only  as  a  specific,  but  also  is  useful  in  removing  mercury  from  its 
loose,  protoplasmic  union  with  the  gummata.  It  is  especially  indi- 
cated when  the  bones,  nervous  system,  and  viscera,  are  seats  of  gum- 
mata, and  when  the  general  health  is  broken.  Patients  may  acquire 
immunity  to  iodides,  and  its  use  should  therefore  be  intermittent  and 
should  alternate  with  mercury.  Mercury  is  conjointly  employed  when 
organs  of  great  importance  are  involved,  such  as  the  larynx,  brain, 
and  eye. 

The  therapeutic  tests  for  syphilis  are  (a)  cure  with  mercury  and 
iodides;  (6)  tolerance  by  the  patient  of  very  large  doses  of  iodides. 
Regarding  their  diagnostic  value,  Gower's  criteria  are:  (1)  that  the 
influence  of  the  drugs  must  be  unec|uivocal  and  fairly  immediate. 
(2)  That  no  other  remedy  be  used.  (3)  That  spontaneous  remissions 
which  are  seen  in  other  diseases  (such  as  brain  tumor),  must  be  ex- 
cluded. (4)  That  the  remedies  used  must  not  operate  on  any  disease 
other  than  syphilis.  (5)  Before  negative  conclusions  are  drawn  re- 
garding the  syphilitic  nature  of  the  lesion,  it  must  be  remembered 
that  loss  of  tissue,  which  occurs  in  arterial  occlusion,  and  paralysis 
from  brain  softening,  cannot  be  restored. 

The  different  iodides  contain  the  follovdng  percentages  of  iodine: 
KI,  75.5  per  cent.;  Nal,  84.6  per  cent.;  Lil,  95.5  per  cent.;  Ami,  87 
per  cent. 

Sodium  iodide  is  milder,  produces  less  iodism,  has  a  less  bitter 
taste,  and  has  less  effect  on  metabolism  than  potassium  iodide,  which, 
however,  is  better  than  other  iodides  (Schmiedeberg),  though  it  irri- 
tates the  stomach  and  bowels,  depresses  the  muscles,  and  disturbs  the 
motor  nerves. 

The  following  proportions  for  a  single  dose  may  be  employed  when 
no  urgency  demands  large  doses: 

Potassii  iodidi gr.  xv  (gm.  1.0) 

Hydrargyri  chloridi  corrosivi     .......  gr.  1/32  (gm.  0.  002) 

Tincturae  opii t^.  2  (gm.  0.  13) 

Syrupi  aurantii  corticis oss  (gm.  2.  0) 

M.  et  S. — After  meals  in  a  glass  of  water. 

Large  doses  of  iodide  are  sometimes  given  in  urgent  cases  5ss-5j 
t.i.d.,  to  break  down  more  rapidly  the  new-formed  granulation  tissue. 
The  author  believes  that  enormous  doses  are  unnecessary  and  are 
not  without  danger  (v.i.).  Iodide  dissolves  in  its  own  weight  of  water; 
hence  one  minim  of  a  saturated  solution  equals  one  grain  of  iodide. 
It  is  best  disguised  by  Syr.  sarsaparillre  co.  dr.  ss  and  Tr.  iodi  nji  1; 
also  by  peptonized  milk,  aerated  waters,  currant,  orange,  or  raspberry 
syrups,  beer,  sassafras,  licorice,  or  anise  oil. 

Iodism  is  often  produced  by  small  doses,  and  usually  ceases  with 
larger  ones.  It  is  obviated  by  intermittent  administration,  by  daily 
baths,  by  stimulating  with  water  the  kidneys,  the  inactivity  of  which 
is  the  usual  cause,  by  giving  aromatic  spirits  of  ammonia,  or  arsenic 


TUBERCULOSIS  303 

and  belladonna.  lodism  is  likely  to  occur  in  renal  disease.  Its  leading 
characters  are:  (a)  Increased  secretion  from  the  eyes,  nose,  mouth, 
salivary  glands,  bronchi,  stomach,  bowels,  skin,  and  kidneys.  The 
eyes,  throat,  larynx,  and  salivary  glands  swell.  The  writer  once  nearly 
suffocated  from  oedema  of  the  pharynx  and  uvula  after  ingestion  of 
10  grains  of  iodide  for  a  cold.  Laryngeal  and  pulmonary  oedema  and 
albuminuria,  or  even  nephritis,  may  develop,  (b)  Gastric  irritation. 
(c)  Nervous  depression,  mental  derangement,  or  excitement.  These 
result  especially  from  the  potassium  salt,  (d)  Acne,  hemorrhages, 
blebs,  and  telangiectases  in  the  skin,  (e)  Cachexia  and  anaemia, 
especially  in  goitrous  subjects;  emaciation,  wasting  of  mammse  and 
testes;  fever,  increased  pulse,  nervousness,  and  neuralgia  of  the  fifth, 
and  other  nerves  which  pass  through  bony  canals. 


TUBERCULOSIS. 

Definition. — A  specific  infection,  characterized  (a)  etiologically  by 
the  Bacillus  tuberculosis,  (b)  pathologically  by  nodes  or  tubercles,  or 
diffuse  tuberculous  infiltration,  and  (c)  clinically  by  symptomatology 
varying  with  the  tissues  or  organs  invaded.  The  term  tuberculosis 
has  special  reference  to  the  tubercles,  but  in  the  light  of  our  present 
knowledge,  to  tubercles  caused  only  by  the  Bacillus  tuberculosis. 

History. — The  term  phthisis  (wasting)  was  first  used  by  Hippo- 
crates. The  history  of  tuberculosis  includes  several  epochs :  Epoch  I. 
The  anatomical  tubercle  was  recognized  by  Sylvius  (1614-1672), 
Morton  (1689)  whom  some  consider  the  real  pioneer,  Mangetus  (1700), 
Bayle  (1810)  w^ho  specially  described  the  miliary  tubercle.  Laen- 
nec,  me  pupil  of  Bayle,  in  1819,  spoke  for  the  unity  of  phthisis.  Vir- 
chow  threw  the  weight  of  his  influence  for  Laennec's  views,  but  in 
1847,  showed  that  caseation  was  only  a  retrogressive  change  and  not 
necessarily  tuberculous.  In  1857,  Buhl  described  a  case  of  miliary 
tuberculosis  arising  from  old  foci  of  caseation.  Cruveilhier,  Rilliet, 
and  Barthez  identified  scrofula  and  tuberculosis. 

Epoch  II  was  opened  by  Villemin  (1865)  who  positively  established 
the  inoculability  of  tuberculosis  by  experiments  on  animals.  Klenkpe 
(1843)  made  successful  inoculations,  but  Villemin  absolutely  proved 
his  point.  It  is  interesting  to  note  that  from  the  time  of  Hippocrates, 
Aristotle,  Aretseus,  and  Galen,  tuberculosis  was  feared  as  a  contagion, 
and  the  older  pathologists,  as  Morgagni,  dreaded  to  section  phthisical 
subjects.  Villemin's  formulations  met  great  scepticism  and  opposi- 
tion, but  were  supported  by  Fox,  Charcot,  Grancher,  and  Thaon,  and 
were  corroborated  by  Cohnheim  and  Salamonson.  The  histology  of 
the  tubercle  was  developed  by  Wagner,  Schueppel  and  Virchow;  Lang- 
haus  fully  described  the  giant  cells  previously  seen  by  Virchow  and 
Rokitansky;  tubercles  were  found  in  lupus  (Friedlander,  1875),  in 
lymph-glands  (Schueppel,  1871)  and  in  fungus  joints  (Koester,  1876). 
The  firm  and  ancient  belief  in  its  contaaiousness  led  to  the  successful 


304  THE  SPECIFIC  IXFECTIOXS 

search  for  the  cause.  It  seems  strange  that  some,  as  Aufrecht,  Baum- 
garten  and  von  Ziemssen,  still  practically  denv  the  infecti^-itv  of  tuber- 
culosis. 

Epoch  III  began  with  Koch's  announcement,  in  1882,  of  the  tubercle 
bacillus.  His  report  was  so  complete  that  scarcely  a  single  essential 
point  has  since  been  added  to  his  initial  communication.  The  bacillus 
was  found  in  all  tuberculous  lesions,  such  as  chronic  phthisis,  miliary 
tuberculosis,  intestinal  ulcers,  scrofulous  lesions,  bone  and  joint  dis- 
ease, lupus,  and  in  the  sputum,  in  cattle,  etc.;  it  occurred  in  no  other 
disease;  it  was  cultivated  by  him  and  inoculated  into  animals  mth 
reproduction  of  tuberculosis. 

Bacillus  Tuberculosis.— 1.  Morphology.— It  is  a  thin,  narrow  rod, 
measuring  ^  to  ^  of  the  red  blood-cell  (1^  to  4/z  long)  and  more  often 
slightly  bent  or  curved  than  straight;  it  contains  no  spores,  the  light 
unstained  areas  in  its  body  being  vacuoles  or  spots  of  degeneration; 
it  is  generally  considered  immotile;  in  young  cultures  it  is  shorter 
than  it  is  in  the  sputum,  or  in  older  growths;  in  old  cultures  and  in 
lung  ca^aties  it  is  longer  and  is  frec|uently  thread-like;  it  occurs  singly 
or  in  groups  and  bundles.  Pleomorphism:  variations  in  form  are 
often  noted,  as  bulging  sides  or  ends,  thread-like  or  branching  forms 
and  even  forms  said  to  resemble  actinomyces.  [See  Figure  under 
Pulmonary  TuBERcrLosis.] 

2.  Staining  Reaction. — It  stains  slowly,  except  at  body-heat,  and 
once  stained  gives  up  the  dye  reluctantly.  Ziehl's  solution  is  the  best 
for  clinical  purposes  (Fuchsin  1,  Absolute  alcohol  10  and  5  per  cent, 
carbolic  acid  solution  100).  The  sputum  is  spread  out  in  a  dish  over 
a  black  background  and  the  yellow-green  areas  selected  are  thinly 
distributed  on  the  slide  which  is  held  in  the  hand,  and  is  heated  until 
dry  at  some  distance  from  the  flame;  it  is  then  stained  by  the  carbol- 
fuchsin,  being  passed  repeatedly  but  lightly  through  the  flame  (with- 
out boiling)  to  deepen  the  stain;  it  is  then  washed,  treated  with 
Gabbett's  stain  (1  part  methylene  blue  to  100  parts  of  25  per  cent. 
sulphuric  acid)  for  ten  to  thirty  seconds,  washed  well,  and  dried.  If 
the  sputum  is  thick  or  if  previous  examinations  were  negative,  quan- 
tities of  sputum  (1.5  c.c.)  with  twice  their  bulk  of  water  (30  c.c.)  are 
treated  vdih  caustic  potash  (8  drops  of  a  10  per  cent,  solution),  are 
shaken  and  allowed  to  settle  for  some  hours,  after  which  the  supernatant 
fluid  is  decanted,  and  the  sediment  is  examined  directly  or  after  centrif- 
ugation.  Spengler  digests  the  sputum  with  pancreatin  instead  of 
using  potassium  hydrate.  The  bacillus  resists  destaining  because  of 
its  fat,  an  almost  pathognomonic  feature.    For  clinical  purposes  only 

(a)  the  bacilli  found  in  bronchiectasis  and  gangrene  of  the  lung  (q.  v.), 

(b)  the  smegma  bacillus  and  (c)  the  leprosy  bacillus,  need  be  consid- 
ered; the  leprosy  germs  are  intracellular,  cover  the  nucleus  of  the 
containing  cell,  and  are  stained  in  six  or  seven  minutes  with  alcoholic 
fuchsin,  while  tubercle  bacilli  are  extracellular,  stain  slowly,  and  require 
more  time  (by  the  cold  method)  than  that  specified;  the  smegma  bacil- 
lus   causes    manv    errors   in   genito-urinarv   examinations;    it    grows 


TUBERCULOSIS  305 

rapidly  in  twenty-four  hours,  does  not  show  the  beaded  appearance 
which  is  seen  in  the  Bacillus  tuberculosis,  and  when  stained  and 
counterstained  in  the  usual  way,  becomes  tinged  with  methylene  blue 
(Weichselbaum). 

3.  Cultures. — These  develop  best  .at  body  heat  in  one  or  two  weeks; 
blood  serum  is  the  best  medium,  but  growths  are  also  successful  on 
bouillon,  glycerine-agar,  and  potato;  they  are  dry,  thin,  grayish,  and 
scale-like.  The  germ  is  a  facultative  aerobe  and  multiplies  by  trans- 
verse fission.  It  seemingly  does  not  lead  a  saprophytic  life  in  nature, 
outside  the  bodies  of  animals  and  of  man. 

4.  Chemistry  and  Metabolism. — It  contains  2  to  16  times  as  much 
fat  as  other  bacteria.  Aronson  holds  that  a  waxy  substance  envelops 
the  bacillus;  its  other  constituents  are  proteids,  a  glycogen-like  sub- 
stance, cellulose,  nucleic  acid,  water,  and  ash;  it  also  develops  tuber- 
culin whose  chief  components  are  peptone,  albumose  and  alkaloidal 
substances;  it  is  soluble  in  glycerine. 

5.  Resistance. — Its  resisting  powers  are  as  a  rule  limited,  (a)  Dry- 
ing is  endured  by  the  bacillus  for  a  few  months  (six  or  even  ten  months). 
In  decomposing  media  its  average  life  is  one  to  one  and  a  half  (pos- 
sibly six)  weeks.  (6)  Heat  (106°)  kills  it  in  a  few  minutes,  (c)  Cold 
is  fairly  well  resisted  and  it  may  survive  14  below  zero  for  weeks,  (d) 
Sunlight  kills  the  bacillus  in  a  few  minutes  to  a  few  hours. 

6.  Virulence. — Koch  was  inclined  to  assume  that  it  had  an  equal 
virulence  independent  of  the  source  of  the  germ,  while  the  Arloing 
school  finds  that  it  has  an  attenuated  virulence  in  glandular  and  osseous 
lesions,  and  Theobald  Smith  holds  that  bovine  cultures  are  more  viru- 
lent for  rabbits  than  is  human  sputum. 

7.  Agglutinating  Properties.^ — ^ Arloing  and  Courmont  (1S9S)  found 
that  serum  from  inoculated  rabbits  or  goats,  agglutinized  tubercle 
bacilli  in  a  dilution  of  1  to  5  or  20,  in  two  to  twenty-four  hours;  eight  to 
twelve  day  cultures,  grown  on  6  per  cent,  glycerin-bouillon  with  1  per 
cent,  peptone,  gave  the  best  results;  agglutination  was  noted  in  95 
per  cent,  of  the  cases  of  lung  tuberculosis  and  in  50  per  cent,  of  the 
cases  of  surgical  tuberculosis.  Its  differential  value  has  not,  however, 
been  generally  conceded. 

8.  Associated  or  Mixed  Infection. — This  has  been  much  emphasized 
by  Ortner,  Weichselbaum,  Struempell,  Roger,  Dieulafoy,  Mosney, 
Marfan,  Osier,  Wolf,  Spengler,  and  King,  though  Straus,  Leyden, 
Baumgarten,  Fraenkel  and  Troje  lay  but  little  stress  upon  it.  Sym- 
biosis has  been  noted  with  the  streptococcus,  staphylococcus  and  pneu- 
mococcus,  to  a  lesser  degree  with  the  Bacillus  pyocyaneus,  influenzae, 
prodigiosiis,  pseudodiphtheriffi,  Friedliinder's  bacillus,  proteus  vul- 
garis, micrococcus  tetragenus  and  sarcinee,  aspergillus,  streptothrix, 
amoebfe,  and  monads. 

9.  Number  of  Bacilli. — Large  numbers  are  found  in  fresh  tubercles; 
few  are  found  in  chronic  articular,  osseous,  or  glandular  lesions,  and 
inoculations  may  be  necessary  to  demonstrate  the  nature  of  long- 
standing lesions. 

20 


306  THE  SPECIFIC  IXFECTIOXS 

Prevalence  in  Man. — Tuberculosis  is  the  greatest  foe  of  man;  it 
causes  14  per  cent,  of  all  deaths,  and  33  per  cent,  of  deaths  between 
fifteen  and  forty-five  years  of  age;  it  causes  more  deaths  than  war, 
famine,  plague,  cholera,  yellow  fever,  and  smallpox  combined;  in 
Germany,  in  1894,  the  deaths  from  diphtheria,  croup,  measles,  scar- 
latina, pertussis,  and  typhoid,  together,  were  7,000  less  than  those  from 
tuberculosis.  Five  million  die  yearly  from  this  plague,  one  million  in 
Europe,  seventy  thousand  in  England,  150,000  in  France,  150,000  in 
the  United  States,  and  170,000  in  Germany.  Postmortem  and  hos- 
pital statistics  do  not  exactly  depict,  the  tuberculosis  situation;  in 
Austria,  the  general  death-rate  from  tuberculosis  is  11  per  cent.;  the 
hospital  rate  is  25  per  cent.,  the  patients  being  drawn  from  the  poorer 
classes.  The  true  total  is  obtained  by  multiplying  the  annual  death- 
rate  by  the  average  duration  of  life  (three  years). 

Quiescent  (latent)  and  healed  tuberculosis  is  found  in  many  post- 
mortems upon  those  dying  of  other  diseases;  Heitler,  of  Vienna,  found 
obsolete  pulmonary  tuberculosis  in  4.8  per  cent,  among  16,562  autop- 
sies. Latent  tuberculosis  occurs  in  25  to  33  per  cent,  of  the  population 
(Baumgarten,  Birch-Hirschfeld  and  Bollinger),  39  per  cent.  (Harris) 
and  50  per  cent.  (Cruveilhier,  Roger,  and  Dejerine).  O.  Naegeli  found 
gross  or  microscopic  evidence  of  tuberculosis  in  97  per  cent,  of  all 
necropsies.  Recently  Franz  obtained  a  tuberculin  reaction  in  61  per 
cent,  of  apparently  healthy  recruits. 

Prevalence  in  Animals. — (a)  Cattle. — In  Germany,  it  is  found  in 
from  4  to  20  or  30  per  cent. ;  in  Leipsic,  it  even  reached  20  per  cent, 
in  bullocks  and  48  per  cent,  in  cows.  Calves  are  less  frequently  dis- 
eased. In  New  York,  the  tuberculin  test  was  positive  in  17  per  cent. 
In  1898,  Theobald  Smith,  and  later,  Koch,  contended  that  bovine  and 
human  tuberculosis  were  separate  infections;  opinions  are  still  divided 
on  this  subject,  though  most  writers  incline  to  the  view  of  Smith  and 
Koch.  In  cattle,  tuberculosis  is  less  often  attended  by  softening  of 
the  tubercle,  and  the  serous  membranes  are  more  often  involved;  the 
lungs  and  pleurae  are  involved  in  40  per  cent.,  the  lungs  alone  in  20  per 
cent.,  and  the  pleurae  and  peritoneum  in  15  per  cent,  of  tuberculous 
cattle.  (6)  Sicine  are  affected  more  often  in  Europe  than  in  this 
country;  in  Saxony  tuberculosis  occurs  in  1  per  cent,  and  in  Copen- 
hagen and  Dantzig,  in  11  per  cent.;  because  their  infection  commonly 
results  from  eating  tuberculous  offal,  the  type  is  usually  alimentary 
(90  per  cent.),  (c)  Other  mammals. — Dogs  and  cats  are  seldom  dis- 
eased except  from  contact  with  man;  the  type  in  dogs  is  respirator}^ 
(83  per  cent.).  Horses,  sheep,  and  goats,  are  rarely  diseased.  Monkeys 
in  captivity  die  frequently  (43  per  cent.)  from  tuberculosis,  referred 
by  Dieulafoy  and  Krishaber  to  foul  cages,  (d)  In  reptiles,  it  is  rarely 
seen,  except  in  those  in  captivity,  (e)  In  most  birds,  tuberculous  lesions 
are  more  frequent  in  the  liver,  spleen,  intestine,  mesenteric  glands, 
bones,  and  joints,  than  in  the  lungs,  though  parrots  suffer  from  skin 
and  lung  localization.  In  avian  tuberculosis  the  l^acilli  grow  rapidly, 
present  greater  morphological  variability,  and  live  longer,  which  char- 


TUBERCULOSIS  307 

acters  seem  to  justify  their  separation  from  the  human  type.  Man 
may  apparently  become  infected  (Pancini),  and  there  are  those  who 
still  contend  for  the  unity  of  the  human,  bovine,  and  avian  bacillus. 
Tubercles  are  not  uncommon  in  animals  from  nematodes,  protozoa, 
and  bacteria,  and  are  designated  pseudotuberculosis.  In  man,  Flexner 
has  described  a  streptothrix  pseudotuberculosis  causing  caseous  pneu- 
monia and  peritoneal  nodes;  the  streptothrix  differed  both  from  the 
tubercle  bacillus  and  the  ray  fungus.  An  aspergillus  tuberculosis  has 
been  described  (y.  diagnosis  Tuberculosis  of  Lungs). 

Atrium. — The  details  will  be  especially  considered  under  the  dif- 
ferent clinical  localizations  of  the  disease. 

1.  By  the  Respiratory  Tract.^ — The  bacillus  enters  the  respiratory 
tract  by  inhalation.  In  the  vast  majority  of  cases  the  sputum  of  dis- 
eased persons  is  causative  both  of  the  disease,  and  its  great  frequency 
of  localization  in  the  respiratory  organs.  It  has  been  estimated  that 
a  phthisical  person  voids  7,200  millions  of  tubercle  bacilli  daily.  As 
the  expired  air  is  proven  germ-free,  the  sputum  must  be  the  chief 
factor  in  dissemination.  Cornet  holds  that  the  greatest  danger  lies 
in  the  drying  of  the  sputum  in  the  room,  on  the  handkerchief,  on  the 
lips,  beard,  hair,  fingers,  and  clothing,  though  Fluegge  contends  that 
dried  sputum  is  less  dangerous  than  the  moist  expectoration.  Fluegge 
demonstrated  that  in  coughing,  which  seemingly  voids  no  secretion, 
in  singing,  in  sneezing,  or  talking,  small  and  almost  invisible  drops  of 
moisture  containing  the  bacilli  are  voided,  and  he  has  cultivated 
bacilli  from  glass  plates  which  were  covered  with  solid  culture  media 
and  held  near  the  patient;  he  believes  that  minute  particles  remain  in 
suspension  in  the  air  and  thus  infect  other  individuals.  Drying  of  the 
sputum  voided  in  the  street  or  other  open  places  is  less  significant  than 
was  formerly  thought,  since  the  sun  soon  kills  the  bacilli.  Hence  the 
ubiquity  of  the  tubercle  bacillus  is  generally  exaggerated  though  it 
is  of  great  importance  in  poorly  ventilated,  dark  dwelling-rooms,  hos- 
pitals, cloisters,  hotels,  or  prisons,  which  are  frequented  by  victims  of 
tuberculosis.  Cornet  found  the  bacilli  in  the  dust  of  such  rooms  in 
large  numbers,  yet  in  about  10  per  cent,  of  tuberculous  wards  no  bacilli 
were  found;  he  experimentally  demonstrated  that  animals  confined 
in  rooms  with  dried  tuberculous  sputum  readily  acquired  tuberculosis. 
Straus,  of  Paris,  collected  the  germ  from  the  nose  in  31  per  cent,  of 
the  attendants  in  tuberculous  wards.  According  to  Cornet,  infection 
is  less  frequent  than  might  be  expected,  because  the  mucus  and  the 
bacilli  absorb  moisture  from  the  air,  and  their  hygroscopic  properties 
thus  make  them  resistant  to  drying.  The  closer  the  contact  with 
tuberculous  subjects,  the  greater  is  the  danger  of  infection,  as  tuber- 
culosis is  surely  an  infection.  In  crowded  prisons,  the  death-rate  is 
three  or  four  times  that  of  the  general  community;  in  Austria,  for 
example,  the  general  mortality  is  11  to  1.5  per  cent.,  and  the  prison 
mortality  is  40  to  even  60  per  cent.  In  nursing  sisterhoods.  Cornet 
found  the  death-rate  ranged  from  63  to  over  75  per  cent.  Six  cases 
were   observed   by   the   writer,    in   two   years,   in   one   si\iall,  closely 


308  THE  SPECIFIC  INFECTIONS 

cloistered  community.  In  Philadelphia,  Flick's  studies  showed  that 
33  per.  cent,  of  infected  houses  contributed  more  than  one  case.  In 
Falkenstein,  Germany,  and  Brompton  Hospital,  London,  acquisition 
of  tuberculosis  by  attendants  is  infrequent,  while  in  Paris,  Straus  puts 
their  mortality  at  a  high  figure.  In  our  dispensary  service,  seven 
rapidly  fatal  cases  were  observed  in  one  family  which  had  no  heredi- 
tary stigma  nor  previous  disease  (Harpole).  Oral  breathing,  caused 
by  adenoids,  inhalation  of  coal-dust  or  stone-dust,  syphilis,  cancer, 
and  leprosy,  are  favoring  factors. 

Dusting,  sweeping,  or  shaking  the  bed  clothes,  disseminates  the 
virus;  there  is  less  danger  of  infection  when  the  windows  and  doors 
are  open  and  when  dusting  is  done  with  moist  cloths  rather  than  with 
feather-dusters.  In  hospital  wards  there  are  more  germs  in  the  air 
during  the  cleaning  hour  than  during  the  other  twenty-three  hours. 
However,  if  bacilli  are  in  the  dust,  they  are  not  necessarily  in  the 
inhaled  air;  if  inhaled,  they  do  not  necessarily  reach  the  lungs,  for 
they  may  be  caught  in  the  upper  air-passages  whose  secretions  antago- 
nize their  development,  and  are  often  waved  back  by  the  ciliated 
epithelium  of  the  lower  air-passages.  Cornet  holds  that  the  state- 
ment that  "every  man  lives  in  the  environment  of  tuberculosis"  is 
surely  exaggeration.  Married  persons,  because  of  their  intimate  asso- 
ciation, may  contract  the  disease  from  each  other,  as  was  noted  by 
Ettmueller  and  Morton,  in  the  seventeenth  century;  the  husband 
more  often  conveys  infection  to  the  wife  than  the  wife  to  the  hus- 
band; in  Weber's  series  of  cases,  a  husband  lost  four  wives,  another 
three  wives,  and  in  four  other  cases  two  wives  contracted  tuberculosis. 
The  danger  of  sleeping  and  living  together  is  somewhat  overdrawn, 
as  the  family  members  are  less  together  than  is  at  first  ap- 
parent. When  bacilli  are  inhaled  into  the  respiratory  tract  (a)  no 
lesions  may  result,  (6)  the  lungs  may  become  diseased,  or  (c)  the 
germs  may  pass  the  mucosa  of  the  mouth  or  bronchi  and  cause 
glandular  tuberculosis — e.  g.,  cervical  or  peribronchial  adenitis  tu- 
berculosa. 

2.  By  the  Digestive  Tract. — Milk  is  most  dangerous  (Gerlach, 
Bollinger,  Bang,  and  others),  though  lately  attempts  have  been  made 
to  minimize  the  danger  from  this  source  of  infection.  It  was  formerly 
thought  that,  in  cows,  a  tuberculous  mastitis  was  necessary  to  milk 
infection,  but  Ernst  and  others  demonstrated  that  milk  may  be  infec- 
tive from  cows  with  tuberculosis  which  does  not  invade  the  udders. 
Pigs,  fed  on  tuberculous  milk,  develop  intestinal  tuberculosis.  Butter 
may  contain  tubercle  bacilli.  Meat  is  less  dangerous,  as  it  is  usually 
well  cooked,  but  tubercles  in  raw  offal  frequently  infect  swine.  Bacilli 
may  pass  the  mucosa,  especially  in  children,  and  produce  the  first 
lesions  in  the  mesenteric  glands. 

3.  Direct  Inoculation. — Inoculation  through  the  skin,  eye,  genito- 
urinary tract,  by  trauma,  or  operations,  is  far  less  significant  and  will 
be  considered  under  the  various  tissues  occasionally  involved.  The 
point  of  entrance  is  often  hard  to  find. 


TUBERCULOSIS  309 

Predisposing  Factors. — These  are  important,  but  if  practically  con- 
sidered, tuberculosis  is  best  prevented  and  treated  as  an  infection, 
communicated  and  acquired  by  direct  personal  contact. 

1.  Heredity. — 1.  Hereditary  Predisposition  to  Tuberculosis. — This 
is  shown  by  the  frequency  with  which  a  tuberculous  family  history  is 
obtained  in  infected  individuals,  and  is  estimated  at  25  per  cent.  (10 
to  S5  per  cent.).  It  is  remarkable  what  statistics  can  be  made  to  estab- 
lish, and  if  moved  by  theory  alone,  one  might  prove  by  figures  a 
formidable  hereditary  influence  in  measles,  pneumonia  and  other  com- 
mon diseases.  Kuthri  found  essentially  the  same  percentage  of  family 
tuberculosis  in  non-tuberculous  as  in  tuberculous  cases.  Tuberculous 
parents  may  infect  their  children  (50  per  cent.),  as  they  may  infect 
others,  but  the  children  usually  (97  per  cent.)  escape  the  disease  when 
removed  from  their  parents.  According  to  Rieffel,  3  per  cent,  of  chil- 
dren acquire  tuberculosis  when  both  parents  are  sound,  22  per  cent, 
when  both  parents  are  tuberculous,  10  per  cent,  when  the  mother  and 
7  per  cent,  when  the  father  is  tuberculous.  Whatever  stress  may  be 
laid  on  statistics,  hereditary  predisposition  is  no  obstacle  to  preven- 
tion and  treatment. 

2.  Congenital  Tuberculosis. — It  is  thought  by  Baumgarten  that  chil- 
dren actually  inherit  the  bacillus,  which  remains  latent,  possibly  for 
years,  and  then  develops  an  active  tuberculosis.  If  his  views  are  cor- 
rect, we  are  confronted  with  a  difficult  problem.  Considering  the 
possibilities  of  bacilliary  inheritance,  congenital  tuberculosis  can  be 
acquired  only  through  (a)  the  spermatozoon,  (6)  the  ovum  or  (c)  pla- 
centa, (a)  The  spermatozoon  is  a  nuclear  structure  which  is  not 
proven  to  be  attacked  by  the  tubercle  bacillus,  though  the  bacillus  is 
sometimes  found  in  the  semen  in  genito-urinary  tuberculosis.  (6)  The 
ovum  has,  in  rare  instances,  been  infected,  but  Virchow,  among 
others,  questions  this  possibility.  Mafucchi  found  that  tuberculosis 
developed  in  chicks,  weeks  or  months  after  the  ova,  from  which  they 
were  hatched,  were  infected,  (c)  Placental  tuberculosis  has  been 
observed  clearly  in  about  22  human  cases  (according  to  Warthin  and 
Cowie  in  only  5),  and  slightly  over  100  cases  in  animals  (Friedman, 
1905).  The  first  indisputable  case  was  that  of  Schmorl  and  Birch- 
Hirschfeld  which  was  confirmed  by  the  inoculation  and  finding  of 
the  bacillus.  The  maternal  and  foetal  circulations  are  quite  distinct, 
but  toxaemias  may  occasionally  allow  the  virus  to  pass  to  the  foetus, 
that  is,  in  typhoid,  scarlatina,  smallpox,  or  anthrax.  Placental  trans- 
mission is  observed  more  often  in  animals  (|  to  1  per  cent.,  Klepp). 
Usually  there  is  a  placental  focus  before  the  foetal  blood  is  infected, 
but  the  bacillus  may  sometimes  pass  directly  to  the  foetus.  Placental 
infection  is  possible,  but  is  so  infrequent  that  many  experienced  ob- 
servers, like  Virchow,  have  never  seen  a  case.  However,  Schmorl  and 
Geipel  recently  found  tuberculosis  in  nearly  50  per  cent,  of  placentae 
of  tuberculous  mothers. 

The  arguments  against  hereditary  tuberculosis  are  (1)  that  children 
born  with  the  disease  die  very  early;    (2)  that  tuberculosis  in  the  first 


310  THE  SPECIFIC  INFECTIONS 

months  of  life  is  extremely  rare;  (3)  that  the  disease  seldom  remains 
latent  until  adult  life,  as  most  cases  of  infantile  tuberculosis  develop 
during  the  period  of  special  growth,  namely  from  the  second  to  third 
year;  (4)  in  congenital  infection,  the  liver  is  chiefly  diseased  because 
of  the  nature  of  its  vascular  relations  to  the  placenta;  in  tuberculosis 
of  children,  the  lungs,  glands,  and  other  organs,  are  more  often  dis- 
eased,— i.e.,  the  infection  is  respiratory,  and  therefore,  extra-uterine. 
(5)  When  removed  from  their  tuberculous  parents,  children  thrive  well. 

II.  Environment. — This  covers  many  points  which  w^ere  mentioned 
under  Atrium.  Dampness  and  poor  drainage,  emphasized  by  Bow- 
ditch  and  Buchannan,  are  factors  which  reduce  the  physiological 
resistance.  Trudeau's  experiments  show  that  inoculated  animals,  kept 
in  dark,  damp  cellars,  die,  while  others,  allowed  to  run  at  large,  out- 
live the  infection.  Density  of  population  raises  the  proportion  of 
tuberculous  cases.  In  recent  years  the  large  cities  have  shown  an 
apparent  decrease  of  tuberculosis,  as  shown  by  Edward  F.  Wells,  of 
Chicago,  and  Jas.  B.  Russel,  of  Glascow.  It  has  also  decreased  in 
New  York  and  London.  In  Massachusetts  the  total  is  less  by  half 
than  it  was  fifty  years  ago.  The  decrease  is  attributed  to  more  intelli- 
gent hygiene.  The  figures  show  a  decided  decrease  in  Chicago  {v. 
Pneumonia);  it  is  possible,  in  recent  years  at  least,  that  this  is  ex- 
plained by  the  fact  that  pneumonia  carries  off  the  less  resistant  of  the 
population.  In  ^Munich,  the  death-rate  from  tuberculosis  was  12  per 
cent,  at  a  time  when  typhoid  was  epidemic;  when  typhoid  was  prac- 
tically abolished,  the  tuberculosis  rate  increased  to  16  per  cent., — 
i.e.,  4  per  cent,  of  those  with  tuberculosis  had  previously  died  from 
typhoid. 

III.  Occupation. — Occupations  involving  work  in  close,  damp 
rooms,  in  dust,  in  crowded  quarters,  particularly  when  associated 
with  poor  food,  alcoholism,  worry,  and  over-exertion,  promote  tuber- 
culosis when  exposure  to  infected  individuals  exists.  Clerks,  steno- 
graphers, or  waiters,  are  naturally  more  easily  infected  than  are  those 
working  in  the  fresh  air,  for  example,  cab-drivers.  It  is  rather  sur- 
prising that  miners  do  not  suffer  more  frequently,  but  the  explanation 
of  this  is  the  dampness,  which  prevents  the  drying  of  infected  sputum, 

IV.  Age. — Cornet's  figures  show  the  following  death-rate  per  10,- 
000  of  population:  first  year  2  to  3,  the  child  being  in  close  contact 
with  the  mother.  These  figures  grow  smaller,  until  the  lowest  figure  is 
reached,  namely,  \,  between  the  fifth  to  tenth  years ;  fifteenth  to  twen- 
tieth years,  17  to  19;  twentieth  to  thirtieth  years,  32  to  36;  thirtieth  to 
fortieth  years,  44;  fortieth  to  fiftieth  years,  55;  fiftieth  to  sixtieth 
years,  76;  sixtieth  to  seventieth  years,  100;  seventieth  to  eightieth 
years,  70;  over  eightieth  year,  20.  In  the  first  decade  of  life,  glandular, 
meningeal,  osseous,  cutaneous,  and  articular  tuberculosis  are  more 
frequent;  the  mucosae  are  more  permeable  and  the  lymph  channels 
wider,  so  that  infection  is  very  often  first  evidenced  in  the  lymph  glands. 

V.  Sex. — Between  five  and  twenty  years  of  age,  girls  are  more  prone 
to  tuberculosis,  because  their  life  is  more  sedentary.     After  twenty 


TUBERCULOSIS  311 

years  males  more  often  contract  tuberculosis,  because  of  their  greater 
exposure  to  infection.  Repeated  pregnancies  and  protracted  lactations 
may  favor  mfection  by  lowering  physiological  resistance.  Skin  lesions 
are  more  frequent  in  women;  lupus,  for  example,  occurs  in  68  per 
cent,  (in  males  in  32  per  cent.);  tuberculosis  of  the  nose,  mouth,  and 
throat,  is  less  frequent  in  women  (4  per  cent.)  than  in  men  (81  percent.). 

VI.  Climate. — Warm,  dry  climates,  high  al^tudes,  and  lack  of  sud- 
den variations  in  temperature,  are  generally  held  to  reduce  tuberculosis. 
Of  late  they  are  apparently  considered  less  beneficial.  The  French 
Alps  were  long  free  of  tuberculosis  until  crowded  by  infected  subjects, 
and  the  same  seems  true  of  other  localities.  Some  writers  even  hold 
that  the  chief  advantages  of  many  resorts  is  their  sparse  population 
and  inaccessibility. 

VII.  Race. — In  this  country  the  Irish  and  negroes  are  most  fre- 
quently diseased.  The  Indians  have  justly  come  to  dread  the  "cough- 
ing white  man,"  and  they  die  in  large  numbers  from  consumption, 
particularly  in  their  Eastern  reservations.  Infection  among  Jews  is 
peculiarly  infrequent. 

VIII.  Individual  Predisposition. — This  was  considered  important 
by  the  oldest  medical  writers,  who  described  the  winged  scapulae,  the 
paralytic  thorax,  and  the  depressed  sternum;  but  poor  thoracic  and 
general  development  is  very  often  an  expression  of  already  existing 
tuberculosis;  phthisis  often  occurs  in  splendidly  developed  chests,  ex- 
posure to  infection  being  the  most  important  factor.  Tuberculosis 
confers  no  immunity  to  relapses  or  to  new  localizations;  a  lung  lesion 
may  heal  while  a  coincident  intestinal  lesion  progresses. 

IX.  Trauma. — This  is  a  somewhat  determining  factor.  Bacilli  in 
the  blood  may  be  localized  in  a  bone  or  joint  by  trauma;  a  blow  on  the 
head  or  spine  may  initiate  meningitis  in  a  tuberculous  subject;  pleurisy 
or  pulmonary  tuberculosis  may  be  initiated  by  injury  to  the  chest, 
which  is  thought  to  awaken  latent  lesions  in  the  peribronchial  glands. 

X.  Other  Factors. — These  are  (1)  diabetes,  in  which  23  to  50  per 
cent,  die  of  tuberculosis  of  the  lung;  (2)  psychoses,  especially  of  the 
depressive  type,  as  melancholia;  (3)  ansemia,  which,  however,  is  more 
often  the  result  than  the  cause  of  tuberculosis;  (4)  inflammation  of 
the  mucous  membranes,  acute  processes,  such  as  heavy  colds,  measles, 
and  pertussis,  and  less  often  scarlatina,  influenza,  or  diphtheria,  may 
predispose  to  infection,  or  they  probably  more  often  awaken  slumber- 
ing glandular  tuberculosis  by  the  irritation  of  the  mucous  membrane 
by  products  absorbed  from  the  bronchi  or  lungs.  Enterocolitis  in  chil- 
dren, or  typhoid  in  adults,  may  in  a  similar  way  awaken  or  initiate 
abdominal  tuberculosis.  Smallpox  and  eczema  sometimes  seem  to 
produce  similar  effects  on  the  skin.  (5)  Contracted  kidney,  cirrhotic 
liver,  sclerosed  arteries,  stenosis  of  the  pulmonary  artery,  aortic  aneu- 
rysm and  narrowed  hypoplastic  aorta  are  predisposing  factors.  As 
Rokitansky  first  pointed  out,  valvular  disease  of  the  left  heart  prevents 
or  checks  infection,  because  it  congests  the  lungs;  Bier's  treatment  of 
surgical  tuberculosis,  by  inducing  congestion  through  ligatures,  is  based 


312  THE  SPECIFIC  INFECTIONS 

on  this  point;  Birch-Hirschfeld,  in  4,359  autopsies,  found  chronic  pul- 
monary tuberculosis  in  21  per  cent.,  and  in  107  autopsies  of  valvular 
heart  disease,  it  was  present  in  but  2.8  per  cent.  Potain,  in  54  cases  of 
mitral  stenosis,  found  pulmonary  tuberculosis  in  16.6  per  cent,  (see 
VALvrLAR  Disease  of  the  Heart).  (6)  Syphilis,  pleurisy  {q.  v.), 
and  haemoptysis  {q.  v.),  are  occasional  predisposing  factors. 

General  Histo-Pathofegy  of  the  Tubercle.— The  only  absolutely 
pathognomonic  feature  of  the  tubercle  is  Koch's  bacillus,  as  similar 
infective  granulomata  are  seen  in  strongylus  in  sheep,  in  actinomycosis, 
and  in  syphilis.  Baumgarten  described  the  changes  following  inocu- 
lation of  the  anterior  chamber  of  the  eye:  (a)  On  the  first  day  the 
bacilli  increase  and  spread  somewhat  along  the  lymph-spaces.  (6) 
By  the  sixth  day,  the  fixed  connective-tissue  cells  proliferate  under  the 
stimulus  of  the  tubercle  bacillus,  which  acts  as  a  foreign  body;  these 
cells,  known  as  epithelioid  cells,  are  large,  rounded  or  polygonal  cells 
with  distended  nuclei,  and  sometimes  contain  tubercle  bacilli;  in 
another  day  or  two  they  show  karyokinetic  figures;  the  bacilli  multiply 
and  the  endothelial  cells  of  the  vessels  proliferate.  The  tubercle  of 
this  stage  is  sometimes  called  the  epithelioid  tubercle,  (c)  On  the 
tenth  or  eleventh  day  the  leukocytes  emigrate.  This  inflammatory 
reaction  results  from  the  toxins  secreted  by.  the  bacillus;  at  first 
most  of  the  white  cells  are  polymorphonuclear,  many  of  which  degen- 
erate; later  they  are  mononuclear,  which  do  not  suffer  retrogressive 
changes;  the  mononuclears  crowd  the  epithelioid  cells  and  dominate 
the  histological  picture,  especially  with  complicating  trauma  (lymph- 
oid tubercle),  (d)  The  reticulum  of  the  tubercle  consists  of  the 
stretched  fibers  of  the  infected  tissue  or  of  coagulation  necrosis,  (e) 
The  epithelioid  cells  increase  in  size  and  are  often  multinucleated. 
From  them  or  from  the  extravasated  leukocytes,  by  growth,  or  by 
fusion,  giant  cells  develop;  they  contain  many  large,  oval,  vesicular 
nuclei  and  tubercle  bacilli;  the  bacilli  ma}^  number  50  to  a  cell  in  very 
active  processes  but  are  few  in  chronic  tuberculosis;  the  giant  cells  are 
particularly  abundant  or  may  even  be  the  chief  histological  finding  in 
chronic  forms,  such  as  lupus,  scrofulous  glands  or  fungoid  joint-dis- 
ease; they  are  few  or  absent  in  acute  processes,  as  in  miliary  tuber- 
culosis; there  seems  to  be  a  certain  antagonism  between  the  nuclei 
and  bacilli,  for  if  the  nuclei  lie  ^on  the  margin  of  the  cell,  the 
bacilli  are  centrally  grouped,  and  if  the  nuclei  lie  at  one  pole  of  the 
cell,  the  bacilli  concentrate  at  the  other  pole.  The  cellular  inclusion 
of  the  bacilli  is  considered  a  phagocytosis  by  Metschnikoff,  which 
Baumgarten,  however,  denies.  The  completed  miliary  tubercle  is 
non-vascular,  cellular,  millet-seed  (miliary)  in  size,  gray  in  color,  and 
translucent.  It  is  the  pathological  unit  of  all  tuberculous  lesions, 
however  extensive.  In  the  dift\ised  inflammatory  tubercle,  the  dif- 
fuse areas  result  from  fusion  of  myriads  of  miliary  tubercles  (see 
Caseous  Pneumonia). 

The  tubercle  then  undergoes  one  of  two  degenerations,  caseation  or 
induration:  (1)  Caseation  results  from  degeneration  of  the  tubercle,  be- 


PLATE  V. 


Retinal   Findings  in  the  More  Important  Diseases. 


1.  Retinitis  diabetica.  2.  Atrophy  (and  pigmentation)  of  retina 
and  optic  nerve.  3.  Choked  disk  in  brain  tumor.  4.  Optic 
neuritis  in  meningitis.     5.   Medullated  nerve  fibers  (normal). 


TUBERCULOSIS  MILIARIS  ACUTA  313 

ginning  at  its  centre,  from  ischsemia  (vascular  obliteration)  and  from 
coagulation  necrosis  (action  of  the  bacilli  and  its  toxins).  The  area  of 
coagulation  necrosis  then  gradually  becomes  more  yellow  and  granular, 
and  finally  results  in  an  amorphous,  homogeneous,  cheesy  debris.  Casea- 
tion is  a  dangerous,  destructive  degeneration.  (2)  Induration,  sclerosis 
or  encapsulation,  results  from  growth  of  connective  tissue  around  the 
tubercle  or  conglomeration  of  tubercles;  it  limits  the  tubercle,  is  the 
measure  of  the  resisting  power  of  the  surrounding  tissue,  and  is  a  con- 
servative process.  It  occurs  most  frequently  in  the  peritoneum,  but 
also  in  the  lungs  and  other  tissues.  Inflammation,  varying  with  the 
tissue  involved,  may  cause  other  histological  findings.  Suppuration 
may  result  from  mixed  infection  with  streptococci,  though  Koch  held 
that  pus  may  be  formed  by  the  tubercle  bacillus  itself;  the  ordinary 
tuberculous  "cold  abscess"  is  not  really  pus,  but  merely  thick,  amor-, 
phous,  granular  debris. 

Extension. — (1)  Tubercles  develop  at  the  point  of  infection  and 
also  in  the  nearest  lymph-glands,  which  permanently  or  temporarily 
arrest  the  process.  (2)  Infection  may  occur  through  the  uninjured 
mucosa  or  skin,  but  the  process  rarely  passes  beyond  the  tributary 
lymph-glands.  (3)  The  later  advance  of  the  process  occurs  inter- 
ruptedly or  gradually,  so  that  it  can  be  traced  clearly  at  autopsy.  (4) 
Extension  usually  occurs  along  the  lymph  vessels  and  glands. 


I.  Tuberculosis  Miliaris  Acuta. 

Definition. — An  acute  general,  sometimes  almost  universal,  embolic 
dissemination  of  the  tubercle  bacillus  in  great  numbers,  by  the  blood 
or  lymph  stream.  It  results  pathologically  in  the  formation  of  miliary 
tubercles,  which  are  wide-spread  in  various  tissues,  and  it  produces, 
clinically,  acute  toxsemia,  pulmonary,  meningitic,  or  other  symptoms, 
and  is  invariably  fatal  in  a  few  weeks. 

Etiology. — 1.  Development. — Acute  miliary  tuberculosis  always 
develops  from  a  tuberculous  focus.  This  is  found  in  direct  ratio  to  the 
carefulness  of  dissection;  von  Buhl,  who  first  fully  described  the  affec- 
tion (1856-1858),  recognized  that  miliary  dissemination  occurred  by 
absorption  from  old  tuberculous  foci,  just  as  pyoemia  results  from 
local  suppuration;  and  he  found  the  primary  focus  in  90  per  cent,  of 
cases.  It  may  be  small  or  even  microscopic  and  may  easily  escape 
detection  (Pizzini,  Cornet,  Spengler),  but  Simmonds  found  the  initial 
lesion  in  100  per  cent.  As  Cornet  remarks,  it  is  curious  that  miliary 
tuberculosis  occurs  from  foci  so  small  as  to  be  easily  overlooked,  and 
that  large  tuberculous  lesions  so  seldom  result  in  miliary  dissemina- 
tion. A  description  of  all  primary  foci  would  be  an  enumeration  of 
every  possible  localization  of  tuberculosis. 

2.  Lesion. — Fidmonary  tubercidosis  is  the  most  frequent  lesion,  and 
causes  over  50  per  cent.  (Ruehle,  Orth,  Litten)  of  the  cases  of  acute 
miliary  tuberculosis  (which  occurs  in  3  per  cent,  of  the  cases  of  pul 


314  THE  SPECIFIC  INFECTIONS 

monary  tuberculosis).  Glandular  lesions  rank  next,  and  articular, 
osseous,  genito-urinary,  and  serous-membrane  tuberculosis,  cause 
most  of  the  balance.  The  more  the  tubercle  is  indurated,  the  less 
is  the  danger  of  local  or  general  dissemination. 

3.  Mode  of  Access  of  Bacilli  into  Blood  Stream. — Sir  Astley  Cooper, 
in  1798,  found  tubercles  in  the  thoracic  duct,  and  this  was  later  con- 
firmed by  Ponfick,  Weigert,  Koch,  and  Meisels.  In  1877,  Weigert 
demonstrated  that  tubercles  invade  the  vessel  walls,  which  Rokitansky 
had  declared  to  be  immune.  Tuberculosis  reaching  a  vessel  usually 
causes  its  gradual  obliteration  and  in  this  way  keeps  the  process  local. 
In  some  cases  bacilli  reach  the  lumen  of  the  vessel  and  are  distributed 
in  the  direction  of  its  current.  Two  views  are  held  as  to  the  nature 
of  the  involvement  of  the  vessels:  (a)  that  of  Weigert,  who  thought 
the  most  frequent  process  was  periangitis,  by  which,  for  instance, 
a  caseated  gland  became  adherent  to  and  emptied  into  a  vein;  and 
ih)  that  of  Benda,  who  contended  that  the  common  lesion  was  end- 
angitis,  by  which  tubercle  bacilli  lodged  in  the  vessel's  intima,  and, 
grouping  there,  further  disseminated  the  infection.  One  of  the  most 
common  methods  is  periadenitis  of  a  tuberculous  bronchial  gland,  its 
adhesion  to  a  pulmonary  vein,  and  final  rupture  into  it.  Tuberculous, 
lesions  may  rupture  into  the  vena  azygos,  pulmonary  artery,  aorta, 
thoracic  duct,  jugular,  thyroid,  supra-renal,  or  renal  veins,  into  the 
cavse,  or  into  the  brain  sinuses.  From  the  pleurae  and  peritoneum 
infection  may  travel  directly  to  the  thoracic  duct. 

4.  Organs  Involved. — (a)  Rupture  into  a  pulmonary  vein  floods 
the  arterial  circulation  with  bacilli,  whence  miliary  deposits  occur  in 
the  brain,  choroid,  liver,  spleen,  kidneys,  thymus,  thyroid,  heart 
(myocardium  near  pulmonary  artery),  bones,  serous  and  mucous 
membranes,  and  in  the  blood-vessels  themselves.  (6)  Rupture  into  a 
portal  venous  radicle  affects  chiefly  the  liver,  (c)  Into  the  pulmonary 
artery,  the  lungs,  and  {d)  into  a  peripheral  artery,  the  tissue  supplied 
by  it. 

5.  Degree  of  Lesion. — Acute  generalization  only  follows  the  intro- 
duction of  large  numbers  of  bacilli,  for  they  do  not  multiply  in  the 
blood.  A  few  bacilli  reaching  the  circulation  cause  a  solitary  tubercle 
in  some  organ — for  example,  in  the  brain.  Repeated  ruptures  of 
moderate  numbers  of  bacilli  lead  to  the  so-called  chronic  miliary 
tuberculosis  {v.  i.). 

6.  Predisposing  Factors. — Though  miliary  dissemination  may  occur 
at  any  age,  it  is  most  frequent  in  children  at  the  developmental  period, 
especially  between  one  and  four  years  of  age,  because  the  circulation 
is  faster,  metabolism  is  quicker,  thrombosis  of  the  vessels  is  less  fre- 
quent, tissue  reaction  is  less  marked,  and  the  lymph-vessels  and  spaces 
are  wider.  Depleting  factors,  pregnancy,  the  puerperium,  trauma, 
bone  operations,  measles,  pertussis,  mixed  infections,  and  the  spring 
and  summer  months,  are  somewhat  predisposing  causes. 

Symptoms. — The  clinical  picture  varies  greatly,  depending  on  (a) 
the  quality  (virulence)  and   quantity   of  the   bacilli;    (6)  the  toxins 


TUBERCULOSIS   MILIARIS  ACUTA  *     315 

thrown  into  the  circulation  from  the  primary  ruptured  focus;  (c) 
the  toxins  developed  elsewhere  by  the  bacilli;  and  (d)  the  localization 
of  the  tubercles  formed.  Naturally  toxsemic  symptoms  precede  local 
symptoms". 

1.  Temperature. — Continuous  fever  may  be  observed  in  very  acute 
cases  with  wide-spread  localization,  which  do  not  involve  the  brain; 
as  a  rule  it  is  lower  than  that  of  typhoid.  Remittent  or  intermittent 
fever  is  more  common;  miliary  tuberculosis  following  pulmonary 
phthisis  may  change  neither  the  hectic  fever  of  the  latter  nor  its  eu- 
phoria. The  typus  inversus  may  occur,  though  it  usually  lasts  but  a 
few  days  (Bruniche).  In  17.5  per  cent,  of  cases  (Rheinhold)  the  course 
is  afebrile;  involvement  of  the  brain  or  meninges  lowers  the  tempera- 
ture or  renders  it  variable;  hemorrhages,  vomiting,  or  diarrhoea,  may 
depress  the  fever  (Litten) ;  low  temperatures  are  common  in  the  aged, 
in  the  ambulant,  and  in  bronchitic  or  cardiac  types. 

2.  Circulation. — (a)  The  pulse  is  faster  than  is  proportionate  to 
the  degree  of  fever,  being  120  in  the  early  stages  and  140  to  160  later; 
the  blood-pressure  is  low  but  dicrotism  is  infrequent;  a  pulse  under 
100  is  very  rare  and  nearly  always  occurs  in  old  people  and  in  cases 
of  meningitic  localization,  (b)  The  heart  is  somewhat  dilated  and  an 
apical  systolic  murmur,  with  accentuation  of  the  second  pulmonic 
sound,  is  fairly  frequent,  (c)  A  pericardial  rub  is  heard  on  rare  occa- 
sions, and  is  due  to  roughening  of  the  serosa  by  the  miliary  eruption 
(Litten).  (d)  Tubercle  bacilli  were  first  found  at  autopsy  in  the  blood 
by  Weischselbaum  and  Meisels,  and  clinically  by  Lustig  and  Rueti- 
meyer.  Sticker,  Ulacacis,  and  Doutrelepoint.  In  the  death  agony  from 
lung  tuberculosis,  bacilli  may  enter  the  blood,  (e)  The  leukocytes 
are  usually  not  increased. 

3.  Respiration. — Early  symptoms  are  frequent,  (a)  There  is  very 
often  a  severe  continuous  cough,  which  is  always  a  suspicious  symptom. 
It  is  due  to  the  toxins  or  to  irritation  of  the  vagus  twigs  by  abundant 
miliary  nodes  in  the  lung;  it  causes  considerable  muscular  pain,  but 
little  voiding  of  sputum  and  ceases  later  if  the  brain  becomes  involved. 
(6)  The  breathing  is  increased  to  40  or  60  in  adults,  and  to  80  or  90 
in  children,  (c)  Dyspnoea  and  cyanosis  develop  from  irritation  of  the 
vagus  (Ruehle)  or  from  diaphragmatic  involvement  (Rheinhold).  The 
tachypnoea,  dyspnoea,  and  cyanosis,  are  peculiarily  significant  diagnos- 
tically  in  that  they  have  no  adequate  explanation  in  the  physical 
findings,  {d)  The  sputum  is  scant,  foamy  white,  and  mucous,  in  acute 
cases.  It  seldom  contains  dots  of  blood,  and  is  rarely  rusty  without 
the  presence  of  complicating  pneumonia.  It  may  be  more  abundant 
in  subacute  cases,  (e)  The  physical  findings  are  not  as  marked  as 
the  urgent  respiratory  symptoms  would  indicate.  A  tympanitic  note 
is  very  frequent,  resulting  from  relaxation  of  the  lung,  or  from  acute 
emphysema  from  coughing.  Dulness  only  results  from  older  tuber- 
culous foci  in  the  lung,  or  from  complicating  atelectasis  or  consolida- 
tion. Auscultation  often  reveals  fine  rales,  which  are  especially 
suggestive  when  they  occur  over  the   upper  chest,  where   stasis   is 


316     ■  THE  SPECIFIC  INFECTIONS 

uncommon.  Juergensen  notes  a  fine  pleural  rub,  which  is  due,  he 
thinks,  to  pleural  tubercles.  A  terminal  pulmonary  oedema  is  frequent. 
At  autopsy  innumerable  translucent  nodes  are  scattered  through  the 
lung,  and  are  most  apparent  on  oblique  illumination. 

4.  Nervous  System.— Nervous  symptoms  may  predominate,  and 
may  result  from  toxaemia  (like  the  symptoms  following  tuberculin 
injection),  or  from  central  organic  changes,  (a)  The  toxaemic  symp- 
toms are  headache,  dulness,  vertigo,  and  tinnitus;  these  are  followed 
by  delirium,  muscular  adynamia  and  tremor,  and  result  in  sopor, 
which  is  broken  by  fits  of  delirium,  and  finally  in  coma.  In  rare 
instances  coma  may  develop  early  in  an  apoplectiform  fashion,  or  the 
sensorium  may  be  normal.  (6)  Meningitic  symptoms  (see  Diseases 
OF  Meninges)  may  develop,  such  as  headache,  variable  pulse  and 
respiration,  tenderness  of  the  spine  with  retraction  of  head  and  spinal 
rigidity,  narrow  and  then  widened  pupils,  strabismus,  paralysis  of 
other  cranial  nerves,  Kernig's  sign,  clonic  contractions,  convulsions, 
and  coma.  The  findings  at  autopsy  are  essentially  those  of  tuber- 
culous meningitis (t;.  Meningitis). 

5.  Digestive  System. — The  tongue  is  febrile  and  there  is  anorexia. 
Nausea  and  vomiting  are  usually  meningitic.  There  is  usually  con- 
stipation and  the  abdomen  is  normal.  Diarrhoea  is  infrequent,  but 
bloody  stools  may  occur  with  tympany  and  without  ulceration  (See, 
Rheinhold).  Litten  once  heard  a  friction  rub  over  the  liver.  Ascites  is 
infrequent  in  miliary  tuberculosis  of  the  peritoneum  (as  distinguished 
from  tuberculous  peritonitis).  Miliary  tubercles  may  occur  in  the 
stomach  and  bowels,  mostly  in  children. 

6.  Choroidal  Tubercles. — These  were  first  found  at  autopsy  by 
Nanz  (1857),  Nusch  and  Cohnheim,  and  clinically  by  von  Graefe 
(1857)  and  Leber.  They  are  said  to  occur  in  16  per  cent.  (Rheinhold), 
22  per  cent.  (Demme),  and  75  per  cent.  (Litten)  of  the  cases.  They 
are  most  likely  to  be  found  when  the  tuberculosis  is  very  general. 
They  occur  singly  or  in  large  numbers  (52,  Cohnheim),  usually  in 
both  eyes  as  whitish-yellow  protuberances  with  irregular  washed  bor- 
ders. They  become  quite  large,  for  they  cause  so  much  atrophy  of 
the  retinal  pigment  layer  which  covers  them  that  they  can  be  seen 
through  it.  Daily  examination  for  them  is  necessary,  as  they  fre- 
quently develop  in  half  a  day.  They  are  seen  only  after  one  or  several 
weeks.     (Tubercles  of  the  choroid  are  depicted  in  Plate  YI,  Fig.  6.) 

7.  Other  Symptoms. — Emaciation  is  often  pronounced;  one  of 
Wunderlich's  cases  was  reduced  to  one-quarter  of  his  ordinary  weight. 
The  spleen  is  e^ilarged  in  70  per  cent.  (Litten),  but  is  usually  smaller 
than  it  is  in  typhoid,  except  in  children,  where  it  may  assume  great 
dimensions.  Collin  observed  swelling  of  the  lymphatic  glands,  which 
in  one  instance  became  enormous.  The  urine  is  concentrated  and 
dark,  from  the  fever  and  from  sweating,  may  contain  albumin  or  pep- 
tone, and  quite  often  shows  the  diazo  reaction.  Rosenstein  observed 
anuria,  especially  in  children.  Hemorrhages  into  the  gums,  nose, 
retinae,  and  intestines,  are  infrequent  and  possibly  result  from  mixed 


PLATE  VI. 


6.  Tubercles  in  choroid.  7.  Syphilitic  choroidoretinitis.  8.  Albu- 
minuric retinitis.  9.  Hemorrhages  in  pernicious  anaemia. 
(Figures  1  to  3  are  from  Jaeger  and  the  balance  are  from  Sahli. 


TUBERCULOSIS  MILIARIS  ACUTA  317 

infections.  The  skin  is  pale  and  cyanotic;  profuse  sweats,  and  there- 
fore sudamina,  are  frequent.  Herpes  may  be  observed,  as  well  as  rose 
spots  (Waller,  Jaccoud,  Collin,  Senator,  Eichhorst,  Hager),  miliary 
tubercles  in  the  skin  (Heller,  Meyer,  Lichtenstern,  Reusberg-Solingen), 
petechiae,  erythema  nodosum,  and  terminal  oedema. 

Types  and  Diagnosis. — All  the  symptoms  enumerated  are  not  con- 
stant.   Waller  (1845)  distinguished  the  following  forms: 

1.  Typhoid  Type. — The  febrile  onset  may  be  gradual  or  sudden, 
with  or  without  chills.  The  status  typhosus,  delirium,  headache, 
moderate  continuous  or  weakly  remittent  fever,  enlarged  spleen,  bron- 
chitis, less  frequently  roseolse,  meteorism,  diarrhoea,  and  intestinal 
hemorrhage,  may  cause  close  resemblance  to  typhoid  (q.  v.  for  differen- 
tiation). Epistaxis  is  less  common;  hyperesthesia, and  lierpes,are  more 
common  but  all  symptoms  may  be  deceptive  except  the  typhoid  bacil- 
laemia  and  the  Widal  reaction  in  typhoid,  as  opposed  to  tlie  tubercle 
bacillajmia  and  choroidal  tubercles  in  miliary  tuberculosis.  The  ty- 
phoid type  is  due  to  greater  toxtemia  with  less  local  reaction  from  the 
tubercle,  and  therefore  with  few  local  findings.  It  is  more  common 
in  children  than  in  adults,  and  runs  a  course  of  ten  to  twenty  days, 
or  somewhat  longer.  Typhoid  and  miliary  tuberculosis  have  rarely 
occurred  in  the  same  subject  (Birch-Hirschfeld,  Burkart,  Massini, 
Schuetze,  and  two  personal  observations).  . 

2.  Respiratory  Type.-^This  has  several  forms.  Pneumonia  may  be 
closely  simulated  by  the  fever,  chills,  pain,  cough,  rusty  sputum,  in- 
creased breathing,  dyspnoea,  cyanosis,  prostration,  or  even  by  tubular 
breathing  (in  children).  Capillary  bronchitis  (bronchopneumonia) 
should  be  differentiated  after  recent  measles,  or  after  pertussis  with 
patches  of  atelectasis.  Diagnosis  should  be  made  from  senile  bron- 
chitis and  emphysema  in  the  aged,  in  whom  this  type  is  particularly 
frequent  without  fever  (Rokitansky  held  that  emphysema  excluded 
tuberculosis,  but  it  does  not).  In  the  respiratory  type  the  toxaemia 
is  rather  subordinated  by  the  local  miliary  eruption.  Tachypnoea, 
dyspnoea,  and  cyanosis,  without  proportionate  physical  findings  are 
always  suggestive.  Tubercle  bacilli  in  the  sputum  (or  urine)  are  no 
part  of  the  miliary  process,  but  may  occur  accidentally.  The  course 
averages  three  to  four  weeks. 

3.  Meningeal  Type  (v.  Meningitis). — The  symptoms  may  be,  as 
stated  above,  clearly  organic,  and  yet,  in  children  who  are  especially 
prone  to  this  form  of  miliary  tuberculosis,  toxaemia  may  very  closely 
simulate  actual  inflammation,  as  in  Henoch's  cases,  where  only  brain 
oedema  was  found  instead  of  the  anticipated  meningitis.  The  in- 
creased deep  respiration,  with  occasional  deep  breathing  and  increased 
irregular  heart  action,  are  suggestive  (Ruehle).  The  choroid  findings, 
the  results  of  lumbar  puncture,  and  Kernig's  sign,  are  corroborative. 
Splenic  puncture  to  recover  bacilli  is  never  justifiable.  Lumbar  punc- 
ture often  shows  the  presence  of  bacilli. 

4.  Other  Types. — These  are  less  frequent,  but  their  mere  mention 
may  show  the  great  and  almost  necessary  liability  to  diagnostic  error 


318  THE  SPECIFIC  INFECTIONS 

in  atypical  forms.  They  are:  the  latent  type  (Leudet),  marked  only 
by  catarrhal  symptoms,  and  often  called  grippal ;  the  ambulant  type, 
as  in  Graewitz's  case,  where  an  apparently  healthy  soldier  died  after 
four  days  of  indisposition;  nephritic  (Collin);  arthritic  (Laveran);  apo- 
plectiform, delirium  tremens  (Waller),  pharyngeolaryngeal  (Catti), 
suffocative  (Graves),  or  asthmatic  (Andral)  type;  fulminant  type 
(Denne,  Hager),  where  the  patient  dies  in  a  few  hours,  or  in  his  sleep. 
In  some  cases,  sepsis,  miliary  carcinosis,  uraemia,  or  the  cyanosis  of 
nitro-benzol  poisoning,  may  be  suggested. 

Remissions  may  occur  for  a  time,  even  for  a  month  of  two,  as  the  tox- 
semia  may  subside,  while  the  tubercles  continue  to  develop.  The  fall  of 
the  fever  resulting  from  brain  implication  may  be  deceptive.  Chronic 
miliary  tuberculosis  is  rare.  As  a  rule  the  course  is  acute,  even 
stormy  or  peracute,  and  death  intervenes  from  exhaustion,  menin- 
gitis, heart  weakness,  dyspnoea,  high  temperature,  hemorrhages,  or 
pulmonary  oedema. 

Severe  infection  is  fatal  in  two  or  three  weeks,  moderate  infection  in 
one  to  two  months.  Recovery  is  almost  impossible,  but  Waller,  Wun- 
derlich,  Burkart  and  Spengler,  believed  that  it  exceptionally  occurred. 
Strieker  saw  recovery  of  a  case  in  which  the  diagnosis  seemed  incontest- 
able, as  he  found  bacilli  in  the  blood.  Therapy  is  useless.  The  symp- 
toms should  be  treated  expectantly,  as  they  are  in  typhoid,  pneumonia, 
and  meningitis. 

II.  Tuberculosis  of  the  Lungs  (Phthisis,  Consumption). 

The  lungs  are  involved  with  great  frequency,  not  because  they  are 
peculiarly  susceptibly,  but  because  infection  by  inhalation  is  the  most 
frequent  cause  of  tuberculosis.  Besides  this  aerogenous  infection, 
secondary  infection  by  the  bloodvessels,  as  in  miliary  tuberculosis 
(hsematogenous  infection),  and  by  the  lymph  vessels  (lymphogenous 
infection),  is  possible. 

Pathology. — The  tubercle  bacillus  localizes  in  the  bronchi  (tuber- 
culous lymphangitis),  bronchioles  or  alveoli  (tuberculous  pneumonia), 
and  causes  a  tubercle  like  that  described  in  the  general  pathology. 
There  is  cellular  hyperplasia  of  the  alveolar,  epithelial,  and  endothelial, 
cells,  and  fibrinous  inflammation  develops.  Isolated  tubercles  by 
fusion  cause  the  conglomerate  tubercle. 

Extension. — (a)  Lymphatic  extension  is  the  most  common  form.  In 
young  individuals  the  lymph  paths  are  wider  and  absorption  generally 
is  greater,  so  that  intoxication  and  bacillary  migration  are  more  active. 
Those  who  have  lost  weight,  as  convalescing  typhoids,  show  greater  ab- 
sorbing powers;  absorption  is  also  greater  after  trauma,  pneumonia, 
etc.  Bacilli  may  pass  the  bronchi  and  reach  the  glands  at  the  hilum, 
which  in  turn  may  infect  the  blood  or  break  into  the  lung.  Extension 
is  usually  along  the  lymph  vessels  in  the  bronchial  walls  (lymphangitis 
tuberculosa),  (b)  Extension  by  the  air  passages  is  quite  common; 
when  a  tubercle  ruptures  into  the  bronchi,  its  contents  may  be  coughed 


TUBERCULOSIS  OF   THE  LUNGS    {PHTHISIS,   CONSUMPTION)     319 

up  or  waved  upward  by  the  ciliated  epithelia  if  they  are  not  injured; 
on  the  other  hand,  a  deep  breath  may  aspirate,  or  coughing  may  impel, 
infected  particles  into  sound  areas,  where  they  develop  into  new  foci; 
much  depeinds  on  whether  the  bacilli  are  living  or  dead;  if  living,  an 
active  tuberculosis  develops;  if  dead,  a  pneumonia  (lobar  or  lobular) 
is  more  common,  (c)  Extension  by  the  bloodvessels  may  cause  a  local 
miliary  dissemination  in  the  lungs  (or  in  the  entire  body).  Preliminary 
to  the  clinical  description  in  which  special  pathological  features  will  be 
fully  described,  it  may  be  said  that  some  caseated  areas  fuse  into  large 
infiltrations;  some  may  encapsulate  or  calcify  and  thus  effect  a  tempo- 
rary arrest  or  a  permanent  recovery;  other  caseated  areas  soften, 
forming  ulcers  and  cavities. 

Symptoms. — A  clinical  description  covering  all  types  is  impossible, 
as  the  course  may  be  galloping,  or  extremely  chronic;  one  form  is 
marked  pathologically  by  caseation,  another  by  ulceration;  one  symp- 
tom, such  as  haemoptysis,  may  indicate  the  type,  and  may  be  the  first 
and  chief  symptom;  in  some  persons  the  symptoms  suggest  other  dis- 
eases and  the  physical  findings  are  indeterminate  or  lacking;  in  others 
the  physical  findings  are  remarkably  dissociated  from  the  usual 
symptoms.  In  the  following  description,  the  symptoms  and  signs 
usually  found  will  be  covered  first  and  the  special  types  will  be  dealt 
with  afterward: 

(.4).  Local  Respiratory  Symptoms. — These  are  usually  the  first  noted, 
and  may  only  appear  months  after  the  primary  focus  has  begun  to 
spread;  they  are  due  to  the  local  tubercle  and  its  toxins. 

1.  Cough. — Cough  is  commonly  one  of  the  first  symptoms;  it  is 
usually  present  from  the  incipiency  to  the  close  of  phthisis,  though  it  is 
sometimes  absent.  The  cause  is  that  the  toxins  irritate  the  vagus 
twigs,  which  irritation  is  referred  to  the  medulla,  from  which  issue 
muscular  contractions,  with  the  glottis  closed  in  order  to  evacuate  the 
slight  secretion;  as  shown  by  Nothnagel,  Stark,  Kohts,  and  Reyher, 
the  interarytenoid  space  and  tracheal  bifurcation  are  the  most  sensitive 
areas.  It  is  sometimes  referable  to  pleurisy,  catarrh  of  the  pharynx, 
enlarged  bronchial  glands,  or  laryngitis.  It  is  slight  at  first,  and  has  no 
peculiar  characteristics,  other  than  being  dry,  difficult  and  paroxysmal. 
Later  it  becomes  more  frequent  but  less  difficult  as  the  secretion  in- 
creases. In  some  cases  it  is  most  severe  in  the  morning,  the  secretion 
having  accumulated  over  night,  while  in  others  it  is  most  severe  at 
night,  for  the  lungs  become  congested  by  the  dorsal  decubitus;  saliva, 
reaching  the  larynx  during  the  night,  may  cause  a  sudden  explosive 
cough.  It  may  be  provoked  by  dust,  smoke,  variations  in  temperature, 
such  as  those  resulting  from  opening  windows  or  getting  into  the  cool 
bed,  by  exertion,  laughing,  or  taking  alcohol.  It  varies  with  the  indi- 
vidual, being  more  marked  in  neurotics  and  less  conspicuous  in  the 
phlegmatic,  the  aged,  or  in  the  insane.  When  quite  obstinate  it  may 
constantly  invoke  vomiting  and  lead  to  great  emaciation. 

2.  Sputum. — The  sputum  is  first  caused  by  the  toxins,  and  later  by 
the  secretion  from  the  tuberculous  focus.    At  first  it  is  glairy  and  con- 


320  THE  SPECIFIC  INFECTIONS 

tains  sago-like  bodies  which  are  composed  of  alveolar  cells  transformed 
into  a  myelin  substance.  It  later  becomes  yellow  from  admixture  of 
pus,  or  yellow  or  red  from  saprophytic  organisms,  such  as  sarcinse,  or 
the  bacillus  aureus  or  squamosus.  A  green  tinge  may  result  from  the 
bacillus  pyocyaneus  or  fluorescens.  Blood  may  give  it  a  red,  rusty, 
flesh-like,  or  chocolate  hue.  It  tastes  sweet  and  smells  slightly  foetid. 
Its  amount  varies  from  a  few  globules  to  over  a  pint.  It  is  more  abun- 
dant in  cavities  than  it  is  in  extension  of  tuberculosis  by  the  blood-  or 
lymph- vessels;  it  stagnates  before  death,  because  of  the  patient's  mus- 
cular weakness;  women  and  children  are  prone  to  swallow  the  sputum. 
Nummular  sputum  from  cavities  is  flat,  "coin-like,"  greenish-gray, 
extremely  abundant,  and  sinks  in  water,  as  it  is  airless;  it  occurs  in 
other  than  tuberculous  cavities,  as  in  bronchiectasis.  The  only  char- 
acteristic of  the  sputum  is  the  tubercle  bacillus  (v.s.),  which  is  found 
only  in  tuberculosis;  it  may  be  seen  before  the  advent  of  any  physical 
finding,  but  in  other  cases  it  must  be  sought  repeatedly,  as  it  appears 
only  when  ulceration  communicating  with  a  bronchus,  develops.  The 
tubercle  bacillus  is  found  in  only  one-third  of  the  cases  of  incipient 
tuberculosis.  Other  bacteria  and  saphrophytes  are  frequent  {v.  Bac- 
teriology, 8).  If  the  patient  expectorates  into  water  a  crumbling  pre- 
cipitate, rich  in  bacilli,  is  obtained  (Virchow).  Elastic  fibers  are  found 
in  70  to  90  per  cent,  and  originate  from  the  vessels,  or  from  the  par- 
enchyma of  the  lung.  The  elastic  fibers  from  the  vessels  are  elongated 
and  twisted,  and  sometimes  considerable  shreds  of  the  vessel-wall  are 
seen;  the  elastic  fibers  from  the  bronchi  are  also  long  and  twining; 
those  from  the  lung  substance  often  show  its  alveolar  arrangement. 
Elastic  fibers  can  often  be  located  by  flattening  the  sputum  between 
two  plates  of  glass  and  picking  out  the  yellowish  areas  for  microscopic 
examination.  Treatment  with  caustic  potash,  and  centrifuging,  facil- 
itate their  detection  when  they  are  scanty.  They  merely  denote  a 
destructive  process,  hence  are  also  found  in  abscess,  gangrene,  infarction, 
and  in  pneumonia.  Detritus,  pus  cells,  red  cells,  alveolar,  bronchial 
and  buccal  epithelium,  myelin  droplets  and  pigment,  are  also  found. 
The  so-called  calculi  of  the  lung  are  sometimes  voided;  they  are  cal- 
cified particles  from  old  areas  of  caseation,  from  bronchial  obstruction, 
or  from  peribronchial  lymph  glands;  from  the  glands  large  calcarious 
masses  may  cause  fatal  obstruction  of  the  trachea,  or  suffocation  may 
be  averted  only  by  immediate  low  tracheotomy.  Chemistry:  88  to  98 
per  cent,  of  the  sputum  is  water;  3  to  11  per  cent,  is  organic,  and  less 
than  1  per  cent,  is  inorganic  matter;  tyrosin,  glycogen,  urea,  lecithin, 
cholesterin,  fatty  acids,  nuclein,  and  a  pepsin-like  ferment,  may  be 
found.      (See  Plate  VII  for  tubercle  bacilli  and  elastic  fibers). 

3.  HEMOPTYSIS. — Haemoptysis  (hfemoptoe,  spitting  of  blood)  occurs 
in  a  variable  percentage.  Prior  saw  it  in  37  per  cent,  of  1,000  cases; 
others  place  it  at  66,  80,  or  even  90,  per  cent. ;  it  is  more  frequent  in 
adult  males  than  in  females  and  is  rare  before  puberty,  (a)  Early 
hoernoptysis  is  due  to  erosion  of  the  mucous  membrane,  or  often  erosion 
of  a  small  vessel  by  tubercles  in  its  perivascular  lymph  sheath.    The 


PLATE  VII. 


Tubercle  Bacilli  and  Elastic  Fibers. 


TUBERCULOSIS  OF   THE  LUNGS   (PHTHISIS,   CONSUMPTION)     321 

toxins  usually  prevent  extensive  early  hemorrhage  by  causing  coagu- 
lation in  the  vessels  in  and  near  the  affected  lung  area.  Haemoptysis  is 
the  first  symptom  in  4  per  cent,  of  phthisis  cases  and  is  fairly  often 
(16  per  cent.)  the  only  symptom,  the  patient  never  having  future 
trouble;  in  most  cases,  however,  other  symptoms  develop;  bacilli  and 
elastic  fibers  may  be  seen  at  the  time  of  bleeding.  Reiche  recently  cor- 
roborated the  old  statement  that  early  haemoptysis  is  not  unfavorable. 
The  bleeding  often  occurs  without  cause,  coming  on  suddenly  with  a 
warm,  salty  taste  in  the  mouth  and  the  evacuation  of  a  dram  or  more  of 
bright  frothy  blood,  either  clear  or  mixed  with  mucus;  small  particles  of 
darker  blood  are  brought  up,  for  a  few  days,  after  which  it  disappears; 
in  4,125  of  the  Brompton  Hospital  cases,  69  per  cent,  evacuated  less 
than  half  an  ounce.  In  other  instances  haemoptysis  is  excited  by  cough- 
ing, laughing,  bathing,  exertion,  or  excitement.  Bubbling  rales  may 
be  heard  on  the  side  of  the  lesion,  and  moulds  of  the  bronchioles  may 
be  voided.  F.  Strieker  collated  900  cases  of  haemoptysis  in  the  German 
army  among  1,728,505  soldiers,  between  1890  and  1895;  in  480  cases 
there  was  no  cause,  and  of  these  87  per  cent,  were  tuberculous;  of  43 
cases  brought  on  by  exertion,  74  per  cent,  were  tuberculous;  and  of  24 
cases  due  to  trauma,  half  were  tuberculous.  The  occurrence  of  early 
hemorrhage,  before  other  symptoms  of  phthisis,  led  Hippocrates, 
Boerhaave,  Van  Swieten,  Morton,  Graves,  Niemeyer,  and  others,  to 
think  that  haemoptysis  caused  phthisis,  while  Laennec,  Louis  and 
Traube,  correctly  regarded  it  as  a  symptom  of  already  established 
phthisis.  The  earlier  idea  is  explained  by  the  fact  that  in  bleeding, 
blood  and  bacilli  may  be  aspirated  into  other  parts,  in  which  the  process 
develops  anew  (v.i.  Acute  Fokms);  fever  following  haemoptysis  is 
therefore  rather  ominous,  (b)  Late  hoemopysis  may  be  slight  or  pro- 
fuse. Profuse  bleeding  is  usually  due  to  erosion  of  bloodvessels  running 
across,  or  in,  the  walls  of  cavities,  which  are  frequently  aneurysmatic 
(Rasmussen) ;  occasionally  larger  vessels,  such  as  the  pulmonary  artery, 
are  ulcerated.  Amounts  as  large  as  a  pint  or  a  quart  may  sometimes 
spurt  out  of  the  mouth,  causing  acute  anaemia,  suffocation,  or  rapid 
exsanguination.  Blood  may  accumulate  in  large  cavities,  never  reach- 
ing the  air  passages.  While  haemoptysis  is  usually  a  sign  of 
tuberculosis,  it  may  occur  from  other  causes  {v.  Diseases  of  the 
Lungs). 

4.  Dyspncea.— This  is  infrequent,  even  when  the  respiratory  area 
is  enormously  contracted,  just  as  it  is  absent  in  pleurisy  of  gradual 
onset;  it  is  often  absent  even  with  great  infiltration,  great  cavity  for- 
mation, or  induration  of  two-thirds  of  the  respiratory  space,  whereas 
in  sudden  miliary  tuberculosis  the  dyspnoea  is  great.  In  some  cases 
dyspnoea  is  neurotic,  or  it  may  follow  pressure  of  swollen  glands  on 
tlie  vagus,  anaemia,  stagnating  secretion,  extensive  vicarious  emphy- 
sema, or  massive  pleural  adhesions.  It  is  most  often  due  to  the  rapid 
heart  action.  In  the  last  stages  it  may  cause  orthopnoea  and  can 
result  from  intercurrent  bronchitis,  pneumonia,  or  pneumothorax. 
Germain  See  has  described  a  tuberculous  pseudoasthma. 

21 


322 


THE  SPECIFIC  IXFECTIOXS 


5.  Paix. — Pain  is  moderately  frequent.  Its  location  may  be  apical, 
basal,  diaphragmatic,  or  on  the  anterior  part  of  the  chest  from  the 
clavicle  to  the  third  rib  or  under  the  scapula.  Its  character  is  usually 
sticking  and  intermittent,  but  not  intense;  the  skin  is  often  hyper- 
sesthetic  to  pressure  and  palpation.  Its  cause  is  chiefly  acute  pleurisy, 
for  lung  disease  causes  no  pain,  and  chronic  pleurisy  is  generally  pain- 
less; other  causes  are  muscular  fatigue  from  coughing,  intercostal 
neuralgia,  and  less  often  intercostal  neuritis.  Pain  may  be  intense  in 
pneumothorax. 

{B).  General  Symptoms. — These  result  from  absorption  of  the  toxins 
secreted  in  the  local  lesions. 

1.  Fever. — This  is  present  in  the  great  majority  of  cases  and  is 
almost  invariable  in  the  early  stages.  Its  cause  is  somewhat  disputed; 
probably  the  dominant  factor  is  the  tuberculous  toxin,  whose  febrile 
action  is  analogous  to  that  of  tuberculin;  secondary  infections  un- 
doubtedly may  cause  fever,  though  not  necessarily,  for  it  is  proven 
that  the  associated  streptococci  are  usually  far  from  ^-irulent.  Fever 
marks  the  tubercle  formation,  fusion  of  foci,  advance  of  the  disease, 
degeneration  of  the  tubercle,  and  probably  secondary  infection;  its 
cessation  is  synchronous  with  temporary  or  permanent  arrest  of  the 
disease  as  manifested  by  improved  health,  strength,  and  weight.  Its 
height  and  course  are  somewhat  influenced  by  the  indi^-idual;  labile 
individuals  possess  labile  temperature  centres  (de  Renzi);  fever  can- 
not be  classified  by  the  clinical  stages,  as  incipient  fever,  ulceration 
fever,  etc. 


Fig.  20. 


104 

DAY    1 

., 

3 

4 

h 

6 

103 

A                                                       A                   K 

102 

A  'A  '    '   i\  i\ 

101 

A..    !/        ^   A    ^      1    \          \ 

.      /   \    /     \      /    \        /           1       \ 

99 

ALA/     \      A    ^ 

/          \/  1           "                  \  /          i     V               \       ! 

9.        :                   V|                        ,                          \i                                                                 1 

Hectic-fever  curve  in  phthisis. 

Types. — Intermittent  fever  may  exactly  resemble  malaria  and  can 
be  detected  only  when  registered  every  two  or  three  hours;  remit- 
tent fever  most  often  occurs  late  in  the  clinical  course;  continuous 
fever  occurs  early  or  in  acute  consumption,  though  it  rarely  resembles 
the  typhoid  curve;  in  some  cases  the  fever  falls  from  high  to  sub- 
normal regi-sters,  sometimes  with,  collapse,  which  was  regarded  as 
unfavorable  by  Ruehle;  the  typus  inversus  with  morning  exacerbation 
and  vesperal  solution  is  very  uncommon.  Fever  may  be  absent  in 
cases  of  old  cavities  and  of  fibrous  induration.    Chills  have  no  relation 


TUBERCULOSIS  OF  THE  LUNGS   {PHTHISIS,   CONSUMPTION)     323 

to  the  fever  nor  to  its  intensity.  As  fever  is  indicative  of  toxsemia,  it  is 
often  associated  with  anorexia,  emaciation,  and  other  symptoms  to  be 
immediately  described. 

2.  The  Blood. — (a)  The  red  cells  rarely  number  less  than  2  million, 
though  Limbeck  records  a  case  with  but  730,000;  the  anaemia  may 
antedate  all  other  symptoms,  whence  the  frequent  confusion  of  chlor- 
anaemia  and  incipient  phthisis.  Again,  anaemia  may  be  inconspicuous 
or  late.  In  some  cases  the  red  cells  are  increased,  notably  in  individ- 
uals prone  to  haemoptysis  (Mircoli).  (b)  The  haemoglobin  may  fall  to 
25  per  cent.,  but  averages  70  to  80  per  cent.;  it  may  be  decreased 
more  than  the  number  of  red  cells,  therein  resembling  chlorosis  {chlor- 
ancemie  tuherculeuse) .  (c)  The  leukocytes  may  be  normal;  again, 
in  cavity  formation  (secondary  infection)  their  number  may  rise  to 
12,000  or  15,000;  they  are  increased  in  cases  of  caseous  pneumonia 
or  protracted  pyrexia;  after  injection  of  tuberculin  the  eosinophiles 
show  a  decided  increase,  {d)  Tubercle  bacilli  are  seldom  found  in  the 
blood  except  in  the  death  agony. 

3.  Sweating. — This  is  more  important  than  in  any  other  disease. 
It  occurs  in  90  per  cent,  of  cases  (Louis).  The  most  likely  cause  is 
the  action  of  toxaemia  on  the  sweat-centre  in  the  medulla,  though  there 
are  many  other  theories.  Heavy  coverings  may  sometimes  cause 
sweating.  It  is  more  frequent  in  acute  than  in  chronic  phthisis  and 
in  younger  than  in  older  subjects.  The  term  "night  sweats"  is  used 
because  nearly  all  of  them  occur  in  the  night,  chiefly  between  2  and 
5  A.M.  They  are  most  frequent  when  cavities  are  forming,  and  in  the 
last  stages.  They  have  no  constant  relation  to  the  fever  but  are  more 
frequent  when  it  is  variable. 

4.  Pulse. — The  pulse  is  rapid,  digestion  is  frequently  disturbed, 
muscular  strength  is  reduced,  and  nutrition  is  depreciated  {v.i.  Com- 
plications, for  details). 

(C).  Physical  Signs — In  adults,  the  apex  of  an  upper  lobe,  more  often 
the  right  than  the  left,  is  first  affected  (Laennec).  The  reasons  ascribed 
are  various,  such  as  a  poor  apex  blood  supply,  slower  lymph  current, 
and  less  expansion, — which  are  scarcely  proven.  It  is  more  correctly 
held  that  coughing  drives  infection  upward  from  the  bronchi,  and 
that  the  clavicle  or  first  rib  compresses  the  bronchi  passing  to  the  apex. 
The  summit  of  the  apex  is  not  invaded  first.  Birch-Hirschfeld,  in 
early  cases  which  died  from  causes  other  than  tuberculosis,  found  that 
in  24  per  cent,  the  disease  began  in  the  fourth  or  fifth  order  of  bronchi 
in  the  upper  lobe  and  that  the  posterior  were  affected  earlier  than  the 
anterior  divisions. 

1.  Inspection. — (a)  The  nutrition  may  be  good,  but,  later,  emacia- 
tion is  marked.  The  face  is  pale,  the  cheeks  hectic,  the  nose  pointed, 
the  eyes  hollowed  and  glistening,  the  neck  thin,  and  the  chest  is  altered 
in  various  ways;  in  some  cases  it  is  long  and  narrow,  with  wide  inter- 
spaces, sharp  costal  angles,  prominence  of  Louis'  angle,  and  more 
vertically  directed  ribs;  in  others  it  is  flattened  anteroposteriorly  and 
the  ribs  are  closely  apposed;    in  still  others  the  funnel-chest  may  be 


324  THE  SPECIFIC  INFECTIONS 

seen.  Laennec  recognized  that  the  ''paralytic  chest"  was  the  result 
and  not  the  cause  of  phthisis.  Examining  the  patient  in  a  good  light, 
the  following  may  be  noted:  (b)  deficient  expa7ision  above  or  below 
the  clavicles,  especially  when  examined  from  behind  and  above;  in 
the  lower  chest,  an  impaired  or  absent  excursion  of  the  diaphragm 
(Litten's  phenomenon).  Deficient  expansion  may  be  due  to  pleural 
adhesions,  to  atelectasis  of  the  lung  resulting  from  caseous  nodes 
obstructing  the  bronchi,  to  a  cavity,  or  to  gradual  induration  of  the 
focus,  which  is  an  effort  towards  encapsulation  and  recovery,  (c) 
Distention  of  the  chest  may  be  due  to  vicarious  emphysema,  effusive 
pleurisy  or  pneumothorax,  (d)  The  cardiac  impulse  may  be  increased 
by  retraction  of  the  left  lung  away  from  the  heart. 

2.  Palpation. — Palpation  shows  (a)  decreased  expansion,  elicited  by 
standing  behind  the  patient  with  the  thumbs  above  either  clavicle 
and  the  fingers  below  it,  or  by  standing  in  front  of  the  patient  and 
applying  the  spread  fingers  and  hands  over  the  anterolateral  parts 
of  the  thorax;  (6)  increased  vocal  fremitus,  obtained  when  the  lung 
is  infiltrated  (caseous  foci  or  pneumonia),  indurated  or  is  the  seat  of 
cavities,  all  of  which  increase  conduction  of  the  voice-sounds  from 
the  bronchi.  The  depth  of  the  focus  is  a  factor,  superficial  lesions 
showing  more  clearly  than  deep  ones;  thick  pleural  adhesions  or 
plugging  of  the  bronchi  with  caseous  material  decrease  the  fremitus. 
(c)  The  systolic  distention  of  the  pulmonary  artery  and  the  second 
pulmonic  closure  are  better  felt  when  the  lung  retracts  from  the  heart 
or  when  it  is  infiltrated  in  its  vicinity. 

3.  Percussion. — (a)  Incipient  infiltration  of  the  apex  gives  a  short 
percussion  note,  which  later  becomes  dull.  According  to  Grawitz 
the  apex  is  first  involved  in  88  per  cent,  of  cases.  Dulness  is  detected 
in  the  apex  or  under  the  middle  of  the  clavicle,  at  which  level  Birch- 
Hirschfeld  found  the  anatomical  beginning  of  tuberculosis.  The 
apices  are  best  percussed  when  standing  behind  the  patient,  and  it 
should  be  remembered  that  the  right  apex  is  normally  less  resonant 
than  the  left.  The  lung  tissue  lying  behind,  or  near,  the  clavicle  can 
be  well  tested  by  gently  tapping  the  clavicle  with  one  finger.  The 
apex  reaches  1  to  2  inches  above  the  clavicle,  and  behind  to  the  ver- 
tebra 'prominens.  Piorry,  Friedreich,  and  Eichhorst,  demonstrated  that 
impaired  resonance  is  produced  only  by  consolidation  measuring  1^  by 
2^  inches  in  area  and  within  f  inch  of  the  surface,  and  that  foci  of 
these  dimensions  lying  deeper  than  2  inches  escape  detection.  Oester- 
reich  holds  that  a  focus  as  large  as  a  cherry  may  cause  dulness.  Small 
multiple  or  deep  foci  give  a  tympanitic  note.  To  detect  slight  early 
alterations  in  note,  percussion  should  be  gentle,  symmetrical  parts 
should  be  compared  and  the  patient  should  hold  his  breath  in  full 
inspiration;  the  muscles  must  be  relaxed,  and  it  should  be  recalled 
that  each  patient  has  his  own  percussion  note,  which  varies  with  the 
individual's  muscles,  fat,  and  bones.  Often  the  first  dulness  of  con- 
solidation is  found  behind,  in  the  supra-  or  interscapular  region.  The 
dulness  may  extend  from  the  clavicle  to  the  second  and  third  costal 


TUBERCULOSIS  OF   THE  LUNGS   {PHTHISIS,   CONSUMPTION)     325 

cartilages,  then  to  1.5  inches  below  the  apex  of  the  lower  lobe  at  the 
level  of  the  fifth  dorsal  vertebra;  this  area  is  almost  always  involved 
when  the  upper  lobe  shows  distinct  consolidation;  extension  occurs 
outward  and  downward  along  the  interlobar  fissure;  then  it  extends 
to  the  apex  of  the  upper  lobe  on  the  other  side,  (b)  Shrinking,  or 
fibrous  induration,  and  a  thickened  pleura,  give  apical  or  other  dulness. 
Sometimes  the  lung  becomes  vicariously  emphysematous  about  an  old 
focus  which  is  thus  hidden  clinically  and  pathologically,  (c)  A  tym- 
panitic, or  cracked-pot  resonance,  may  be  obtained  over  cavities  {v.  i.) ; 
percussion  over  a  cavity  sometimes  induces  sudden  evacuation  of  its 
contents. 

4.  Auscultation. — This  is  the  most  important  aid,  next  to  the  micro- 
scopic examination  of  the  sputum,  (a)  The  vesicular  murmur,  espe- 
cially at  the  apex,  is  altered, — for  detection  of  which  the  patient  is  best 
examined  without  deep  breathing  or  coughing;  the  jerky  "cog-wheel" 
hreathing  may  be  due  to  small  tubercles  in  the  pleura  or  bronchi, 
somewhat  stenosing  their  lumina;  it  is  only  suggestive  and  occurs  in 
normal  individuals;  Potain  considers  it  due  to  pounding  of  the  heart 
on  the  lung  during  inspiration  (also  a  cause  for  the  cardiorespiratory 
systolic  whiff,  which  is  heard  in  the  front,  sides,  and  back,  of  the  chest 
during  deep  inspiration,  in  healthy  as  well  as  tuberculous  subjects). 
The  breathing  may  be  weak,  indeterminate,  or  'puerile.  A  rude,  rough 
inspiration  may  be  heard,  which  is  due  to  peribronchial  tubercles  com- 
pressing the  bronchioles.  The  expiration  is  frequently  prolonged, 
rougher,  and  higher  pitched,  in  apical  "catarrh";  it  is  long,  sharp,  and 
bronchial,  in  older  foci.  It  must  be  remembered  that  the  breath-sounds 
are  physiologically  higher  pitched  on  the  right  than  on  the  left  side, 
and  that  what  seems  clinically  to  be  catarrh  is  often  consolidation, 
pathologically.  (6)  Bronchial  hreathing  is  caused  by  various  consoli- 
dations (tuberculous,  pneumonic,  neoplastic,  or  gangrenous  infiltration) 
and  by  cavities,  tuberculous  and  otherwise.  Bronchial  breathing  of 
moderate  degree  is  physiological  in  the  interscapular  region,  but  is 
considerably  less  intense  than  that  of  consolidation,  (c)  Rales  are 
rather  an  evidence  of  infiltration  (consolidation)  than  of  "catarrh".  If 
they  are  heard  in  the  apex,  the  presence  of  tuberculosis  should  be  sus- 
pected, though  they  may  occasionally  occur  there  physiologically. 
The  vibrations  of  the  accessory  muscles  of  respiration,  when  the  patient 
takes  a  long  forcible  breath,  may  be  confused  with  rales,  but  are  easily 
differentiated  after  a  little  experience.  Rales  may  not  be  heard  unless 
the  patient  breathes  deeply  or  coughs,  and  auscultation  should  be 
made  before,  and  then  after,  coughing  and  deep  inspiration.  In  incip- 
ient consolidation,  small  crackling  crepitant  rales  are  heard  over  the 
alveoli  and  smaller  bronchioles,  at  the  end  of  inspiration;  they  later 
become  larger,  ringing  and  resonant,  which  proves  that  the  alveoli 
and  bronchioles  have  become  airless  over  a  considerable  area,  or  that 
softening  or  formation  of  cavities  is  in  progress;  scattered,  clear, 
large,  crackling  rales  are  heard  over  small  cavities  in  the  apex  or 
in  the  smaller  bronchi,  and  indicate  a  viscid  secretion.     Clicking  rales 


326  THE  SPECIFIC  IXFECTIOXS 

near  the  heart  may  occur  in  the  systole,  as  the  heart  beats  upon  an 
adjacent  infiltration.  In  emphysematous  patients,  whose  chests  ex- 
hibit sibilant  and  bubbling  rales,  auscultation  and  diagnosis  of  develop- 
ing tuberculosis  may  be  most  difficult,  (d)  Bronchoplionij  (a  bronchial 
quality  imparted  to  the  voice-sounds)  is  heard  when  the  patient  counts 
or  speaks  during  auscultation;  it  indicates  infiltration  or  cavity  for- 
mation but  is  absent  when  the  bronchi  are  plugged  with  secretion. 
/Ego-phony  is  merely  a  higher  grade  of  bronchophony  and  occurs,  as 
Skoda  demonstrated,  in  cases  of  consolidation,  in  middle-sized  cavities, 
and  above  pleural  exudates  and  transudates,  (e)  Pleural  friction  may 
result  from  rough  tubercles  in  the  pleura,  or  from  fibrinous  pleurisy. 
(/)  A  systolic  bruit  over  the  subclavian  artery  is  probably  due  to 
pleural  adhesions  to  the  artery. 

5.  Roentgen  Rays. — The  rays  show  shadows  which  may  be  due  to 
consolidation,  thick-walled  ca\dties,  calcified  foci,  gangrene,  pleural 
callus,  or  pleural  exudate.  The  excursion  of  the  diaphragm  can  be 
follo-ued;  shadows  toward  the  apices,  due  to  the  muscles,  may  be 
readily  eliminated,  by  moving  the  arms;  the  results  are  often  confus- 
ing. 

The  findings  of  inspection,  palpation,  percussion  and  auscultation 
are  grouped  together,  because  they  are  found  together  clinically,  one 
part  showing  the  signs  of  consolidation,  another  those  of  cavity  for- 
mation or  of  induration.  To  summarize,  (a)  the  signs  of  consolidation 
are  decreased  expansion,  increased  vocal  fremitus,  initial  tympany  fol- 
lowed by  dulness,  high-pitched  expiration,  then  distinct  bronchial 
breathing,  crepitant  rales  and  bronchophony;  (b)  the  signs  of  indura- 
tion are  retraction,  or  lagging  behind  of  the  fibrous  area  on  breathing, 
pleural  adhesions,  increased  vocal  fremitus,  dulness,  usually  large 
rales,  bronchial  breathing  and  bronchophony,  (c)  The  signs  of  cavity 
formation  are:  (i)  increased  vocal  fremitus,  if  it  is  near  the  surface; 
(ii)  tympanitic  note,  which  may  increase  in  intensity  when  the  cavity 
is  percussed  mth  the  mouth  open  (Wintrich's  change  of  note;  it  is 
also  observed  in  cases  of  consolidation  lying  over  a  bronchus),  when  it 
is  percussed  during  inspiration  (Friedreich's  change  of  note),  or  when 
it  is  percussed  with  the  patient  in  the  sitting  posture  (Gerhardt's 
change);  the  note  may  be  metallic;  the  cracked-pot  note,  Laennec's 
hruit  de  pot  fele,  is  obtained  in  cases  of  superficial  ca^dties  measuring 
2^  inches  with  thin  walls,  which  communicate  with  an  open  bronchus 
by  a  small  opening;  variation  in  the  percussion  note  from  accumula- 
tion (dulness),  or  emptying  of  secretion  (tympany),  is  most  suggestive 
of  cavity  formation;  (iii)  the  breathing,  which  is  loudly  bronchial,  or, 
if  the  cavity  is  quite  large,  is  metallic,  amphoric  or  metamorphosing; 
metamorphosing  breathing  is  breathing  which  begins  normally  and 
suddenly  becomes  bronchial  (Seitz) ;  (iv)  bronchophony  and  segophony ; 
(v)  large,  resonant  rales,  which  are  the  most  frequent  and  important 
finding;  metallic  rales  in  the  apices  are  most  suggestive  of  cavities; 
they  may  acquire  an  amphoric  character  in  very  large,  thin-walled 
excavations;    (vi)  nummular  sputum;    (vii)  systolic  murmurs,  which 


TUBERCULOSIS  OF   THE  LUNGS   [PHTHISIS,   CONSUMPTION)     327 

are  sometimes  booming  or  metallic,  and  are  due  to  propagation  of  the 
heart  tones;  they  are  occasionally  heard  at  some  distance  from  the 
patient. 

Cavities  are  due  to  the  breaking  down  of  caseous  areas  and  are 
usually  connected  with  the  bronchi.  Their  evacuation  into  the  bronchi 
is  partly  favorable,  in  that  the  infective  material  is  evacuated;  partly 
unfavorable,  because  it  opens  up  avenues  for  infection  by  aspiration. 
They  rarely  heal  by  obliteration;  they  may  leave  fistulous  cicatrices 
(Laennec's  cicatrices  fistuleuses);  if  they  are  held  by  adhesions  the 
cavity  remains,  contracting  cicatrization  being  impossible;  there  is 
always  danger  of  their  further  extension  by  secondary  infection,  or 
of  gangrene.  The  cavity  has  a  well-marked  limiting  membrane,  from 
which  pus,  nummular  sputum,  elastic  fibers,  and  grayish  granular 
detritus  composed  of  masses  of  tubercle  bacilli,  are  voided;  the  cavi- 
ties are  frequently  multilocular,  may  heal  on  one  side  and  extend  on 
another,  and  sometimes  occupy  an  entire  lobe  or  even  an  entire  lung. 
They  may  rupture  into  the  pleura,  pericardium,  or  bloodvessels;  in 
one  instance  the  author  saw  a  cavity  rupture  into  the  mammary  gland, 
resulting  in  diffuse  subcutaneous  emphysema. 

Stages  of  Pulmonary  Tuberculosis. — Tuberculosis  usually  develops 
for  six  to  eighteen  months  before  any  symptoms  appear. 

1.  Phthisis  Incipiens. — In  incipient  phthisis  the  general  and  local 
symptoms  appear  as  above  described,  with  fever,  anaemia,  and  rapid 
pulse.  The  modes  of  onset  are  various,  for  tuberculosis  may  simulate 
chlorosis,  malaria,  dyspepsia,  laryngitis,  or  bronchitis,  or  may  appear 
in  other  forms  more  directly  suggestive  of  tuberculosis,  such  as  haemo- 
ptysis, pleurisy,  or  cervical  adenitis.  The  physical  findings  are  uncer- 
tain or  absent. 

2.  Phthisis  Confirmata.— The  appearance  of  distinct  physical  find- 
ings indicate  not  incipient  phthisis,  but  confirmed  established  phthisis. 

3.  Phthisis  Consummata. — This  is  advanced  consumption,  with 
marked  hectic  fever,  cavity  formation,  and  emaciation. 

Course. — The  average  case  of  "chronic  ulcerative  phthisis,"  with 
the  symptoms  and  signs  already  described,  stands  midway  between 
the  following  very  acute  and  extremely  chronic  groups: 

{A).  Acute,  Galloping  or  Florid  Consumption. — This  type  probably 
always  develops  from  some  old  focus,  such  as  tuberculosis  of  the 
bronchial  glands,  or  from  a  small  cavity  which  by  rupture  disseminates 
the  process;  possibly  the  virulence  of  the  germ  is  greater  in  these 
cases;  pregnancy,  diabetes,  alcoholism,  measles,  whooping-cough, 
influenza,  or  trauma,  may  be  the  immediate  cause. 

1.  Acute  Pneumonic  Form.— The  acute  pneumonic  form  is  acute 
caseous  pneumonia.  The  terms  are  employed  because  of  the  great 
clinical  resemblance  to,  and  confusion  with, acute  lobar  pneumonia;  but 
it  must  be  remembered  that  genuine  lobar  pneumonia  does  not  caseate, 
and  that  this  form  is  not  synonymous  with  tuberculosis  compli- 
cated by  acute  pneumococcic  pneumonia,  which,  in  this  association, 
runs  its  usual  course.     Acute  caseous  pneumonia  begins  in  an  indi- 


328  THE  SPECIFIC  IXFECTIOXS 

^'idual  in  seemingly  perfect  health,  or  perhaps  in  one  whose  health  is 
somewhat  but  not  suggestively  reduced.  An  initial  rigor  is  fairlv  com- 
mon, or  the  spitting  of  blood  may  be  the  first  symptom.  There  mav 
be  cough,  pain  in  the  side,  rapid  breathing,  and  sudden  fever,  which 
are  all  apparently  compatible  with  a  diagnosis  of  genuine  pneumonia. 
The  fever,  however,  is  remittent  or  intermittent,  and  more  variable 
than  in  lobar  pneumonia;  dyspnoea  and  cyanosis  are  less  frequent 
than  a  gradually  increasing  pallor;  sweating  is  usually  copious.  In 
a  few  days  dulness  prevails  over  a  lower  lobe  but  much  more  often 
over  an  upper  lobe  or  over  an  entire  lung.  The  breathing,  which  is 
at  first  indistinct,  may  remain  so  (Traube),  but  quite  often  becomes 
bronchial  and  is  associated  with  crepitant  and  coarse  mucous  rales. 
The  sputum  is  often  typically  pneumonic,  viscid  and  rusty,  or  again 
is  of  an  olive  or  grass-green  color  (Traube).  Tubercle  bacilli  are 
sometimes  found,  but  in  this  case  originate  not  from  the  fresh  pseudo- 
pneumonic  patches,  but  from  the  causal  focus  (the  primary  cavity). 
In  some  few  cases  the  physical  signs  of  the  primary  ca^aty  in  an  upper 
lobe  can  be  elicited.  Albuminuria  is  uncommon;  the  diazo  reaction 
is  nearly  always  present.  The  physical  findings  change  but  little, 
though  the  crepitant  rales  decrease  and  are  replaced  by  coarse  mucous 
rales;  the  anticipated  crisis  does  not  occur,  and  most  cases  are  still 
called  unresolved  pneumonia  until  the  increasing  anaemia,  loss  of 
strength  or  rapid  pulse,  suggests  a  tuberculous  pneumonia.  Of  13 
eases  reported  by  Fraenkel  and  Troje,  11  died  within  six  weeks,  and 
Traube  observed  a  fatal  issue  in  thirteen  days.  In  some  few  cases 
considerable  regression  may  occur  and  it  is  barely  possible  for  connect- 
ive tissue  to  develop,  dragging  out  the  course  for  three  months  or 
even  for  years.  The  findings  at  autopsy  are  most  interesting;  usually 
an  old  focus  of  tuberculosis  is  found,  a  ruptured  ca\-ity  or  gland; 
from  it  caseous  material,  containing  bacilli  and  tuberculous  toxins, 
is  aspirated  into  many  finer  alveoli  and  bronchioles,  where  they  set 
up  a  miliary  caseous  lobar  pneumonia,  depending  on  the  size  of  the 
affected  area  only.  The  inflammation  is  seemingly  due  wholly  to 
Koch's  bacillus  or  its  toxins,  and  is  (a)  partly  fibrinous  and  desquam- 
ative, red  and  white  polynuclear  and  mononuclear  cells  being 
poured  out;  proliferative  changes  are  noted,  as  the  epithelioid  and 
giant  cells  which  are  seen  in  the  typical  tubercle;  caseation  ensues, 
as  shown  in  the  already  fused  and  fusing  yellowish-gray  areas;  (6) 
the  most  rapid  exudation  is  serous,  Laennec's  "gelatinous  or  smooth 
pneumonia,"  which  is  probably  due,  as  Fraenkel  and  Troje  insist,  to 
the  toxins  of  the  tubercle  bacillus  and  not  to  mixed  infection  as  Ortner 
and  others  maintain;  this  part  of  the  inflammation  may  regress,  and 
does  not  necessarily  caseate.     Cavities  rarely  form  in  this  type. 

2.  Acute  Disseminated  Form. — Acute  disseminated  tuberculosis, 
sometimes  characterized  especially  by  htiemoptysis,  may  occur  as  a 
special  acute  type,  or  may  complicate  the  ordinary  form  of  phthisis. 
Following  the  rupture  of  a  small  centre  of  softening,  which  is  usually 
located  only  at  the  postmortem,  and  following  dissemination  by  aspira- 


TUBERCULOSIS  OF   THE  LUNGS  {PHTHISIS,   CONSUMPTION)     329 

tion,  there  develop  fever,  repeated  h?emoptysis,  chills  perhaps,  rapid 
pulse,  rapidly  increasing  dyspnoea,  diffuse  crepitant  or  bubbling  rales, 
considerable  delirium,  or  even  a  pronounced  status  typhosus.  Haemo- 
ptysis is  absent  in  some  cases.  The  sputum  is  absent  or  scanty,  and 
the  bacilli  are  sometimes  absent  throughout  the  course.  Death  may 
occur  acutely  in  three  to  four  weeks  without  a  breaking  down  of  the 
foci,  or  a  remission  may  take  place,  after  which  there  is  breaking 
down  of  the  indistinct  foci  which  cause  slight  dulness  and  distant 
bronchial  breathing.  At  autopsy,  scattered,  opaque,  yellow,  partly 
caseous  peribronchial  nodular  foci  are  seen;  in  some  cases  the  pres- 
ence of  tuberculosis  is  proven  only  by  microscopic  examination,  for 
the  foci  may  resemble  the  ordinary  bronchopneumonic  patches  and 
may  present  no  caseation.  Secondary  infection  with  streptococci  is 
usually  said  to  cause  this  form,  but  Prudden's  experiments  have 
demonstrated  that  the  above  lesions  may  result  from  the  tubercle 
bacilli  alone. 

3.  Acute  Disseminated  Ulcerative  Form. — The  acute  dissemi- 
nated ulcerative  type  is  often  observed  in  children  between  two  and 
six  years  of  age  (Grancher),  in  pregnancy,  alcoholism,  diabetes,  and 
influenza.  The  foci,  which  vary  from  the  size  of  a  pea  to  that  of  a 
walnut,  are  widely  disseminated;  they  fuse,  break  down  early,  and 
develop  cavities  without  walls,  which  are  only  ulcers  or  consist  of 
necrotic  caseous  material.  There  are  present  clinically  hectic  or 
continuous  fever,  pronounced  anaemia,  exhausting  sweats,  rapid 
emaciation,  and  viscid  sputum,  which  may  be  brownish  but  is  more 
often  purulent  and  contains  many  bacilli;  diffuse  fine  and  large  rales 
and  bronchial  breathing  may  be  heard.  The  course  is  galloping,  and 
ends  fatally  in  one  to  four  months. 

4.  Acute  Miliary  Form. — Acute  miliary  tuberculosis  (q.  v.)  de- 
velops in  3  per  cent,  of  the  cases  of  pulmonary  phthisis. 

(B).  Chronic  Tuberculosis. — 1.  Chronic  Ulcerative  Form. — The 
ordinary  chronic  ulcerative  phthisis  may  run  a  course  which  is  long 
latent,  except  for  ansemia,  dyspepsia,  or  other  undistinctive  symptoms. 
Improvement  may  follow  the  detection  of  such  positive  lung  findings  as 
an  apical  catarrh,  and  the  cough,  fever,  sweats,  and  anorexia,  may 
subside;  another  relapse  may  occur  after  quiescence  for  years,  or 
exacerbations  may  develop,  with  loss  of  weight  and  strength.  Recovery 
may  occur,  even  with  pronounced  physical  signs.  Cornet  regards  the 
breaking  out  after  years  of  new  tuberculous  manifestations  as  rein- 
fections rather  than  relapses. 

2.  Phthisis  Fibrosa. — Phthisis  fibrosa  is  the  slow  development  of 
fibrous  connective  tissue  excited  by  the  tubercle  bacillus.  It  may 
begin  acutely  or  follow  an  insidious  course  from  the  onset.  Its  explana- 
tion is  difficult;  Auclair  thinks  the  bacillus  secretes  two  toxins,  one 
with  a  necrosing  action  which  leads  to  caseation,  and  another  with 
an  indurating  action  which  leads  to  fibroid  phthisis.  There  may  be 
no  cough,  sputum,  fever,  emaciation,  or  anaemia.  Bacilli  may  or  may 
not  be  found  in  the  sputum.    Ulceration  may  result  onlv  from  mixed 


330  THE  SPECIFIC  IXFECTIOXS 

infection.  Sometimes  there  is  hsemoptysis.  It  may  develop  in  an 
emphysematous  chest  (Sokolowski).  If  left-sided,  the  spleen  rises 
higher  and  the  retraction  of  the  lung  away  from  the  heart  makes  its 
apex  wider,  the  cardiac  shock  more  diffuse,  and  the  pulsation  of  the 
pulmonary  trunk  more  visible.  If  right-sided,  the  liver  rises,  the  right 
ventricle  is  apparently  enlarged  (from  lung  retraction)  and  is  often 
actually  hypertrophied  and  dilated  from  increased  intrapulmonary 
tension.  The  heart  may  be  drawn  to  the  right  or  left  by  the  inevitable 
pleural  adhesions,  bronchiectases  are  not  uncommon,  the  sound  lung 
is  vicariously  emphysematous,  and  the  diseased  lung  is  smaller,  flatter, 
and  depresses  the  shoulder,  impairing  expansion  and  often  presenting 
bronchial  breathing  and  large  rales. 

3.  Pleuritic  Form. — The  pleuritic  form  (see  Pleurisy)  foHows 
small  latent  foci  in  the  lungs,  lymph  glands,  and  spine.  Exudates  not 
due  to  rheumatism,  inflammation  in  contiguous  organs,  tumor,  or 
nephritis,  are  always  suggestive  of  tuberculous  pleurisy.  Pleurisy,  in 
fact,  more  often  precedes  than  succeeds  pulmonary  tuberculosis  and 
repeated  attacks-  are  frecjuent,  with  moderate  irregular  or  continuous 
fever,  perhaps  with  rales  in  the  apex  of  the  affected  side  (not  the  rales 
frequently  heard  just  above  the  upper  level  of  the  exudate),  or  with 
dulness  in  the  contralateral  apex.  Bowditch,  following  up  90  cases  of 
pleurisy,  found  that  33  per  cent,  developed  pulmonary  tuberculosis  later 
in  life. 

Variations  According  to  Age. — {A).  Children. — Tubercle  bacilli 
easily  pass  the  bronchial  mucosa  and  produce  tuberculosis  of  the 
bronchial  and  mediastinal  glands;  the  wide  lymph-vessels  and  more 
active  metabolism  have  already  been  noted.  In  children  the  process 
in  the  glands  attacks  secondarily  the  hilum  of  the  lung  and  the  lower 
lobes  (80  to  98  per  cent.).  This  invasion  also  explains  the  frequency 
with  which  the  thoracic  duct  and  bloodvessels  are  attacked  and  miliary 
dissemination  results. 

1.  Chronic  Generalized  Tuberculosis. — The  younger  the  child 
the  less  local  and  the  more  general  is  the  tuberculosis.  ^leasles,  pertussis 
and  influenza  are  very  prone  to  arouse  a  latent  tuberculosis  in  the 
bronchial  glands.  The  course  is  generally  less  chronic  than  active, 
like  that  of  tumors  in  children.  Emaciation,  anaemia,  enlargement  of 
the  spleen  and  liver,  moderate  intumescence  of  such  peripheral  lymph- 
glands  as  the  cervical,  inguinal,  and  occipital,  are  observed.  Fever 
may  occur  only  toward  the  end  of  the  process.  Hectic  fever  is  seen 
chiefly  in  children  over  three  years.  The  sputum  is  swallowed,  but 
washing  the  stomach  recovers  bacilli-laden  sputum. 

2.  Acute  Miliary  Tuberculosis  (r.  s.). 

3.  Localized  Lung  Tuberculosis. — Localized  lung  tuberculosis 
may  be  (a)  of  the  acute  caseous  type  resembling  pathologically  bron- 
chopneumonias of  other  causation,  and  the  microscope  may  be  necessary 
to  detect  its  nature;  htemoptysis  is  rare,  though  Henoch  has  observed 
over  a  dozen  cases  under  six  years  of  age.  (b)  Chronic  localized  forms, 
like  those  of  adults,  are  very  infrequent  under  six  or  seven  years  of  age. 


TUBERCULOSIS  OF   THE  LUNGS   {PHTHISIS,   CONSUMPTION)     331 

In  children,  the  physical  findings  are  often  absent;  when  present 
thev  are  usually  over  the  lower  lobes,  very  seldom  near  the  clavicles. 
In  half  the  cases  the  wrong  diagnosis  is  made  (Henoch).  Percussion 
is  more  difficult  than  in  adults,  because  of  the  small  chest  and  its 
thinner  walls;  for  example  a  cracked-pot  resonance  can  be  obtained 
in  a  normal  young  chest  by  strong  percussion.  Children,  too,  breathe 
irregularly,  and  puerile  respiration  is  physiological.    Induration  is  rare. 

(B).  The  Aged. — In  the  aged,  haemoptysis  is  rare,  physical  findings 
are  less  frequent  than  in  adolescence,  because  the  breathing  is  weaker, 
and  emphysema  is  more  common.  Cough  and  fever  are  also  less  con- 
spicuous. 

Diagnosis  of  Pulmonary  Tuberculosis. — Early  diagnosis  is  most 
important.  A  positive  family  history  is  of  some  value,  but  it  does  not 
establish  the  diagnosis  in  a  doubtful  case,  nor  does  its  absence  exclude 
tuberculosis.  The  Bacillus  tuberculosis  distinguishes  pulmonary  tuber- 
culosis (a)  from  other  catarrhs,  such  as  acute  and  chronic  bronchitis, 
or  influenza;  (b)  from  other  consolidations,  pneumonia,  broncho- 
pneumonia, actinomycosis,  neoplasm,  or  syphilis;  (c)  from  other 
vomicae,  such  as  the  cavities  of  abscess,  gangrene,  actinomycosis, 
echinococcus,  syphilis,  or  bronchiectasis;  (d)  from  indurations  other 
than  tuberculous.  Cultures  and  inocidations  may  be  made  in  doubtful 
cases.  Injection  of  Koch's  tuberculin  produces  a  local  exudative  reac- 
tion, and  after  four  or  five  to  ten  hours,  a  systemic  reaction,  which 
is  characterized  by  chill,  fever  elevation  of  even  5  degrees,  headache, 
general  pains,  malaise,  nausea,  sometimes  by  erythema  nodosum, 
an  increase  of  sputum,  rales  or  even  a  slight  area  of  pulmonary 
dulness;  if  the  first  injection  of  1  mg.  of  Koch's  older  tuberculin  is 
negative,  a  second  injection  of  2  mg.  may  be  given  the  following  day. 
A  reaction  generally  means  that  there  is  a  tuberculous  focus  in  the 
body,  but  not  necessarily  in  the  lungs,  unless  rales  develop  at  the  sus- 
pected spot  after  the  injection.  In  some  cases  positive  reactions  have 
been  obtained  in  chlorosis,  syphilis,  leprosy,  cancer,  and  actinomycosis. 
Whatever  the  percentage  of  individuals  with  latent  tuberculosis,  it  is 
large  enough  to  cause  many  errors  and  render  it  of  little  clinical 
value;  thus,  a  case  with  enlarged  mediastinal  and  supraclavicular 
glands,  without  other  physical  findings,  gave  a  positive  tuberculin  reac- 
tion, though  the  autopsy  showed  that  they  were  carcinomatous  from 
a  clinically  latent  gastric  carcinoma,  and  the  reaction  came  from  a 
single  tuberculous  mediastinal  gland  which  was  of  no  diagnostic  signifi- 
cance. In  veterinary  medicine  it  is  more  valuable,  leading  to  a  cor- 
rect diagnosis  in  more  than  90  per  cent.  (Bang)  or  97  per  cent.  (Voges). 
The  author  no  longer  uses  it,  for  four  cases  of  miliary  tuberculosis 
have  apparently  resulted  from  its  employment.  Marmorek  has  lately 
devised  a  more  rapid  method,  by  which  material  (tissue  or  fluid)  from 
the  suspected  case  is  injected  into  the  peritoneum  of  a  guinea  pig, 
followed  in  twenty  minutes  by  0.3  c.c.  of  tuberculin;  if  the  fluid  is 
tuberculous,  the  reaction  is  obtained.  The  serum  agglutination  test 
is  again  reviewed  by  Arloing  and  Courmont  (1904)  in  400  cases;  the 


332  THE  SPECIFIC  INFECTIONS 

bacilli  (from  homogeneous  liquid  cultures)  produce  macroscopic 
agglutination  in  a  few  hours;  the  test  was  positive  in  88  per  cent, 
of  clearly  tuberculous  cases,  in  73  per  cent,  of  surgical  tuberculosis, 
in  27  per  cent,  of  apparently  healthy  persons,  but  is  apt  to  fail  in 
advanced  consumptives. 

Sticker  recommended  the  use  of  'potassium,  iodide  in  small  doses  (gr. 
iij);  it  congests  the  lungs  at  the  seat  of  the  lesion,  possibly  makes  the 
auscultation  findings  clearer,  and  carries  bacilli  into  the  sputum;  its 
use  is  not  wholly  free  from  danger.  Neurasthenics  may  develop  a 
phthiseophobia,  just  as  they  may  develop  a  syphilophobia. 

Pseudotuberculosis. — The  Rhizomucor  parasiticus  (Lucet  and  Con- 
stantin),  the  ray  fungus,  streptothrix  (Eppinger),  and  the  aspergillus 
may  cause  pseudotuberculosis.  The  form  caused  by  the  Aspergillus 
fumigatus  is  described  as  a  primary  lung  affection  by  Dieulafoy, 
Chantemesse,  Widal,  Renon,  Grancher,  and  Sergent.  Many  writers 
consider  it  secondary  only.  The  fungus  is  composed  of  mycelia  with 
clubbed  ends.  It  stains  with  thionine  and  can  be  grown.  The  symp- 
toms of  streptothricosis  are  haemoptysis  (23  per  cent.),  fatigue,  ano- 
rexia, dry  cough,  and,  later,  a  greenish  purulent  sputum.  The 
physical  findings  are  those  of  bronchitis,  less  often  those  of  slight 
consolidation  or  cirrhosis  of  the  lung.  Ashton  and  Wright  (1905) 
collated  26  cases  of  streptothricosis  pulmonum,  of  which  most  had 
symptoms  resembling  phthisis;  over  50  per  cent,  were  unmixed  infec- 
tions, and  76  per  cent.  died. 

Prognosis  of  Pulmonary  Tuberculosis. — Two  issues  are  possible, 
recovery  and  death. 

1.  Recovery. — Autopsies  on  hospital  cases  show  25  per  cent.  (4  to 
50  per  cent.)  of  healed  tuberculosis.  Many  of  the  recoveries  are  only 
relative,  since  Kurlow's  inoculations  from  seemingly  latent  caseous 
foci  into  guinea-pigs  were  positive  in  77  per  cent.;  such  foci  may  be 
aroused  by  intercurrent  disease,  though  it  is  the  tendency  of  some 
writers  to  regard  such  recurrence  as  a  fresh  infection  rather  than  the 
awakening  of  an  old  one.  Watson  observed  a  clinical  course  of  fifty- 
four  years,  and  Fagge  one  of  thirty-five  years.  Recovery  is  effected 
by  encapsulation,  scar  formation,  and  the  deposit  of  lime  salts.  Lie- 
bermeister  believes  recovery  is  possible  in  50  per  cent,  of  incipient 
cases.  The  outlook  depends  on  several  factors;  (a)  the  hereditary 
vital  endowment  of  the  patient;  (6)  his  character,  social  situation, 
habits  and  intelligence;  (c)  whether  the  localization  of  the  disease  is 
single  or  multiple;  {d)  secondary  or  mixed  infection;  {e)  digestion; 
(/)  degree  of  toxin  absorption  (fever  and  emaciation);  {g)  youth, 
diabetes,  pregnancy  and  lactation  are  unfavorable;  and  Qi)  compli- 
cations {v  .i.). 

2.  Death. — The  clinical  course  is  variable,  even  in  chronic  cases; 
it  averages  two  years  (Bayle,  Laennec,  Andral),  over  two  and  a  half 
years  (Pollock),  three  years  (Cornet),  and  seven  years  ([Williams  and 
Dettweiler],  though  the  latter's  cases  did  not  include  acute  forms  nor 
cases  in  children).     The  process   of   death  is  usually  peaceful  and 


TUBERCULOSIS  OF   THE  LUXGS   {PHTHISIS,   CONSUMPTION)     333 

painless,  though  at  times  it  comes  with  dyspnoea  (stagnant  secre- 
tion), delirium  or  convulsions.  Mechanism  of  death:  (a)  heart  failure 
is  the  common  cause,  associated  with  oedema,  asthenia,  anaemia, 
and  maraSlnus.  Other  causes  are  far  less  frequent,  as  (b)  pro- 
fuse fatal  h?emoptoe;  (c)  pneumothorax;  (d)  pulmonary  embolism 
(clots  or  gas);  (e)  uraemia;  (/)  meningitis;  (g)  perforative  peritonitis; 
(h)  sudden  death  w^ithout  adequate  pathological  findings.  In  cases 
of  sudden  death,  Arnold,  Brissaud,  and  Toupet,  have  found  in  the 
liver  large  numbers  of  bacilli,  which  probably  caused  an  acute  intoxi- 
cation, since  Mafucci's  experiments  have  demonstrated  that  the 
injection  even  of  dead  bacilli  causes  rapid  marasmus  and  death. 

Complications. — Tuberculosis  in  other  organs  will  be  considered 
below. 

1.  Respiratory. — (a)  Tracheitis  and  bronchitis  occur  in  almost  every 
case;  and  laryngitis  in  many  cases  results  from  the  toxins,  (b)  Dys- 
phagia usually  results  only  from  local  involvement  of  the  pharynx  or 
larynx;  swallowing  into  the  larynx  is  usually  the  result  of  paralysis 
of  the  epiglottic  depressors.  Hoarseness,  dysphonia,  and  aphonia,  al- 
ways suggest  laryngeal  tuberculosis,  but  may  develop  from  such  other 
causes  as  syphilis,  erosions,  or  catarrh;  from  paralysis  of  the  recur- 
rent laryngeal  nerve  from  pressure  by  lymph  glands;  from  inflamma- 
tion, on  the  right  side  by  pleural  scars,  and  on  the  left  by  large  pleural 
effusions;  or  from  thickening  at  the  hilum.  (c)  Pulmonary  gangrene 
may  develop  in  the  cavity  wall.  Lobar  pneumonia  is  not  infrequently 
a  cause  of  death,  (d)  Dry  pleurisy  is  an  almost  invariable  complica- 
tion, and  is  a  conservative  process,  which  lessens  the  probability  of 
pneumothorax.  Exudative  pleurisy  more  often  develops  previously  to 
lung  phthisis  than  during  its  course.  In  the  latter  instance  it  is  usually 
serofibrous,  and  is  generally  not  extensive.  Hemorrhagic  pleurisy  is 
more  common  in  pleural  than  in  pulmonary  tuberculosis.  Chyliform 
or  adipose  effusions  may  occur  (see  Chylothorax  and  Chylous 
Ascites);  purulent  forms  result  from  mixed  infection,  from  cavities,  or 
from  pneumothorax.  Some  pleurisies  appear  to  result  from  toxaemia 
rather  than  from  direct  bacterial  invasion.  Effusions  by  compression 
sometimes  seem  to  exert  a  favorable  effect  on  a  lesion  of  the  lung. 
Litten  thought  that  their  sudden  absorption  might  occasion  miliary 
tuberculosis,  (e)  Pneumothorax  is  observed  in  5  per  cent,  of  the  cases 
(Powell,  West),  and  results  from  rupture  of  superficial  cavities  Mdiich 
were  forming  rapidly  without  a  limiting  membrane.  Perforation  occurs 
most  frequently  between  the  second  and  fourth  interspaces,  and  be- 
tween the  mammary  and  axillary  lines.  Its  onset  is  spontaneous,  or 
results  from  straining,  or  coughing.  Its  occurrence  is  usually  marked 
by  sudden  symptoms,  as  great  dyspnoea,  orthopnoea,  and  cyanosis, 
and  sudden  physical  signs,  as  lying  on  the  side  of  rupture,  sudden 
ectasia,  immobilitj',  dislocation  of  the  heart,  spleen,  or  liver,  weak 
vocal  fremitus,  voice  sounds  and  breathing,  a  tympanitic  note,  and 
when  serum  or  pus  forms,  succussion.  The  onset  is  occasionally 
gradual  and  less  urgent,  so  that  pneumothorax  may  be  an  accidental 


334  THE  SPECIFIC  INFECTIONS 

finding.  Death  in  a  few  hours  may  result,  but  Hfe  may  be  prolonged 
weeks  or  months.  Infrequently  pneumothorax  (q.v.)  may  exert  a 
beneficial  effect  on  the  lung  trouble. 

2.  Circulatory. — (a)  The  rapid  pulse  first  appears  only  after  meals 
or  exertion,  but  later  becomes  permanent.  It  is  probably  toxsemic, 
but  may  be  due  to  mechanical  pressure  of  large  lymph-glands  on  the 
vagus,  or  to  compression  or  inflammation  of  the  vagus  from  medi- 
astinitis,  pleurisy  or  pericarditis.  There  is  a  constant  and  early  lower- 
ing of  the  blood-tension,  and  the  vasomotor  instability  causes  the 
bright-red  cheeks.  The  pulse  may  be  soft  and  full  throughout  the 
course.  Sometimes  a  capillary  pulse  or  a  centripetal  venous  pulse  is 
observed.  (6)  A  functional,  systolic  murmur  over  the  pulmonary 
valves  is  very  common.  The  heart  is  pale,  fatty,  flabby,  and  weak, 
and  has  been  described  as  atrophied  since  the  time  of  Laennec,  but 
Potain  considers  that  the  small  heart  is  merely  accommodative  to  the 
malnutrition  and  anaemia.  Cardiac  hypertrophy  is  due  to  renal  dis- 
ease, pericardial  or  pleural  adhesions,  valvular  disease,  or  emphysema. 
Hypertrophy  and  dilation  of  the  right  heart  may  follow  pulmonary 
induration  or  massive  pleural  adhesions.  Adhesive  or  effusive  peri- 
carditis may  result  by  extension  from  pleurisy  or  caseated  lymph- 
glands,  but  may  be  due  to  tuberculosis,  pyogenic  infection,  or  to 
toxsemia  alone.  Endocarditis  tuberculosa  is  very  infrequent;  tubercle 
bacifli  may  be  deposited  in  cardiac  clots,  or  in  endocarditic  excres- 
cences of  non-tuberculous  origin.  They  were  first  found  by  Kundrat 
and  Heller,  but  Tripier's  case  of  tuberculous  endocarditis  was  the  first 
clear  one;  according  to  Benda,  this  endocarditis  is  due  to  miliary 
deposits  in  the  intima,  and  clinically  escapes  recognition  in  most  cases, 
though  it  is  sometimes  suspected  on  account  of  a  systolic  murmur,  (c) 
Thromho-phlehitis  occurs  in  about  1  percent,  of  the  cases. 

3.  Nervous  and  Muscular. — (a)  There  may  be  brain  ansemia.  In 
some  instances  the  mental  power  may  be  normal;  oftener  there  is  a 
slight  mental  weakness,  irritability,  psychical  lability,  self-concentra- 
tion, lack  of  endurance,  and  triviality.  Sleep  is  often  disturbed.  Con- 
sumptives are  usually  optimistic,  and  they  may  plan  for  the  future  on 
the  day  of  their  death  {Spes  phthi-sicorum);  occasionally  melancholia 
or  mania  develops ;  fever,  anaemia,  toxaemia,  marasmus,  and  vasomotor 
changes  in  the  brain,  such  as  oedema,  may  cause  terminal  aberration 
or  paralysis.  (6)  Neuralgia  and  hyperaesthesia  are  not  uncommon. 
INIultiple  neuritis  not  infrequently  results  from  the  toxaemia  (Pitres  and 
Vaillard) ;  it  may  be  latent  or  may  cause  only  slight  sensory  disturb- 
ance, or  it  may  result  in  amyotrophy;  it  may  in  part  explain  the 
oedema  when  it  is  not  due  to  cardiac  weakness  or  to  thrombo-phlebitis. 
(c)  The  same  toxins  which  reduce  the  body  weight  one-half  or  more, 
result  in  marked  muscular  degeneration  and  atrophy,  which  causes  the 
flat  chest,  and  possibly  also  the  cardiac  wasting.  The  muscular  and  adi- 
pose wasting  is  expressed  in  the  terms  synonymous  with  tuberculosis- 
consumption,  phthisis,  tabes.  The  muscles  are  dry,  pale,  thin,  fatty; 
they  show  transverse  rents,  separation  of  the  sarcolemma,  poor  mark- 


TUBERCULOSIS  OF   THE  LUXGS   {PHTHISIS,   CONSUMPTION)     335 

ings,  granular  degeneration,  some  pigmentation,  nuclear  multiplication 
or  hyperplasia  of  the  connective  tissue;  myositis  is  described  by  De- 
lorme  and  Reverdin.  Their  wasting  and  the  nervous  toxaemia  explain 
the  asthenia  and  incapacitation  for  work,  a  matter  of  national  eco- 
nomical importance.  The  muscles  are  often  irritable,  show  fibrillary 
contractions,  and  when  tapped  or  pinched  show  local  contraction  or 
lumps,  known  as  myoidema,  which  also  results  from  emaciation  in 
other  such  affections  as  typhoid  or  carcinoma. 

4.  Digestive. — (a)  The  tongue  may  be  furred,  or  red  and  clean. 
Aphthae  are  frequently  distressing.  Excessive  redness  of  the  gums  is 
a  frequent  complication,  but  is  also  common  in  other  affections.  (6) 
Stomach  disorder  is  present  in  33  to  66  per  cent,  of  cases;  it  may  be 
the  initial  symptom  of  toxaemia,  or  appear  only  late  in  the  process. 
The  appetite  may  be  unimpaired,  and  Cornet  instances  an  advanced 
patient  who  complained  that  he  could  only  eat  four  beefsteaks  for 
dinner.  Anorexia  varies  in  degree  and  occurrence,  being  most  marked 
toward  evening,  when  the  fever  is  higher,  and  most  frequent  in  those 
with  previous  dyspepsia  or  poor  appetite;  it  is  sometimes  nervous 
(anorexia  nervosa)  with  normal  gastric  chemism;  again  it  may  be 
due  to  glands  compressing  the  vagus  (Peter,  de  Mussy).  Brieger 
found  the  chemism  normal  in  50  per  cent,  in  the  incipient  stage,  in 
33  per  cent,  in  moderately  severe,  and  in  but  16  per  cent,  in  severe 
advanced  cases.  Klemperer  thinks  that  hyperacidity  is  usual,  while 
Marfan  considers  it  exceptional.  After  eating  there  may  be  a  sense 
of  fullness  or  even  of  pain.  Nausea,  gagging  and  vomiting  may  result 
from  pharyngitis,  coughing,  or  from  forced  feeding.  In  advanced 
cases,  nausea  and  vomiting  occur  from  over-eating,  from  toxae- 
mic  gastric  catarrh,  swallowing  of  sputum,  weakness  of  the  stomach 
musculature,  and  deficient  secretion;  anatomically,  the  stomach  shows 
anaemia,  catarrh,  fatty  degeneration  of  the  glands  (36  per  cent.), 
interstitial  hyperplasia,  and  sometimes  amyloid  infiltration  (12  per 
cent.)  or  peptic  ulcer. 

(c)  Intestines. — Constipation  may  be  caused  by  gastric  hyperacidity. 
Diarrhoea  is  usually  late;  it  may  be  caused  by  the  toxin  in  the  blood 
or  in  swallowed  sputum,  by  intestinal  catarrh,  toxaemic  obliteration  of 
the  lymph-  and  bloodvessels  in  the  gut,  peptic  or  duodenal  ulcers, 
tuberculous  ulcers,  amyloid  degeneration  or  amyloid  ulceration  in  the 
gut.  Tuberculous  ulcers  may  exist  without  symptoms  or  may  cause 
colic,  tenderness,  pain,  and  diarrhoea;  much  depends  on  their  loca- 
tion. According  to  Nothnagel,  ulcers  in  the  small  gut,  caecum  and 
ascending  colon  probably  cause  diarrhoea  only  when  combined  with 
catarrh  or  amyloid  degeneration;  ulcers  in  the  lower  colon  and  rec- 
tum almost  constantly  induce  diarrhoea.  It  may,  therefore,  occur 
from  causes  other  than  ulceration,  and  ulcers  may  exist  without  it. 
Blood,  pus,  haematin  crystals,  and  tubercle  bacilli,  may  be  present, 
but  not  always.  Tubercle  bacilli  do  not  necessarily  indicate  intestinal 
tuberculosis,  as  they  may  pass  through  with  the  sputum  swallowed. 
Anal  fistula  occurs  in  1.3  to  5  per  cent,  of  the  cases,     {d)  The  liver  is 


336  THE  SPECIFIC  INFECTIONS 

fatty  (in  10  to  15  per  cent.);  Jonescu  (1902)  collected  33  cases  of  cir- 
rhosis cardiotuberculosa  (induration  from  stasis,  with  tuberculous 
granulations  and  fatty  degeneration).  (e)  Tuberculous  peritonitis 
(v.  i.)  may  occur  by  (i)  lymphogenic  infection — e.  g.,  from  the  pleura 
or  pericardium,  (ii)  from  the  intestine,  (iii)  from  the  genito-urinary 
tract,  or  (iv)  from  the  blood  stream.  It  occurs  in  5  to  15  per  cent,  of 
pulmonary  tuberculosis.  Its  forms  are  diffuse  exudative,  dijffuse  adhe- 
sive, and  tumor-like  agglomerations. 

5.  Amyloid  Degeneration. — This  occurs  mostly  in  chronic  ulcerative 
phthisis.  According  to  Blum,  80  per  cent,  of  all  amyloid  degenera- 
tion is  due  to  tuberculosis,  and  68  per  cent,  to  pulmonary  tubercu- 
losis; it  is  found  in  8.8  per  cent,  of  tuberculous  autopsies.  The  spleen 
is  affected  in  93  per  cent.,  the  kidney  in  77  per  cent.,  the  liver  in  62 
per  cent.,  the  intestines  in  28  per  cent.,  and  the  stomach  in  12  per  cent, 
of  cases. 

6.  Genito-urinary — Urinary. — The  loss  of  weight  causes  phosphat- 
uria  (calcium  and  magnesium),  increase  of  nuclein  and  chlorides  (0.5 
to  1  or  even  12  gm.) .  Moreproteid  is  excreted  than  is  ingested.  Album- 
ose  is  sometimes  present.  Albuminuria  usually  indicates  nephritis,  am- 
yloidosis, or  local  tuberculous  disease.  Acute  and  chronic  parenchym- 
atous nephritis  is  not  infrequently  due  to  long-standing  toxsemia. 
Amyloid  disease  of  the  kidney  produces  albuminuria  in  but  50  per 
cent,  of  the  cases;  in  amyloid  of  the  kidney,  nephritis  is  also  present 
in  75  per  cent.,  and  the  chronic  parenchymatous  type  in  66  per  cent. 
Bacilli  are  seldom  found,  unless  there  are  secondary  genito-urinary 
deposits.  Ehrlich's  diazo  reaction  is  very  frequently  present,  and  is 
usually  of  unfavorable  import;  the  converse  is' not  true — i.  e.,  the 
prognosis  is  not  necessarily  good  if  the  reaction  is  absent. 

Sexual. — In  some  individuals,  the  sexual  desire  is  more  intense, 
particularly  in  women,  though  its  increase  is  grossly  exaggerated. 
The  menses  often  disappear  early,  and  pregnancy  is  less  apt  to  occur. 
Pregnancy  often  temporarily  betters  the  condition  of  the  lungs,  but 
a  more  rapid  course  is  usual  after  delivery.  Hypertrophy  of  the 
mammary  glands,  described  by  Bedor  in  1836,  occasionally  develops, 
particularly  in'  males,  but  is  rather  a  simple  chronic  interstitial  mas- 
titis than  an  actual  hypertrophy. 

7.  Skin. — -Cyanosis  is  not  common.  Pityriasis  versicolor  occurs  very 
frequently  in  the  tuberculous;  it  is  due  to  the  tinea  furfur  (Eichstedt). 
Chloasma,  desquamation,  coarseness  of  the  hair,  herpes  zoster,  lichen 
scrofulosorum,  and  purpura,  are  sometimes  observed.  Clubbing  of  the 
fingers  (the"Hippocratic  fingers"), and  toes,  develops  chiefly  in  chronic 
cases,  is  largely  due  to  hypertrophy  of  the  soft  tissues  (see  Acromegaly) 
and  is  not  pathognomonic  of  tuberculosis,  for  it  occurs  also  in  con- 
genital cardiac  disease,  aneurysm,  bronchiectasis,  and  emphysema. 
Emphysema  of  the  skin  is  very  uncommon;  it  follows  interstitial 
emphysema  of  the  lungs,  and  results  from  rupture  of  the  alveoli, 
pneumothorax,  or  cavities.  (Edema  results  from  anremia,  cardiac 
weakness,  phlebitis,  or  neuritis. 


TUBERCULOSIS  OF   THE  LYMPH  GLANDS  337 

Treatment  of  pulmonary  tuberculosis  is  considered  later,  after  de- 
scription of  other  localizations  of  the  tubercle  bacillus. 

III.  Tuberculosis  of  the  Lymph  Glands. 

Glandular  tuberculosis  is  most  frequent  in  young  children,  68  per 
cent,  being  found  in  the  first  ten  years  of  life  (Wohlgemuth).  It  also 
occurs  fairly  often  in  adolescence  and  sometimes  even  in  the  aged. 
It  is  found  anatomically  in  99  per  cent,  of  tuberculous  children  (Ster- 
ner and  Neureuther),  or  according  to  other  statistics  in  80  to  90  per 
cent. ;  it  is  found  in  25  per  cent.  (Mueller)  to  50  per  cent.  (Babes)  of 
all  autopsies  on  children.  Scrofula  is  glandular  tuberculosis,  but  it 
presents  characteristics  different  from  those  of  pulmonary  infection, 
in  explanation  of  which  it  is  held  by  Arloing  that  the  virulence  of  the 
bacilli  is  less  in  scrofulous  glands;  he  found  that  inoculations  made 
from  infected  glands  produced  local  tuberculosis  only  in  rabbits,  while 
generalized  tuberculosis  resulted  in  the  more  susceptible  guinea  pig. 
Others  explain  it  as  an  infection  with  very  few  bacilli.  Neither  of 
these  explanations  is  wholly  adequate,  whence  the  assumption  of  a 
special  glandular  tendency  to  infection;  it  has  been  suggested  that  the 
glands  invaded  are  poorly  developed.  The  skin,  mucous  membranes, 
and  lymph  vessels,  are  physiologically  more  patent  or  more  permeable 
in  the  very  young,  and  an  increase  of  this  condition  or  its  persistence 
in  older  children  is  regarded  as  an  infantilism  or  embryoism  of  the 
glands,  mucosae,  and  skin,  i.  e.,  a  structural  tendency  toward  infec- 
tion. The  accessory  causes  are  the  same  as  in  pulmonary  tuberculosis: 
(a)  an  hereditary  tendency;  (6)  poor  hygiene,  dark,  damp  dwellings, 
inadequate  nutrition  and  coarse  food  given  to  the  very  young;  (c) 
infections,  such  as  pertussis  and  measles,  to  a  less  extent  scarlatina, 
diphtheria,  variola,  or  syphilis. 

General  Characteristics. — (a)  It  usually  runs  an  extremely  chronic 
course.  (6)  Recurrence  is  very  frequent,  (c)  Multiple  lesions  are 
usual,  (d)  Glandular  involvement  is  frequently  associated  with  affec- 
tions of  the  skin  (as  eczema,  scrofuloderma,  or  lupus),  inflammations 
of  the  mucous  membranes  (as  conjunctivitis,  otitis,  rhinitis,  or  bron- 
chitis), and  disease  of  the  bones  or  joints  (as  coxitis,  or  Pott's  disease). 
This  association  is  frequently  known  as  scrofula,  of  which  some 
authors,  as  Cornet,  distinguish  two  varieties — (i)  the  tuberculous  and 
(ii)  the  pyogenic,  caused  by  the  staphylococcus  or  less  often  by  the 
streptococcus.  There  is  much  dispute  regarding  this  division,  and  it 
certainly  seems  incongruous  to  unnecessarily  associate  tuberculous 
lymphadenitis  and  arthritis  with  non-tuberculous  forms. 

General  Anatomy. — (a)  Few  bacilli  may  cause  but  little  inflamma- 
tory reaction  and  little  cellular  proliferation;  regression  is  possible. 
(6)  Conglomerate  tubercles  form,  with  the  following  issues:  death  of 
the  bacillus  in  the  central  caseation,  softening  and  external  rupture, 
sometimes  calcification  or  extension  locally  by  the  lymph  stream  or 

22 


338  THE  SPECIFIC  INFECTIONS 

generally  by  the  blood  current,  (c)  Hyperplasia  with  epithelioid  pro- 
liferation (Ziegler)  may  occur,  without  caseation  or  with  very  late 
caseation;  this  form  results  from  infection  with  few  bacilli.  The 
lymphadenoid  tissue  is  compressed  by  epithelioid  spindle-shaped  cells; 
the  glands  may  reach  the  size  of  an  egg,  and  their  cut  section  show 
no  gross  evidence  of  tubercle,  (d)  Mixed  infection  causes  rapid  casea- 
tion, necrosis,  softening,  and  early  rupture;  their  cut  section  appears 
"  like  that  of  a  raw  potato  but  not  so  moist "  (Virchow) ;  the  inflammation 
is  often  not  limited  to  the  glands,  but  causes  a  periadenitis,  whereby 
the  glands  fuse,  a  phlegmon  results,  and  generalization  of  the  process 
throughout  the  body  ensues.  In  the  purely  pyogenic  (non-tuberculous) 
lymphadenitis,  the  glands  may  become  homogeneous  and  dry  (the 
hyperplastic  lymphoma  of  Virchow),  or  productive  inflammation  may 
result  in  fibrous  induration. 

1.  Cervical  Tuberculous  Adenitis. — Infection  occurs  through  the 
nose,  eye,  scalp,  mouth,  pharynx,  teeth,  or  ear;  the  primary  atrial 
lesion  may  leave  no  mark;  or  the  bacillus  may  pass  through  the  mucous 
membranes  without  producing  any  lesion  in  them.  Writers  who  de- 
scribe scrofula  as  a  special  symptom-complex,  distinguish  four  stages: 
(a)  the  initial  skin  or  mucous  membrane  inflammation;  (b)  the  lymph- 
adenitis; (c)  involvement  of  the  joints  and  bones;  and  (d)  various  com- 
plications, as  amyloid  degeneration,  or  miliary  tuberculosis. 

The  figures  of  Balman  (first  column)  and  Wohlgemuth  (second 
column)  show  the  following  localizations: 

Per  cent.      Per  cent. 

Cervical  and  occipital  glands, 81  93 

Axillary  (from  the  mamma), 6  2. 78 

Inguinal  (from  the  hip,  ilium,  testicle,  and 

knee), 7  0.93 

Cubital  (from  the  fingers), 5  0.23 

Popliteal  (from  the  foot), 0.7  0.23 

Pre-  and  postauricular, 2 . 9 

The  cervical  glands  thus  make  96  per  cent,  of  Wohlgemuth's 
series.  In  cervical  scrofula,  the  glands  at  the  angle  of  the  jaw 
and  beneath  or  anterior  to  the  sternomastoid  muscle  are  most  often 
involved;  in  bilateral  involvement,  the  glands  of  one  side  are 
usually  larger.  The  glandular  swelling  is  slow  in  onset,  intermittent 
in  progression,  is  usually  unattended  by  pain  or  other  symptoms,  and 
is  frequently  an  accidental  finding.  In  some  cases  the  first  symptoms 
are  acute,  but  the  trouble  subsides  in  two  or  three  weeks.  The  intumes- 
cence is  first  confined  to  glands  which  are  discrete  and  freely  movable. 
Later  the  nodes  may  blend  into  large  nodular  masses,  and  periadenitis 
may  fuse  the  glands  and  cause  their  adherence  to  the  skin,  which  be- 
comes oedematous,  dough-like,  and  reddened.  Softening  and  fluctua- 
tion are  then  frequent,  with  burrowing  of  the  pus  in  various  directions 
and  external  rupture  through  small  fistula?.  The  fistulre  widen,  dis- 
charge cheesy  and  milky  material,  and  form  ulcers  covered  with  granula- 
tion tissue  and  difficult  to  heal.  Cicatrization  leaves  deep,  deforming, 
depressed  scars.     Extension  may  occur  to  the  deeper  glands  or  to  the 


TUBERCULOSIS  OF   THE  LYMPH  GLANDS  339 

subpectoral  or  axillary  glands.     Fever,  anaemia,  and  other  toxsemic 
manifestations,  may  develop,  as  in  lung  tuberculosis. 

2.  Bronchial  Glands. — The  bronchial  glands  are  very  frequently 
diseased.  In  autopsies  on  tuberculous  children  they  are  almost  in- 
variably affected  (in  98  per  cent,  of  Steiner's  and  Neureuther's  and  in 
100  per  cent,  of  Northrup's  series) ;  in  adults  they  are  affected  in  40 
to  80  per  cent.  In  children  tuberculosis  of  the  bronchial  glands  is 
primary,  the  bacillus  passing  the  patent  intact  bronchial  mucosae,  and 
tuberculosis  of  the  lung  is  secondary.  In  adults  lung  involvement  is 
usually  primary  and  bronchial  adenitis  is  secondary.  Small  tubercu- 
lous foci  cause  neither  glandular  enlargement  nor  symptoms.  Biedert, 
in  1,346  autopsies  on  tuberculous  children,  found  the  lungs  diseased 
in  80  per  cent.,  the  bronchial  glands  in  78  per  cent.,  the  intestines  in 
32  per  cent.,  and  the  mesenteric  glands  alone  in  40  per  cent. 

Symptoms. — In  most  cases  no  symptoms  develop;  in  others,  pri- 
mary or  secondary  pulmonary  lesions  overshadow  the  symptoms  of 
bronchial  involvement;  in  others,  miliary  tuberculosis  develops,  pro- 
moted by  the  close  contact  of  the  bronchial  glands  with,  and  easy  rup- 
ture into,  the  pulmonary  vessels;  in  still  others,  symptoms  result  from 
the  pressure  of  the  glands  on  the  nerves,  vessels,  or  air  tubes  in  the 
mediastinum;    in  very  few  cases  are  there  actual  physical  findings. 

Pressure  Symptoms. — Pressure  on  the  vagus,  known  to  Wrisberg, 
causes  the  rapid  heart  which  occurs  so  frequently  in  tuberculous  chil- 
dren; paroxysmal  asthma,  dyspnoea,  or  spasmodic  cough  which  some- 
times closely  resembles  that  of  whooping-cough;  lessening  of  the 
sensitivity  of  the  bronchi,  which  favors  infection;  and  it  finally  leads 
to  cardiac  dilatation  and  death.  Pressure  on  the  recurrent  laryngeal 
nerve  is  marked  by  hoarseness,  aphonia,  dyspnoea,  or  laryngospasm. 
The  air  passages,  trachea,  or  bronchi,  may  be  compressed.  This  may 
be  marked  by  dyspnoea,  impaired  expansion  of  one  or  both  sides  of 
the  chest,  and  holding  the  head  backward.  The  pupils  may  be  unequal 
from  pressure  on  the  sympathetic  nerve.  Other  pressure  symptoms 
are:  hypertrophy  of  the  heart  or  the  paradoxical  pulse,  from  pressure 
on  the  aorta;  oedema  and  cyanosis  of  the  face  and  arms,  from  compres- 
sion of  the  superior  vena  cava;  cough,  rales,  or  haemoptysis,  from  sten- 
osis of  the  pulmonary  veins;  a  murmur  over  the  innominate  vein  on 
throwing  the  head  backward;  dysphagia,  from  oesophageal  compres- 
sion. 

Signs. — Bronchial  breathing  is  occasionally  heard  between  the 
second  and  fourth  dorsal  vertebrae,  more  clearly  behind  than  in  front; 
more  on  the  rio;ht  than  on  the  left  side;  and  more  markedlv  than  the 
high-pitched  breathing  heard  physiologically  over  this  region.  If  the 
bronchus  is  compressed  there  is  neither  bronchial  breathing  nor  in- 
creased vocal  fremitus.  An  irregularly  outlined  dulness  is  elicited 
on  exceptional  occasions  either  between  the  clavicle  and  third  rib, 
on  either  side  of  the  sternum,  or  behind  between  the  third  and  fifth 
dorsal  vertebra?.  It  is  due  to  enlarged  glands  near  a  bronchus,  or  some- 
times to  a  distended  obstructed  vein.     Sometimes  a  tympanitic  note 


340  THE  SPECIFIC  lyFECTIOXS 

in  the  upper  lobes  results  from  relaxation  of  the  lung.  Both  the  symp- 
toms and  signs  are  extremely  variable,  appearing  suddenly  and  remit- 
ting unaccountably. 

Issues. — (a)  Tuberculosis  of  the  lung  (in  children);  (b)  miliary 
tuberculosis;  (c)  tuberculous  pleurisy  or  pericarditis:  (d)  pressure  by 
calcification  or  fibrosis;  (e)  adhesion  to  and  rupture  into  the  air  pas- 
sages, causing  sudden  suffocation;  (/)  fatal  hemorrhage  into  the  air 
tubes,  which  is  less  frequent,  as  the  vessels  yield  before  pressure,  but 
which  may  result  froni  rupture  simultaneously  into  a  bronchus  and  a 
vessel;  (g)  rupture  into  the  oesophagus  or  traction  upon  it,  causing  an 
oesophageal  diverticulum. 

Diagnosis. — As  Henoch  puts  it,  "A  diagnosis  can  rarely  be  made 
(from  the  physical  signs),  but  if  made  is  nearly  always  correct,"  as  the 
bronchial  glands  are  nearly  always  enlarged  in  infantile  tuberculosis. 

3.  Mesenteric  Glands. — The  bacilli  pass  the  patent  intact  intestinal 
mucosa  and  settle  in  the  mesenteric  glands,  precisely  as  they  pass  the 
bronchial  mucosa  and  lodge  in  the  bronchial  glands.  Carriere  found 
that  but  1  per  cent,  of  his  cases  were  primary;  of  the  secondary  cases, 
the  primary  focus  was  in  the  peritoneum  in  40  per  cent.,  in  the  lungs 
in  30  per  cent.,  in  the  intestines  in  20  per  cent.,  in  other  glands  and 
bones  each  in  5  per  cent.  There  are  few  characteristic  symptoms. 
The  glands  may  be  palpable  as  thick  nodular  masses  through  a  thin 
abdominal  wall,  but  are  often  obscured  by  the  abdominal  distention. 
The  general  emaciation  (tabes  mesaraica)  contrasts  strikingly  with 
the  tumid  belly.  Digestive  disturbance  is  most  frequent,  and  there 
is  usually  a  diarrhoea  with  thin,  stinking  stools.  Compression  is  less 
frequent  in  the  more  distensible  abdomen  than  in  the  less  yielding 
thorax,  though  the  veins  of  the  abdomen  mav  stand  out  and  oedema 
of  the  legs  may  appear.  The  glands  sometimes  heal  by  induration 
and  calcification,  or,  by  softening,  rupture  into  the  intestine  or  peri- 
toneum (plastic  or  exudative  peritonitis).  Amyloid  degeneration  may 
result  from  cases  of  long  standing. 

4.  Generalized  Lymphadenitis. — This  may  closely  resemble  Hodg- 
kins's  disease,  as  was  first  pointed  out  by  Richard  Paltauf  and  his 
co-worker,  Sternberg,  though  the  latter  goes  too  far  in  declaring  that 
most  cases  of  pseudoleuksemia  are  glandular  tuberculosis.  In  two  per- 
sonally observed  instances  of  supposedly  clear  pseudoleukeemia,  the 
clinical  and  gross  pathological  findings  were  typical  of  that  disease,  and 
only  the  epithelioid  hyperplasia  and  the  bacilli  tuberculosis  stamped 
them  as  tuberculous.    This  form  is  rather  common  in  the  negro. 

The  treatment  of  tuberculous  lymphadenitis  is  that  of  tuberculosis 
in  general  (v.  i.),  and  is  surgical  if  the  process  is  accessible  and  local- 
ized. In  175  cases  of  cer\dcal  adenitis  which  were  operated  on,  58 
per  cent,  were  cured  after  three  years,  8  per  cent,  had  recurrence,  11 
per  cent,  developed  pulmonary  tuberculosis,  and  23  per  cent.  died. 
In  another  series  of  about  700  cases  which  were  treated  medically,  28 
per  cent,  developed  tuberculosis  in  some  other  organ  (Demme).  The 
syrup  of  the  iodide  of  iron  and  cod-liver  oil  are  very  largely  used.    In- 


TUBERCULOSIS  OF   THE  SEROUS  MEMBRANES  341 

unctions  of  green  soap,  recommended  by  Richter  (1846)  and  Kap- 
pesser  (1878)  are  considered  beneficial  by  HofFa;  3ss-j  should  be 
thoroughly  rubbed  into  the  back  two  or  three  times  a  week. 


IV.  Tuberculosis  of  the  Serous  Membranes. 

These  membranes  may  be  involved  simultaneously  or  separately. 
Multiple  serous  involvement  is  known  as  multiple  serositis  or  polyor- 
rhomenitis.  Multiple  serositis  may  be  acute,  subchronic,  or  chronic;  it 
may  be  serous,  fibrinous,  or  purulent;  it  may  occur  with  or  without 
lymphadenitis  or  visceral  tuberculosis. 

{A).  Pleura. — Tuberculous  pleurisy  has  been  touched  upon  as  a 
complication  of  phthisis,  and  must  be  separately  considered  under 
Pleurisy  {q.  v.).  It  may  develop  as  an  apparently  primary  infection, 
it  may  be  clearly  secondary  to  unmistakable  phthisis,  or  it  may  appear 
as  a  terminal  infection.  Miliary  tubercles  in  the  pleura  may  occur 
without  coincident  pleurisy.  Pleurisy  develops  in  some  form  in  66  to 
100  per 'cent,  of  pulmonary  phthisis.  It  may  be  acute,  subacute,  or 
chronic;  it  is  most  often  serous  or  serofibrinous;  it  may  be  serohem- 
orrhagic, purulent,  less  often  chyliform  or  adipose.  Pleurisy  may  result 
from  direct  bacillary  invasion  from  the  bronchial  glands,  lung,  spine,  or 
peritoneum,  or  possibly  from  simple  toxic  action  without  the  presence 
of  bacilli.  In  some  cases  the  pleura  proliferates  and  forms  a  thick, 
massive,  adhesive,  obliterative  membrane.  Sometimes  the  interstitial 
tissue  of  the  lung  is  invaded,  resulting  in  pulmonary  cirrhosis  (pleurog- 
enous  cirrhosis).  The  symptoms  are  those  of  fibrinous,  effusive  or 
adhesive  pleurisy  (g.  v.). 

(B).  Pericardium. — Miliary  tubercles  may  in  rare  cases  cause  tuber- 
culous pericarditis;  these  accidental  miliary  deposits  must  be  sharply 
distinguished  from  tuberculous  pericarditis  wherein  inflammation  pre- 
dominates. It  is  less  common  than  pleural  and  peritoneal  involve- 
ment, but  is  not  a  rare  pathological  finding.  It  is  found  in  2  to  3  per 
cent,  of  pulmonary  tuberculosis.  Tubercles  may  be  detected  beneath 
the  fibrin  deposits  or  adhesions,  as  they  are  in  pleurisy  of  the  same 
type.  Without  association  with  some  other  tuberculous  lesion  (espe- 
cially that  of  the  pleura)  it  is  rarely  separable  clinically  from  the 
ordinary  forms  of  pericarditis.  Like  these  forms  it  may  be  symptomati- 
cally  latent,  it  may  form  an  unessential  part  of  a  generalized  tubercu- 
losis, or  it  may  present  the  ordinary  symptoms  of  pericardial  effusion 
or  concretion  {q.  v.).  Only  eight  primary  cases  are  recorded  (Scagliosi, 
1904). 

(C).  Peritoneum. — Tuberculosis  of  the  peritoneum  was  known  to 
Bayle,  Laennec,  Bichat,  and  others,  a  century  ago,  but  became 
especially  important  when  Louis,  in  1825,  declared  that  nearly  all 
chronic  peritonitis  was  tuberculous.  Though  some  chronic  periton- 
itides  are  due  to  trauma,  alcoholism,  nephritis,  portal  and  cava- 
stasis,  most  of  them  are  tuberculous. 


342  THE  SPECIFIC  IXFECTIOXS 

Frequency. — It  complicates  9  to  13  per  cent,  of  pulmonarv  tubercu- 
losis and  according  to  Grawitz  and  Brunn,  it  was  found  in  2  per  cent, 
of  13,422  autopsies.  According  to  Cummins  it  constitutes  one-quarter 
of  all  kinds  of  peritonitis. 

Age. — It  is  almost  equally  frequent  in  the  second,  third,  fourth,  and 
fifth  decades,  ranging  close  to  20  per  cent,  in  each;  66  per  cent,  of 
all  cases  occur  between  ten  and  forty  years  of  age;  in  the  very  young 
and  the  very  aged  it  is  infrequent. 

Sex. — Ninety  per  cent.  (Xothnagel),  or  78  per  cent,  according  to 
Konig,  occurs  in  women.  More  cases  are  found  in  autopsies  on 
males,  though  more  women  are  operated  on.  In  America  it  is  more 
common  among  the  negroes  than  among  the  whites.  It  is  very  seldom 
(0.7  per  cent.)  primary,  but  is  secondary  to  (a)  lung  or  pleural  tuber- 
culosis (in  80  per  cent.,  Leube);  (b)  intestinal  ulcers  or  mesenteric 
and  retroperitoneal  adenitis,  especially  in  children.  Tubercle  bacilli 
may  pass  the  intestinal  wall  without  localizing  in  it  and  may  reach  the 
peritoneum.  It  is  thought  by  some  that  intestinal  lesions  are  the  most 
frequent  cause;  (c)  tuberculosis  of  the  Fallopian  tubes,  which  some 
consider  causative  of  a  third,  or  half,  of  the  cases;  tubal  tuberculosis, 
however,  is  usually  secondary  to  some  small  focus  in  the  bronchial 
glands.  Infection  by  contiguity  and  by  the  lymph-stream  is  said  to 
be  far  more  common  than  hsematogenous  infection,  although  the 
writer  believes  that  tuberculous  peritonitis  is  haematogenous. 

Tuberculous  peritonitis  is  a  frequent  complication  of  liver  cirrhosis, 
as  pointed  out  by  Rokitansky,  Foerster,  and  Weigert,  though  it  seems 
strange  that  tuberculosis  should  develop  in  any  stasis.  It  also  compli- 
cates ovarian  tumors.  In  some  instances  it  follows  trauma,  which 
probably  disseminates  infection  from  a  preexisting  quiescent  focus. 
Occasionally  it  is  found  in  a  hernial  sac  (tuberculosis  herniosa),  of 
which  62  cases  are  reported  (1903). 

Types. — A  clinical  description  is  impossible,  for  the  disease  may  be 
acute,  subacute  or  chronic,  latent  or  stormy,  circumscribed  or  diffuse; 
it  may  be  marked  by  adhesions,  by  free  or  encapsulated  ascites,  or  by 
large  tumor-like  masses;  it  may  be  obscured  by  coincident  miliary 
tuberculosis,  liver  cirrhosis,  exudative  pleurisy,  or  ulcerative  phthisis,  or 
may  appear  as  a  seemingly  primary  clinical  fact.  Though  the  forms 
are  similar  and  atypical  cases  are  common,  certain  types  may  be  de- 
scribed. The  unessential  forms  of  miliary  tubercle,  and  the  small 
and  usually  non-inflammatory  tubercles  seen  over  intestinal  ulcers  or 
in  chronic  phthisis,  are  not  taken  into  clinical  consideration. 

1.  The  acute  form  usually  begins  with  severe  symptoms,  which 
include  fever,  rapid  pulse,  abdominal  tenderness  and  pain,  free  fluid 
in  the  peritoneal  sac,  which  shifts  with  change  of  position,  considerable 
meteorism  from  paresis  of  the  gut,  vomiting,  sometimes  diarrhoea  or 
at  other  times  constipation.  This  type  may  resemble  typhoid  when 
the  intoxication  is  more  marked  than  the  local  signs.  On  the  other 
hand,  cases  occur  which  simulate  internal  strangulation  and  ileus, 
which  at  times  actuallv  results  from  intestinal  adhesions  or  incar- 


TUBERCULOSIS  OF   THE  SEROUS  MEMBRANES  343 

ceration  beneath  bands.  The  writer  has  seen  three  cases  precipitated 
by  deHvery  and  for  this  reason  resembhng  a  puerperal  infection.  Indi- 
canuria,  so  frequent  in  other  acute  peritonitides,  is  usually  absent. 
The  ascitic  ffiiid  is  usually  lemon-colored,  serous  or  slightly  flocculent, 
and  generally  of  a  specific  gravity  of  over  1,014;  red  blood-cells  some- 
times impart  to  it  a  hemorrhagic  hue;  the  leukocytes  are  usually 
mononuclear.  In  rare  instances  the  acute  peritonitis  is  suppurative, 
and  is  due  to  perforation  of  a  tuberculous  ulcer  in  the  gut.  In  some 
cases  the  acute  type  is  a  terminal  infection.  Though  it  is  commonly 
diffuse,  there  is  sometimes  acute  local  pain  or  circumscribed  effusion, 
which  may  occur,  for  instance,  over  an  intestinal  ulcer.  Plastic  adhe- 
sions occasionally  tend  to  modify  the  freedom  with  which  this  ascitic 
form  shifts  with  alteration  of  posture.  Acute  tuberculous  peritonitis 
comes  more  often  under  the  care  of  the  physician  than  of  the  gynae- 
cologist or  surgeon. 

2.  Subacute  or  chronic  forms  present  more  or  less  diffuse  peritoneal 
involvement,  (a)  The  fibrino-jplastic  form,  causing  adhesions,  may 
result  from  the  acute  form  or  may  develop  slowly  and  insidiously; 
symptoms  and  signs  are  usually  lacking,  or  when  present  are  not  dis- 
tinctive, (b)  The  fibrino-caseous  form  is  characterized  by  the  develop- 
ment of  tubercles,  which  by  fusion  often  form  large  pigmented  solid 
masses.  There  are  adhesions,  and  thickening  of  the  intestine,  mesen- 
tery, and  omentum.  Between  the  recesses  formed  by  the  inter-intes- 
tinal adhesions,  or  by  the  growth  of  the  gut  to  the  liver  or  spleen, 
pockets  of  exudate  frequently  occur,  containing  blood-stained  serum, 
cold  abscesses,  or  cheesy  material ;  the  intestine  is  thickened  and  con- 
tracted, the  mesentery  deformed,  and  the  omentum  shrunken,  (c) 
The  effusive  formis,  marked  by  serous,  serofibrinous,  serohemorrhagic, 
and  less  often  by  puriform  or  adipose  exudate,  which  is  more  or  less 
encapsulated. 

All  these  types  and  subtypes  vary  so  much  that  the  individual 
symptoms  will  be  considered  separately. 

Individual  Symptoms — l.  Adhesions  and  Retraction. — The  infil- 
trated omentum  gradually  indurates  and  retracts  so  that  it  is  found 
above  the  navel  (Bamberger)  or  along  either  costal  arch  as  a  fibro- 
caseous  tumor-like  mass;  it  may  often  be  palpated,  even  when  there 
is  much  exudate,  and  becomes  clearer  after  paracentesis;  it  may  be 
mistaken  for  carcinoma  of  the  stomach,  enlarged  liver,  or  distended 
gall-bladder,  especially  when  in  chronic  forms  there  is  no  temperature; 
it  may  also  occur  in  simple  or  carcinomatous  chronic  peritonitis,  but 
is  quite  suggestive  of  tuberculosis.  The  ivalls  of  the  gut  are  fre- 
quently so  thickened  that  intestinal  stenosis  and  longitudinal  short- 
ening result;  the  gut  may  measure  but  one-half  or  one-third  of  its 
original  length;  it  may  be  thickened,  adherent,  surrounded  by  exudate, 
and  may  also  resemble  a  tumor.  Adhesions  may  continue  to  retract 
until  the  entire  peritoneal  sac  is  deformed  (Kleb's  peritonitis  defor- 
mans); this  is  a  species  of  spontaneous  recovery  but  is  attended  by 
danger  of  intestinal  stenosis.     The  mesenteric  thickeninjr  and  retrac- 


344  THE  SPECIFIC  INFECTIONS 

tion  {mesenteritis  retrahens)  affects  the  character  of  the  physical  find- 
ings and  the  tympany  and  the  dulness;  the  mesentery  may  measure 
one-half  to  one  inch  (1  to  2  cm.)  in  thickness, 

2.  Ascites;  Exudate. — The  abdomen  is  often  moderately  enlarged, 
which  is  due  to  serous  exudation  and  meteorism ;  in  some  cases  inspec- 
tion reveals  no  objective  change.  Large  exudates  may  cause  some 
distention  of  the  abdominal  veins,  as  in  ascites  {q.v.),  because  the 
cava  is  compressed.  When  the  abdomen  protrudes,  its  centre  is  not 
usually  flattened  nor  are  its  sides  bulging  as  in  the  ordinary  ascites 
of  liver  or  cardiac  disease  (Bouilly),  but  it  is  often  prominent  in  the 
median  line,  as  in  ovarian  cyst.  Lohlein  states  that  most  of  his 
cases  were  sent  to  him  with  a  diagnosis  of  ovarian  tumor  or  cyst.  In 
cases  without  adhesions  the  dulness  shifts  easily  with  change  of  pos- 
ture, so  that  tympany  exists  over  the  supernatant  gut  and  dulness 
is  found  over  the  settling  fluid.  The  physical  signs,  however,  differ 
from  those  of  a  common  ascites  in  that  the  tympany  is  often  on  the 
right  side ;  Thomeyer  pointed  out  that  the  mesenteritis  retrahens  pulls 
over  the  small  gut  to  the  right  side,  and  that  its  chief  cause  is  tubercu- 
lous (less  often  carcinomatous  or  simple)  peritonitis;  though  this  dis- 
position of  the  tympany  is  common,  nevertheless,  a  tuberculous  mass 
may  develop  anywhere,  as  for  instance,  in  the  right  iliac  region,  in 
which  case  it  dislocates  the  tympanitic  intestines  to  the  left,  or  in  the 
median  line  or  in  the  pelvis.  In  general  the  abdominal  distention  is 
asymmetrical  rather  than  symmetrical;  it  is  generally  less  extensive 
than,  for  instance,  is  liver  cirrhosis,  with  which  it  may  co-exist.  In 
very  rare  cases  the  fluid  may  break  through,  into  the  bowel  or  exter- 
nally through  the  navel.  Dulness  does  not  always  indicate  the  presence 
of  fluid  but  may  result  from  close  adhesions,  from  thickening  of  the 
gut,,  from  caseous  masses  or  enlarged  glands. 

3.  Meteorism.— This  may  result  from  sudden  paresis  of  the  gut 
in  the  acute  type,  or  from  chronic  fibrous  obstruction  in  cases  of  long 
standing.  Tuberculous  tumors  may  also  impair  peristalsis  and  thus 
cause  gaseous  accumulations.  Meteorism  is  one  of  the  stigmata  of 
tuberculosis  of  the  mesentery  glands  {tahes  or  phthisis  mesaraica)  and 
then  is  often  due  to  coincident  peritonitis;  in  both  conditions,  but 
most  often  in  children  (Berggriin  and  Katz),  the  stools  may  appear 
uncolored  and  fatty. 

4.  Palpation. — A  doughy  sensation  is  often  experienced  on  palpa- 
tion, which  is  usually  referred  to  peritoneal  adhesions  or  constricted 
intestine,  .but  in  some  instances  is  due  to  early  infiltration  of  the  pre- 
peritoneal (subserous)  tissues. 

5.  Friction  Sounds. — In  some  cases  the  Beatty-Bright  friction-rub  can 
be  elicited. 

6.  Pelvic  Effusion. — This  is  particularly  common  in  women,  who  also 
suffer  from  painful  and  disturbed  menstruation. 

7.  Temperature. — Temperature  frequently  occurs,  but  is  irregular 
in  character;  it  is  sometimes  continuous,  even  typhoidal,  and  some- 
times remittent,  or  hectic;    it  is  most  frequent  in  acute  types  or  in 


TUBERCULOSIS  OF   THE  SEROUS  MEMBRANES  345 

acute  exacerbations  of  chronic  cases.  In  some  chronic  cases  it  is  ab- 
sent or  subnormal.  The  disease  therefore  cannot  be  excluded  by  the 
absence  of  temperature.  Fever,  with  pain  and  tenderness,  usually,  but 
not  alwaySjdistinguishes  tuberculous  encapsulation  from  simple  ascites. 

8.  Pain  and  Tenderness. — These  are  generally  conspicuous,  though 
moderate  in  degree  and  by  no  means  constant. 

9.  Marasmus — Emaciation  is  common  and  has  been  especially 
emphasized  by  Vierordt;  Konig,  however,  remarks  upon  the  frequency 
with  which  cases  of  tuberculous  peritonitis  present  a  good  color  and 
robust  appearance. 

10.  Gastro-intestinal  Disturbances. — Digestive  disorders  are  fairly 
frequent;  the  usual  constipation  is  occasioned  by  impaired  peristalsis; 
in  some  cases  diarrhoea,  amounting  to  3  or  4  movements  daily,  is  pos- 
sibly caused  by  toxaemia. 

11.  Other  Symptoms. — The  spleen  may  be  enlarged,  but  is  difficult 
to  find  in  the  majority  of  cases.  In  rare  instances  there  are  icterus, 
pylethrombosis,  and  other  complications  due  to  special  localizations  of 
the  process. 

Diagnosis. — The  diagnosis  is  usually  made  correctly,  though  some- 
times there  are  no  just  grounds  for  even  suspecting  the  presence  of 
the  disease.  Considerable  importance  should  be  attached  to  tuber- 
culous lesions  elsewhere,  as  in  the  lungs,  pleurae,  glands,  or  Fallopian 
tubes.  Multiple  serositis  is  extremely  suggestive.  If  another  tuber- 
culous lesion  cannot  be  established,  tuberculous  peritonitis,  which 
causes  nearly  all  chronic  peritonitides,  is  very  probably  present;  malig- 
nancy and  traumatism  must  be  considered.  Tuberculin  injections 
may  be  given  but  do  not  prove  that  the  lesion  is  peritoneal  or  tuber- 
culous. Inoculation  may  be  made  with  fluid  withdrawn  by  paracentesis 
(see  Pleurisy).  Exploratory  laparotomy  is  justifiable,  particularly 
as  simple  abdominal  section  is  the  foremost  therapeutic  measure. 

Course. — The  onset  is  usually  insidious  with  marked  but  not  extreme 
pain,  tenderness,  anorexia,  vomiting,  colic,  fever,  and  constipation  or 
diarrhoea.  The  course,  independent  of  all  therapeutic  measures,  shows 
spontaneous  remissions,  as  Vierordt  and  Nothnagel  have  particularly 
insisted. 

Treatment. — Simple  rest  in  bed,  good  hygiene,  and  full  feeding, 
very  often  arrest  the  process.  The  tumors,  exudate,  and  adhesions, 
may  recede  and  no  symptom  reappear  for  months  or  even  years. 
Spontaneous  recovery  was  first  described  by  Bamberger  but  was 
ignored  until  relatively  recent  times.  In  1884  Konig  proved  what 
Spencer  Wells  had  observed  twenty  years  earlier,  that  healing  may 
follow  laparotomy  (Czerny,  Hegar,  Chrobak,  Bumm,  Israel).  Tuber- 
cles may  heal  entirely  in  six  or  seven  weeks.  Then  Lindner,  Phillips, 
Valenta,  Roersch,  Hinterberger,  and  others,  showed  that  recovery  was 
frequent  (in  25  per  cent,  of  the  cases)  without  either  medication  or 
laparotomy.  Experimental  researches  have  shown  that  the  tubercles 
heal  by  simple  degeneration,  or  by  vascularization  and  development 
of  connective  tissue. 


346  THE  SPECIFIC  INFECTIONS 

Operation  gives  various  results,  recovery  occurring  in  33  per  cent. 
(Frees),  55  per  cent.  (Chrobak),  64  per  cent.  (Konig),  91  per  cent. 
(Dohrn)  and  94  per  cent.  (Mazzoni).  Larger  numbers  of  cases  give 
equally  high  percentages;  70  per  cent.,  Roersch,  358  cases;  85  per 
cent.,  Margarucci,  250  cases;  von  Krenecki,  266  cases,  72  per  cent, 
recoveries  in  ascitic,  62  per  cent,  in  adhesive,  and  75  per  cent,  in  en- 
cysted forms;  75  per  cent,  in  405  cases,  Adossides.  If  the  primary 
focus  is  accessible,  as  in  tuberculous  tubes,  it  should  be  removed, 
thereby  raising  the  percentage  of  recoveries  from  71  to  97  per  cent. 
(Mayo).  Simple  paracentesis  is  much  inferior  to  laparotomy.  Lavage 
is  superfluous.  It  is  thought  that  the  access  of  air  or  sunlight,  or 
manipulation  or  lavage,  is  the  potent  curative  factor  in  operative  treat- 
ment. Veit  advances  the  plausible  theory  that  the  withdrawal  of  fluid 
allows  the  access  of  fresh  serum  with  increased  antitoxic  properties. 
Operation,  in  the  author's  opinion,  is  clearly  of  great  value;  but  it 
may  be  mentioned  that  some  conservative  writers  believe  that  the 
tubercles  which  heal  after  operation  were  already  in  process  of  healing 
spontaneously. 


V.  Tuberculosis  of  the  Brain  and  Meninges. 

Involvement  may  result  from  (a)  the  miliary  tubercle,  (6)  the  soli- 
tary, or,  as  Virchow  prefers  to  call  it,  the  conglomerate  tubercle,  (c) 
the  tuberculous  abscess,  and  (d)  meningitis,  acute  or  chronic.  The 
miliary  form  has  already  been  described;  the  solitary  or  conglomerate 
tubercle  produces  symptoms  identical  with  those  of  brain  tumor 
(q.v.),  and  tuberculous  meningitis  will  be  described  with  other  menin- 
gitides  (v.  Meninges). 

Primary  cerebral  tuberculosis  is  extremely  rare.  Warfringe,  Fraen- 
kel,  Alvarez  and  Duerck  have  described  primary  meningitis,  but  it  is 
extremely  probable  that  small  or  microscopic  foci  elsewhere  escaped 
detection.  Fraenkel  found  tuberculous  meningitis  in  4.7  per  cent,  of 
adults  dying  with  pulmonary  phthisis. 

VI.  Tuberculosis  of  the  Alimentary  Tract. 

1.  Lips. — The  lips  are  very  seldom  afi'ected;  lupus  or  tuberculous 
ulcers  may  invade  them.  The  latter  are  very  painful  and  may  be 
confused  with  cancer  or  chancre. 

2.  Gums. — The  gums  are  seldom  involved,  though  tuberculosis  has 
followed  caries  or  extraction  of  the  teeth. 

3.  Tongue. — This  is  involved  in  1  to  2  per  cent,  of  cases.  Tuber- 
culous tumors  may  develop  in  its  substance.  They  are  sometimes 
mistaken  for  gumma  or  cancer,  and  may  break  down  into  cold  ab- 
scesses. Tuberculous  ulcers  develop  on  the  dorsum  or  edges;  they 
have  rough  caseous    bases  with  uneven  or  undermined  edges;    they 


TUBERCULOSIS  OF  THE  ALIMENTARY   TRACT  347 

are  almost  never  primary;  they  are  differentiated  from  syphilitic  ulcers 
by  the  inefficiency  of  mercury  and  iodides,  from  cancer  by  the  absence 
of  glands  in  the  neck,  and  from  both  by  the  presence  of  bacilli  and  the 
results  of  inoculation. 

4.  Pharynx. — Pharyngeal  involvement  was  known  to  Morgagni  but 
was  especially  studied  by  Ricord  (1865).  Primary  disease  is  most 
infrequent,  and  involvement  secondary  to  pulmonary  or  laryngeal 
phthisis  is  more  common,  but  still  is  infrequent;  Heller  saw  but  4 
instances  in  8,000  throat  cases;  Kidd  found  6  cases  in  500  tuberculous 
autopsies.  The  process  begins  largely  in  the  lymphoid  structures, 
which  are  infected  by  tuberculous  sputum  or  food,  or  it  extends  by 
the  lymph-vessels  from  the  larynx.  Three-fifths  of  the  cases  (Marti- 
neaux)  are  associated  with  tuberculous  disease  of  the  intestine,  and  15 
per  cent.  (Barth)  with  oral  tuberculosis.  It  is  promoted  by  syphilis, 
by  the  use  of  alcohol  and  tobacco,  by  trauma,  and  by  preexisting 
ulceration.  The  cervical  glands  may  be  affected  in  acute,  but  rarely 
in  chronic,  cases.  The  ulcerations  are  usually  superficial ;  when  pro- 
pagated from  the  larynx,  the  most  distressing  dysphagia  results.  Retro- 
pharyncjeal  abscess  (Read,  Lindenbaum,  Northrup)  usually  results 
from  suppuration  of  the  lymph  glands  and  from  spinal  or  osseous 
disease.' 

5.  Palate. — The  palate  is  said  to  be  affected  in  1  per  cent,  of  cases 
of  phthisis ;  in  swallowing  or  coughing,  tubercle  bacilli  from  the  sputum 
come  in  close  or  even  forcible  contact  with  the  palate.  Lublinski  ob- 
served three  instances  among  16,000  throat  cases,  and  Kidd  saw  4 
cases  in  500  tuberculous  autopsies. 

6.  Tonsils. — The  tonsils  are  diseased  in  4  per  cent,  of  cases  of 
pulmonary  tuberculosis  (Warthin);  their  folds  and  crypts  contain 
bacilli ;  the  process  may  stop  at  the  tonsils,  for  they  act  as  barriers  to 
the  infection  or  a  tuberculous  cervical  adenitis  may  develop.  Their 
infection  may  be  primary^  and  Dieulafoy  holds  that  tonsillar  infection 
may  be  followed  by  a  descending  tuberculous  adenitis,  which  in  turn 
infects  the  lungs.  Some  maintain  that  the  tonsils  are  almost  invariably 
infected  by  the  sputum  in  phthisis  of  the  lungs;  Schlenker  finds  them 
tuberculous  in  65  percent.,  Krueckmann  in  48  per  cent.,  and  Dmo- 
chowski  in  100  per  cent,  of  his  cases  of  pulmonary  phthisis.  The 
lesions  are  miliary  more  often  than  caseous. 

7.  Salivary  Glands. — These  are  fairly,  but  not  absolutely,  immune. 

8.  (Esophagus. — The  oesophagus  is  also  relatively  immune  and  is 
infected  less  frequently  even  than  the  throat.  No  clear  primary  case 
is  recorded,  and  Cone  could  collect  only  48  secondary  cases.  Oesoph- 
ageal trauma,  cancer,  or  ulceration,  tends  to  localize  the  bacillus. 
Infection  by  contiguity,  from  the  peribronchial  glands,  is  more  com- 
mon than  infection  by  tuberculous  sputum;  these  glands  may  occasion 
oesophageal  perforation,  hemorrhage,  diverticula,  or  stenosis.  Exten- 
sion from  the  larynx  or  pharynx  along  the  lymph  tracts  in  the  sub- 
mucosa,  or  from  the  spine  or  lung  cavities,  is  possible.  Miliary 
deposits  have  no  clinical  importance. 


348  THE  SPECIFIC  INFECTIONS 

9.  Stomach. — The  stomach  almost  never  shows  primary  ulceration. 
There  are  only  four  cases  on  record  in  which  the  smallest  claim  for 
primary  involvement  can  be  made.  Secondary  disease  in  pulmonary 
tuberculosis  is  estimated  at  four-tenths  of  one  per  cent,  to  2  per  cent. 
Letorey,  in  1895,  collected  21  cases  of  tuberculous  ulcer,  but  they  are 
more  frequent  than  statistics  show.  Ricard  and  Chevrier  assert  that 
there  are  on  record  sixteen  cases  of  tuberculous  stenosis  of  the  pylorus. 
Klebs's  idea  that  gastric  localization  was  promoted  by  round  ulcer 
is  not  generally  accepted.  The  HCl  is  inimical  to  gastric  tubercle. 
Tuberculous  ulceration  of  the  stomach  occurs  from  the  sputum,  from 
invasion  by  contiguity  (glands,  peritoneum,  or  colon),  or  in  few  cases 
from  hsematogenous  infection. 

10.  Intestinal  Tuberculosis. — This  was  first  observed  by  Bayle, 
(1810).  (a)  It  is  usually  secondary  to  lung  tuberculosis  with  cavity 
formation,  and  results  from  infective  sputum;  its  frequency  is  30 
per  cent.  (Eichhorst),  34  to  38  per  cent.  (Leroux  and  Mueller,  in  chil- 
dren), 51  per  cent.  (Heinze),  or  90  per  cent.  (Weigert,  Orth,  Warthin). 
Tubercle  bacilli  may  be  swallowed  without  causing  intestinal  tuber- 
culosis. Of  all  kinds  of  intestinal  ulceration,  tuberculous  ulcers  are 
the  most  frequent.  Infection  in  some  cases  may  occur  from  the  peri- 
toneum or  mesenteric  glands,  but  adhesions  often  render  th6  deter- 
mination of  the  primary  focus  impossible.  Hsematogenous  infection 
is  barely  possible.  (6)  Primary  intestinal  tuberculosis  is  much  more 
rare,  occurring  in  but  0.3  per  cent.  (Eisenhardt),  and  in  only  0.1  per 
cent,  of  the  cases  in  adults.  The  intestinal  mucosa  in  children  is  like 
the  bronchial,  as  it  often  allows  of  the  passage  of  tubercle  bacilli 
through  it  to  the  intestinal  glands  without  disease  of  the  intestine  itself; 
this  is  due  to  the  loose  infantile  mucosa  and  the  large  lymph  vessels, 
Kingston,  in  339  autopsies  on  children  with  tuberculosis,  found  its 
atrium  was  respiratory  in  64  per  cent.,  intestinal  in  19  per  cent., 
and  uncertain  in  17  per  cent.  Infection  may  occur  by  infected  milk 
or  meat.  Koch  takes  an  extreme  view  in  denying  infection  by  milk, 
and  Behring  takes  the  opposite  extreme  in  affirming  that  it  is  the 
chief  cause  of  tuberculosis. 

The  ulcers  are  most  frequent  in  (i)  the  ileo-coecal  region  and  next  in 
the  colon,  (ii)  They  always  originate  in  the  lymj)hadenoid  follicles 
or  Peyer's  patches  and  never  in  the  mucous  membrane;  they  are  pro- 
moted by  erosions  or  obstipation.  Small  tubercles  fuse  into  large 
ones,  which  caseate  and  ulcerate;  in  exceptional  cases  the  caseous 
nodes  do  not  rupture  but  cause  the  peritoneum  and  mucosa  to  bulge 
out.  (iii)  The  ulcers  are  irregular  in  shape,  and  (iv)  their  disposition 
is  ring-like;  i.e.,  they  are  located  transversely  around  the  gut,  because 
extension  occurs  by  the  lymph  vessels  (lymphangitis  tuberculosa). 
Occasionally  they  lie  in  the  long  axis  of  the  gut  and  are  ovoid,  corre- 
sponding, though  often  incompletely,  to  Peyer's  patches,  (v)  They 
are  single  or  multiple,  and  sometimes  cover  nearly  all  the  surface  of 
both  the  large  and  small  intestines,  (vi)  Their  bases  are  rough  or 
caseous  and  their  edges  infiltrated;    the  infiltration  also  invades  the 


TUBERCULOSIS  OF   THE  ALIMENTARY  TRACT  349 

contiguous  mucosa  and  submucosa.  (vii)  Localized  adhesive  peri- 
tonitis is  a  common  issue  when  the  process  reaches  the  serosa.  An 
early  stage  of  this  is  seen  in  the  serous  and  subserous  miliary  tubercles 
and  in  the  bead-like  tuberculous  lymphangitis;  perforation  occurs  in  5 
to  10  per  cent,  of  the  cases,  but  is  resisted  by  the  muscular  coat  and 
by  adhesions;  it  results  in  pericsecal  abscess  and  in  suppurative  peri- 
tonitis. Stenosis  of  the  intestine,  single  or  less  often  multiple  (129 
cases  collected  by  Arbuson,  1904),  may  also  result;  recovery  is  very 
rare.  Konig  in  two  years  saw  5  cases  recover,  and  Eisenhardt  saw  10 
complete  and  26  incomplete  instances  in  567  tuberculous  ulcerations. 
Hepatic  suppuration  or  steatosis,  may  result. 

Symptoms.— The  symptoms  are  those  of  any  form  of  intestinal 
ulceration  {q.v.);  they  commence  usually  with  signs  of  catarrhal 
enteritis,  diarrhoea,  pains,  and  fever.  They  may  for  a  while  resemble 
those  of  typhoid.  The  only  pathognomonic  finding  is  the  tubercle 
bacillus,  and  it  is  possible  that  its  presence  may  result  only  from  swal- 
lowed sputum.  Rosenblatt's  method  of  detecting  the  bacilli  in  the 
fseces  is  to  give  laudanum  until  the  stools  become  hard,  and  then  ex- 
amine the  mucus  on  their  surface;  the  bacilli  are  usually  found  on 
the  first  examination,  for  the  hard  faeces  apparently  scrape  the  bacilli 
from  the  ulcers.  Pus  is  often  found  and  hemorrhage  occasionally 
results.  Girode  called  attention  to  the  black  stools,  which  are  usually 
ominous,  as  they  indicate  malnutrition;  the  picture  of  dysentery  is 
rarely  observed.  Fatal  hemorrhage  is  infrequent,  though  cases  have 
been  recorded  by  Vallin,  Hanot,  Osier,  Chandeze  and  others.  An 
appendicitic  form  may  be  noted,  with  quick  or  insidious  onset  and  with 
some  induration;  recurrence  is  frequent  and  fistulse  occasionally 
develop.  In  typhlitis  tuberculosa  there  is  great  thickening  in  the  csecal 
region,  with  a  hard,  slightly  movable  or  totally  adherent,  vertically 
disposed,  tender  tumor.  The  onset  is  usually  insidious,  pain  is  recur- 
rent, symptoms  of  increasing  intestinal  stenosis  are  present  and  con- 
stipation alternates  with  diarrhoea.  Hemorrhage  is  infrequent,  fever 
is  usually  absent  and  emaciation  is  sometimes  pronounced.  Duguet 
described  this  condition  in  1869,  and,  since  it  so  fully  resembles  cancer 
or  sarcoma,  it  has  attracted  the  especial  attention  of  the  surgeons, 
Bassini  (1887),  Bouilly  (1889),  and  Billroth  (1891).  Campiche  (1906) 
collected  379  cases  of  tuberculosis  of  the  appendix  and  csecum;  about 
25  per  cent,  of  the  operated  cases  died  from  the  operation;  about 
35  per  cent,  were  well  for  months  or  years;  and  about  40  per  cent, 
ultimately  died  of  tuberculosis.  It  sometimes  co-exists  with  cancer. 
The  process  usually  begins  in  the  mucosa  and  is  marked  by  ulcera- 
tion, villosities  in  the  mucosa,  great  local  infiltration  and  hypertrophy 
of  the  bowel,  and  destruction  of  the  ileocsecal  valve.  The  process 
may  begin,  as  shown  by  Conrath,  in  the  serosa,  with  which  tuberculous 
glands  may  come  in  contact.  Patients  may  die  of  acute  obstruction, 
or  only  after  a  chronic  course  of  a  decade  or  more;  recovery  by  fibrosis 
is  possible.  Benoit  and  Dieulafoy  regard  the  process  as  primary  in 
80  per  cent,  of  subjects. 


350  THE  SPECIFIC  INFECTIONS 

In  the  rectum,  ulcers,  either  anal  or  rectal,  lupus,  tuberculosis  cutis 
verrucosa,  and  periproctal  abscess,  are  sometimes  seen.  Fistula  in  ano 
occurs  in  1  to  5  per  cent,  of  cases  of  phthisis,  and  rarely  develops  in 
other  conditions;  the  general  idea  that  its  excision  excites  pulmonary- 
disease  is  a  confusion  of  cause  with  effect. 

11.  Liver. — The  liver  is  involved  less  in  adults  than  in  children 
(38  per  cent.  Leroux),  but  at  all  ages  it  is  of  greater  pathological  than 
clinical  interest,  (i)  Large  tubercles  may  develop  in  the  liver,  some- 
times with  peritonitis  and  perihepatitis,  (ii)  Miliary  tubercles  are  of 
no  clinical  significance,  (iii)  Hanot  maintains  that  there  is  a  pri- 
mary cirrhosis  of  the  liver,  associated  with  tubercles  and  fatty  degen- 
eration; at  the  most  it  is  extremely  rare;  it  is  said  to  be  associated 
sometimes  with  tuberculous  peritonitis  and  perihepatitis  (y.  s.  Tuber- 
culosis OF  THE  Lungs:  Complications). 

12.  Spleen. — The  spleen  is  involved  in  43  to  47  per  cent,  of  tuber- 
culous children  (Leroux  and  Mueller).  Bayer  (1904)  collected  28 
cases  of  primary  tuberculosis  of  the  spleen;  19  were  not  recognized 
clinically;  9  were  operated  on,  of  which  2  died  and  7  recovered.  (See 
Diseases  of  Spleen:  Splenomegaly  with  Cyanosis.) 


VII.  Tuberculosis  of  the  Genito-urinary  Tract. 

Genito-urinary  tuberculosis  was  described  by  Morgagni  and  by 
Bayle  in  the  beginning  of  the  last  century,  but  for  the  first  time  fully 
by  Lichtheim,  in  the  cadaver,  and  by  Rosenstein,  Babes,  and  Smith, 
clinically.  It  is  most  frequent  in  the  period  of  greatest  sexual  activity 
(twentieth  to  fortieth  year),  and  72  per  cent,  occur  in  males,  in  whom 
the  two  tracts  have  more  continuity  and  community  of  surface. 

Modes  of  Infection. — 1.  Hsematogenic  Infection. — This  is  the  most 
frequent  variety.  It  occurs  in  5  per  cent,  of  cases  of  chronic  pulmon- 
ary tuberculosis.  The  majority  (76  per  cent.)  of  cases  are  secondary 
to  some  lung  or  peribronchial  glandular  focus,  which  very  often  has 
produced  no  symptoms,  so  that  most  seemingly  primary  foci  are 
really  secondary.  Jani  found  tubercle  bacilli  in  perfectly  sound  testes 
and  prostate  glands,  but  they  were  clearly  an  invasion  of  the  blood 
occurring  in  the  death  agony. 

2.  Urogenic  Infection. — The  general  opinion  was  previously  that 
a  secondary  infection  mounted  from  the  lower  genital  to  the  higher 
uropoietic  structures.  It  may  be  conveyed  by  infected  fingers,  instru- 
ments, or  catheters.  Infection  by  sexual  intercourse  is  possible  but 
has  been  grossly  overrated.     It  may  follow  syphilis  and  gonorrhoea. 

3.  Infection  from  the  Peritoneum  and  Contiguous  Structures. — The 
Fallopian  tubes  are  diseased  in  a  third  to  a  half  of  the  cases  of  tubercu- 
lous peritonitis.  Jani  found  tubercle  bacilli  in  the  tubes  in  women 
dying  of  phthisis.  The  bladder,  seminal  vesicles,  and  vasa  deferentia, 
may  be  invaded  fer  contiguitatem  from  peritoneal,  vertebral,  rectal, 
and  other  foci.     In  many  cases  it  is  impossible  to  determine  where 


TUBERCULOSIS  OF   THE  GENITO-URINARY   TRACT  351 

the  process  began,  for  extension  may  have  occurred  so  rapidly  and 
diffusely. 

(.4).  Renal  Tuberculosis. — The  kidney  in  miliary  tuberculosis  is 
involved  in  90  per  cent.  (Frerichs),  but  is  marked  by  no  distinguish- 
ing symptoms.  Caseous  nodes  develop  in  the  cortex,  infection  reach- 
ing it  most  often  (in  90  per  cent.)  from  the  blood  stream  (desquamative 
caseous  nephritis);  they  often  break  down  into  cavities,  and  may 
form  cold  abscesses  or  undergo  secondary  pyogenic  infection,  or  the 
process  may  remain  localized  in  one  pole  of  the  kidney.  Tubercles 
also  develop  in  the  apices  of  the  pyramids  and  pelvis  of  the  kidney, 
and  form  caseous  infiltration  and  ulcers;  involvement  in  this  form 
was  at  one  time  considered  the  result  of  an  ascending  infection,  though 
Caspar  and  Walker  oppose  this  view;  some  maintain  that  infection 
from  below  may  pass  through  the  bladder  (without  causing  lesions  in 
it)  and  reach  the  kidneys,  just  as  the  bacilli  may  pass  the  lungs  or 
intestine  and  cause  bronchial  or  mesenteric  adenopathies.  Israel  and 
others,  on  the  contrary,  believe  that  the  process  often  (41  per  cent, 
of  cases)  descends  from  the  kidney  to  the  bladder.  Wherever  the 
process  begins,  upward  and  downward  extension  in  the  kidney  itself 
often  occurs,  so  that  the  entire  organ  may  be  more  or  less  diseased. 
When  the  process  is  well  developed  there  is  a  tuberculous  pyonephrosis. 
The  entire  kidney  may  become  a  large  sac  of  caseous  material,  detritus, 
and  lime  salts;  this  is  called  degenerescence  massive  by  Tuffier.  The 
kidney  is  often  adherent  to  adjacent  structures;  its  capsule  is  thick- 
ened, its  removal  strips  off  particles  of  renal  substance,  and  it  is  some- 
times perforated,  causing  tuberculous  paranephritis.  The  surface  of 
the  kidney  may  be  smooth  and  normal,  lumpy  from  caseous  deposits, 
or  softened  in  many  places  from  diffuse  ulceration.  In  exceptional 
cases  spontaneous  healing  is  possible.  Whether  one  or  both  kidneys  are 
diseased  depends  on  the  stage  of  the  process,  and  is  a  most  important 
matter  when  surgical*  interference  is  considered.  Israel,  in  his  cele- 
brated observations,  stated  that  he  found  one  kidney  involved  usually 
without  any  other  genito-urinary  disease.  Pallet  and  Albarran  ob- 
served unilateral  disease  in  80  to  85  per  cent,  of  their  cases,  while  post- 
mortem figures  show  unilateral  renal  disease  in  but  48  per  cent. ; 
naturally,  in  autopsy  figures,  the  extent  of  the  disease  is  greater  than  in 
clinical  figures.  Compensatory  hypertrophy  of  the  sound  kidney  is 
frecjuent. 

Symptoms. — These  may  be  absent  if  the  renal  pelvis  remains  sound. 
Otherwise  the  symptoms  are  (1)  urinary,  (2)  local,  and(3)  general. 

1.  Urinary. — The  urinary  symptoms  are  chiefly  those  of  pyelitis 
(f/.  v.).  The  urine  is  acid,  though  alkalinity  develops  in  complicating 
tuberculous  or  non-tuberculous  cystitis,  which  may  be  determined  by 
the  cystoscope.  Urination  is  often  difficult  (dysuria)  or  frequent  (poUiak- 
uria),  so  that  the  existence  of  cystitis  is  at  first  suspected;  it  is  a  safe 
rule  always  to  consider  the  possibility  of  renal  phthisis  in  eveiy  cystitis 
the  origin  of  which  is  not  entirely  clear  and  the  treatment  of  which 
is  unsuccessful.     Bladder  symptoms  are  reflex  or  are  due  to  compli- 


352  THE  SPECIFIC  INFECTIONS 

eating  cystitis,  simple  or  tuberculous.  The  urine  is  sometimes  in- 
creased; Guyon  describes  an  early  polyuria  in  which  the  urine  is 
clear,  and  a  later  polyuria  in  which  it  is  turbid.  Hcematuria  (q.v.) 
is  frequent;  it  may  be  severe  or  slight  and  its  occurrence  is  more  often 
early  than  late;  its  frequent  recurrence  is  so  marked  in  some  cases  as 
to  justify  the  term  "hemorrhagic  type";  it  may  last  one  and  a  half 
months  (Routier)  to  four  and  a  half  years  (Tuffier).  Pyuria  generally 
occurs  when  the  pelvis  is  invaded,  but  is  not  observed  when  cortical 
foci  do  not  communicate  with  the  pelvis  nor  when  the  ureter  is  oc- 
cluded; the  pus  cells  correspond  to  the  amount  of  albumin.  Epithe- 
lial cells,  sometimes  caseous  matter,  elastic  fibers,  and  necrotic  renal 
tissue,  are  found.  The  sediment  is  often  a  crunibly,  rapidly  settling 
detritus;  tubercle  bacilli  are  often  found,  but  must  not  be  confused 
with  the  smegma  bacillus  (v.  General  Bacteriology);  sometimes 
bacilli  in  the  urine  are  found  in  pulmonary  tuberculosis  without  any 
disease  of  the  kidneys.  Casts  are  very  infrequent.  In  unilateral  renal 
disease  with  occlusion  of  the  corresponding  ureter,  the  urine  is 
naturally  normal.  Urinary  segregation  or  ureteral  catherization  deter- 
mines which  kidney  is  involved. 

2.  Local. — Local  symptoms  are  lumbar  pain  and  tumor.  Lumbar 
pain  sometimes  results  from  capsular  tension;  it  is  severe,  colicky 
and  is  reflected  to  the  groins  and  testes,  which  may  be  retracted  as 
they  are  in  renal  colic;  this  is  probably  due  to  the  passage  of  caseous 
particles  or  blood  clots;  differentiation  from  calculous  disease  (q.v.) 
may  be  difficult  in  such  cases  until  tubercle  bacilli  are  found.  Tumor, 
in  tuberculous  pyonephrosis  or  hydronephrosis,  is  a  small,  tender  en- 
largement, though  seldom  of  the  size  attained  in  calculous  or  other 
obstructive  disease. 

3.  General. — General  symptoms  are  hectic  fever,  malnutrition, 
tuberculosis  in  the  lungs,  and  foci  in  the  testes.  The  heart  is  almost 
never  hypertrophied.  In  60  per  cent,  of  the  cases  operated  on,  the 
diagnosis  was  found  correct.  The  course  is  chronic,  with  remissions; 
two  or  three,  or  even  five,  years  is  the  usual  duration;  recovery  from 
circumscribed  lesions  is  possible;  death  results  from  tuberculous 
generalization,  less  often  from  sepsis,  perinephritis,  or  amyloid  de- 
generation, and  rarely  from  nephritis  or  uraemia.  The  treatment  is 
surgical.  In  Kronlein's  cases,  the  operative  mortality  of  nephrectomy 
was  5.8  per  cent,  and  the  ultimate  mortality  was  17.6  per  cent.;  70  per 
cent,  was  cured.  Caspar  claims  that,  since  the  introduction  of 
ureteral  catheterization  and  functional  renal  tests,  the  mortality  has 
fallen  to  7.7  per  cent.  This  is  denied  by  Israel.  In  Albarran's  series 
the  operative  mortality  was  3  per  cent. 

(B).  Ureter  and  Bladder. — The  ureter  is  thickened,  infiltrated, 
caseous,  ulcerated,  and  often  stenosed;  it  is  involved  in  80  per  cent, 
of  cases  of  renal  tuberculosis  (Palet)  and  may  cause  various  adhesions, 
such  as  to  the  peritoneum.  Secondary  involvement  from  the  kidney 
may  be  limited  to  the  ureter  at  its  vesical  ending  or  may  spread  more 
widely  over  the  mucosa  of  the  bladder. 


TUBERCULOSIS  OF   THE  GENITO-URINARY  TRACT  353 

Bladder  disease  is  rarely  primary;  secondary  disease  results  per 
contiguitatem  or  from  hsematogenous  deposits,  as  can  be  seen  by 
means  of  the  cystoscope.  Israel  (v.s.)  noted  tuberculous  cystitis  in 
41  per  cent."  of  cases  of  renal  tuberculosis,  and  Vignernon  in  50  per 
cent.  Cystitis  of  long  standing  should  always  excite  suspicion  of  tuber- 
culosis, even  when  it  has  gonorrhoeal  or  other  antecedents.  Medical 
measures  are  only  palliative.     Surgical  intervention  is  indicated. 

(C).  Male  Genitalia. — The  epididymis  is  more  often  involved  than 
the  testis,  except  in  youth,  when  the  epididymis  and  tunica  albuginea 
are  more  frequently  affected;  in  the  first  years  of  life  testicular  disease 
results  from  generalized  tuberculosis;  about  one-half  of  Jullien's  cases 
occurred  under  two  years  of  age.  Some  hold  that  these  cases  are  con- 
genital, though  the  weight  of  evidence  is  against  this  view.  Sometimes 
no  caseation  results,  as  is  the  case  in  the  hyperplastic  lymphadenitis, 
and  even  microscopic  confusion  with  sarcoma  is  possible  unless  the 
bacilli  are  especially  looked  for.  Testicular  tuberculosis  is  most  often 
confused  with  syphilis  {q.  v.),  though  in  the  latter  there  is  less  pain 
and  fever  and  more  nodular  enlargement.  The  seminal  vesicles,  vasa 
deferentia  and  urethra  may  be  invaded  and  a  rectal  examination 
should  never  be  neglected.  Recently  the  prostate,  "the  cross  road 
of  the  urinary  and  genital  tracts,"  has  attracted  especial  attention; 
its  primary  involvement  (Lancereaux)  is  disputed  by  some,  but  the 
gland  is  affected  in  50  to  80  per  cent,  of  the  cases  of  genital  tuberculosis 
in  the  male.  The  lungs  are  invaded  in  primary  genital  tuberculosis 
in  70  per  cent,  and  the  urinary  tract  in  56  per  cent.  Treatment  is  sur- 
gical.    Medical  measures  are  usually  unavailing. 

(D).  Female  Genitalia. — The  female  genitalia  become  tuberculous 
in  1.5  to  2.5  per  cent,  of  the  cases  of  pulmonary  tuberculosis.  Infec- 
tion is  secondary  in  over  80  per  cent.  Tuberculous  tubes  are  found 
in  1.5  per  cent,  of  abdominal  operations;  according  to  W.  Williams, 
8  per  cent,  of  the  tubes  removed  for  inflammatory  lesions  were  found 
tuberculous.  Probably  nearly  all  cases  are  due  to  some  small  focus 
in  the  bronchial  glands.  The  tubes  show  nodules,  infiltration,  caseation 
and  ulceration;  bilateral  involvement  is  usual,  and  its  true  nature 
may  be  apparent  only  under  the  microscope;  tuberculous  salpingitis 
may  simulate  tuberculous  peritonitis;  tubal  disease  may  be  found  in 
very  young  children.  The  uterus  ranks  next  and  is,  as  a  rule,  involved 
secondarily;  systematic  microscopic  examination  would  doubtless 
show  higher  percentages  than  those  usually  given.  Ovarian  phthisis 
is  almost  always  secondary.  Tuberculosis  of  the  vagina,  cervix,  vulva, 
and  female  urethra,  are  very  exceptional. 

Mammae. — The  mammse  are  occasionally  diseased;  Schley  (1903) 
collected  65  cases  of  which  12  were  primary.  Carcinoma  may  be 
closely  simulated,  for  tuberculous  lesions  occur  at  the  same  age,  often 
cause  nipple  retraction  and  tumor  formation,  or  involve  the  axillary 
glands  (66  per  cent,  of  the  cases).  When  cold  abscesses,  fistula?,  or 
ulcers  form,  the  diagnosis  is  naturally  more  definite.  A  chronic  inter- 
stitial non-tuberculous  mastitis  was  described  by  Bedor. 

23 


354  THE  SPECIFIC  INFECTIONS 


VIII.  Tuberculosis  of  the  Upper  Respiratory  Tract. 

{A).  Nose.— The  nose  is  seldom  affected,  because  its  irritation 
excites  lachrymation,  sneezing,  and  increased  secretion,  which  is  inim- 
ical to  the  development  of  tubercle  bacilli.  Nasal  localization  was  first 
described  bj  Willigk  (1853).  In  the  rare  primary  form  there  are  very 
few  bacilli  and  there  is  an  exuberant  non-caseous  growth,  which  may 
somewhat  resemble  sarcoma;  the  absence  of  caseation  is  not  unique 
because  it  is  sometimes  seen  in  lymphadenopathies  and  in  the  Fal- 
lopian tubes;  there  is  little  pain  and  the  chief  symptom  is  a  chronic 
coryza.  In  the  secondary  form  the  bacilli  are  abundant;  multiple 
caseation  and  ulceration  occur  as  in  other  localizations;  suppressed 
coughing,  with  the  mouth  closed,  is  thought  to  force  germs  into  the 
nose.  Nasal  infection  may  occur  by  picking  the  nose,  and  is  promoted 
by  foreign  bodies,  wounds  and  ulcers,  and  by  stagnation  of  the  secre- 
tion by  various  obstructive  processes.  Infection  may  spread  by  the 
lymph  vessels,  especially  in  children,  to  the  cervical  glands  or  even 
to  the  meninges.    Lupus  (in  33  per  cent.)  affects  the  nose  (Bender). 

{B).  Nasopharynx. — Its  primary  involvement  is  infrequent.  Second- 
ary disease  usually  develops  late  in  phthisis  and  occurs  in  20  per  cent. ; 
it  is  promoted  by  coughing  with  the  lips  closed.  It  may  extend  by 
contiguity  from  the  pharynx.  The  third  tonsil  may  be  affected  (Ler- 
moyez);  adenoids  are  tuberculous  in  20  per  cent.  (Dieulafoy)  or  in 
27  per  cent.  (Moure  and  Brindel). 

(C).  Ear. — Tuberculous  otitis  media  occurs  chiefly  in  late  phthisis 
(according  to  Fraenkel  in  32  per  cent.);  otitis  may  occur  from  mixed 
infection.  It  is  promoted  by  measles  and  scarlatina,  is  rarely  primary, 
and  often  causes  cervical  lymphadenitis. 

(D).  Larynx. — Laryngeal  phthisis  is  very  rarely  primary,  though 
some  well  established  cases  are  recorded.  Louis,  in  1825,  held  that  it 
was  secondary  to  lung  disease  resulting  from  infection  by  sputum, 
which  view  still  holds;  hsematogenous  and  lymphogenous  infection 
is  rare.  Laryngeal  tuberculosis  develops  in  20  to  30  per  cent,  of  cases 
of  pulmonary  tuberculosis  in  adults;  it  develops  in  only  3  per  cent, 
of  pulmonary  phthisis  in  children  (Parrot).  It  complicates  9  per  cent, 
of  lupus  cases.  Promoting  factors  are  inflammation,  fissure,  and  syph- 
ilis. In  700  cases  Krieg  observed  unilateral  involvement  in  275  (39 
per  cent.),  of  which  92  per  cent,  occurred  on  the  same  side  as  the 
lung  lesion;  Kreig  attributed  this  to  lymphatic  extension;  Cornet 
refers  it  to  paresis  of  the  vocal  cord  on  the  affected  side,  (which  is  due 
to  compression  or  neuritis  of  the  recurrent  laryngeal  nerve),  and  to 
stagnation  of  the  sputum  in  various  recesses  on  the  paralyzed  and 
anaesthetic  side.  Unilateral  disease  usually  becomes  bilateral  from 
contact. 

Symptoms. — ^The  cough  varies  with  the  time  of  onset  of  laryngeal 
symptoms;  in  those  rare  and  unfavorable  cases  in  which  the  trouble 
begins  with  laryngeal  symptoms,  the  cough  is  often  somewhat  dry, 


TUBERCULOSIS  OF   THE   UPPER  RESPIRATORY  TRACT      355 

brassy,  or  metallic;  it  may  come  on  in  the  form  of  acute  laryngitis. 
In  cases  clearly  following  lung  disease,  the  ordinary  bronchitic  hack 
frequently  becomes  brassy;  in  the  last  stages  it  becomes  incomplete, 
ineffectual,  or  like  an  eructation  (Trousseau),  as  the  vocal  cords  can- 
not come  in  apposition.  Tickling  in  the  larynx  is  common.  Pain 
and  hoarseness  are  followed  by  dysphonia  (or,  later,  aphonia),  dyspnoea, 
and  the  most  painful  and  distressing  dysphagia. 

Forms. — (a)  The  most  common  form  is  the  ulcerative;  ulcers  are 
found  in  the  interarytenoid  region,  vocal  cords,  posterior  wall  of  the 
larynx,  arytenoids,  and  epiglottis;  they  are  not  deep  but  are  broad; 
their  edges  are  ragged  or  "nibbled,"  and,  on  their  rather  pale  and 
sometimes  caseous  bases,  papillary  excrescences  are  fairly  frequent. 
Particles  may  be  inhaled  into  the  lungs,  causing  tuberculous  or  sup- 
purative foci.  They  are  to  be  distinguished  from  syphilitic  ulcers  (q.  v.), 
which  are  more  often  single  and  are  redder,  have  more  "cut  out" 
edges,  frequently  show  cicatrization,  involve  oftener  the  parts  nearer 
the  pharynx  (epiglottis  and  posterior  surface  of  the  arytenoids),  and 
less  often  attack  the  vocal  cords;  show  no  tubercle  bacilli,  do  not 
show  local  reaction  on  tuberculin  injection  and  do  respond  to  mercury 
and  iodides.  Ninety  per  cent,  of  all  laryngeal  necrosis  is  tuberculous. 
Perichondritis  may  occasion  sudden  oedema  glottidis,  urgent  dyspnoe  b 
and  early  death  unless  timely  tracheotomy  is  performed,  (b)  In  other 
cases  the  submucous  tissues  are  infiltrated  and  the  mucosa  is  thick- 
ened or  sometimes  hardened  (pachydermous  form);  the  true  cords 
are  less  involved  than  other  parts;  stenosis  rarely  occurs,  and  if 
ulceration  develops  it  is  inconspicuous,  (c)  Caseous  tumors  are  not 
frequent;  they  may  precede  the  ulcerative  form  or  occur  independ- 
ently of  it.  (d)  The  vegetative  type  occurs  with  ulceration,  and  small 
excrescences  develop  on  the  floor  of  the  ulcers,  or  without  ulceration, 
in  which  case  they  appear  on  the  otherwise  intact  mucosa,  (e)  The 
miliary  form  is  of  no  essential  importance,  as  the  deposits  can  rarely 
be  seen  and  their  symptoms  are  obscured  by  the  pulmonary  or  cere- 
bral manifestations. 

Treatment. — Treatment  is  unsatisfactory,  as  pronounced  lung 
changes  already  exist  and  dysphagia  occasions  rapid  emaciation  and 
disinclination  to  eat.  Besides  general  measures  (v.i.),  local  measures 
may  be  employed,  but  as  a  rule  they  do  not  essentially  modify  the 
process.  Insufflations  of  boric  acid,  iodoform,  or  iodol,  and  painting 
with  10  per  cent,  menthol,  10  per  cent,  carbolic  acid  or  20  per  cent, 
lactic  acid  solution  (gradually  increased  in  strength  to  80  per  cent.), 
may  relieve  the  local  pain;  gr.  \  of  morphine  hypodermically  and  10 
per  cent,  solution  of  cocaine  locally,  allow  the  patient  to  eat,  for  a 
time  at  least,  but  finally  fail  to  anaesthetize  the  widespread  ulceration. 
The  patient  may  be  able  to  draw  up  milk  and  water  by  a  tube,  when 
the  head  is  turned  over  the  edge  of  the  bed.  Caustics,  such  as  silver 
nitrate,  do  more  harm  than  good. 


356  THE  SPECIFIC  INFECTIOXS 


IX.  Tuberculosis  of  the  Heart  and  Vessels. 

(a)  Pericardium:  (v.  Serous  Membranes).  (6)  Myocardium:  miliary 
tubercles  are  occasionally  seen;  tuberculous  fibrous  myocarditis  is 
quite  rare;  caseous  nodes  are  very  uncommon  and  occur  chiefly  in 
the  young;  Anders  in  1902  collected  but  72  cases,  (c)  Endocardium: 
Weichselbaum,  Birch-Hirschfeld,  Klebs,  Kotlar,  and  Chiari,  have 
found  tubercle  bacilli  in  cardiac  thrombi;  Heller,  Kundrat,  Tripier, 
Londe,  Petit,  and  Courmont,  found  them  in  endocarditic  vegetations; 
Hanot  holds  that  toxins  cause  the  excrescences  in  which  the  bacilli  are 
later  deposited;  Norris  found  endocarditis  in  only  1.4  per  cent,  of  over 
11,000  phthisical  necropsies;  tuberculous  endocarditis  is  almost 
always  vegetative  and  very  rarely  ulcerative  or  caseous;  secondary 
infection  is  the  cause  of  some  cases  of  endocarditis  which  complicate 
tuberculosis,  (d)  Involvement  of  the  vessels  has  been  described  under 
miliary  tuberculosis.  Primary  disease  of  the  vessels  seems  highly 
improbable,  though  some  few  cases  are  reported;  18  cases  of  tubercu- 
losis of  the  aorta  are  mentioned  in  the  literature  collected  by  Simmitsky. 

X.  Tuberculosis  of  the  Bones  and  Joints. 

This  topic  properly  belongs  to  surgery,  but  its  relations  to  glandular, 
pulmonary,  and  other  lesions  demand  some  consideration.  Koch  was 
the  first  to  demonstrate  the  almost  invariably  tuberculous  nature  of 
caries,  fungus  joint  lesions,  and  tumor  albus,  and  Damsch  first  deter- 
mined this  relation  by  inoculations.  Schuchart,  Krause,  Demme  and 
Renke  proved  that  spina  ventosa  was  usually  tuberculosis.  Konig  and 
Orth  found  that  about  SO  per  cent,  of  bone  and  joint  tuberculosis 
was  clearly  secondary  to  pulmonary,  glandular,  genito-urinary,  and 
other  tuberculosis.  Probably  all  cases  are  secondary  to  tuberculosis 
elsewhere.  Infection  is  hmmaiogenic  in  the  majority  of  cases,  far  less 
often  lymphogenic.  Trauma  has  long  been  considered  an  important 
etiological  factor,  and  experimentation  shows  that  it  may  determine 
localization  in  animals  already  infected  with  the  Bacillus  tuberculosis. 
This  factor  has  probably  been  overestimated,  and  Sprengel  even  main- 
tains that  the  joints  oftenest  involved  are  those  least  subject  to  trau- 
matism. Thirt}-three  per  cent,  of  the  cases  occur  in  the  first  decade 
of  life,  and  50  per  cent,  in  the  first  two  decades.  Tuberculosis  in 
children  involves  the  bones  and  joints  in  22  per  cent,  of  cases  (Miiller). 

Localization. — Watson  Cheyne,  from  his  own  and  other  cases,  esti- 
mates that  the  knee  is  affected  in  16.5  per  cent,  of  cases,  the  hip  in 
14.6  per  cent.,  tarsus  and  ankle  in  14.4  per  cent.,  elbow  in  6.3  per 
cent.,  skull  and  face  in  5.5  per  cent.,  sternum,  clavicle  and  ribs  in  5.2 
per  cent.,  pelvic  bones  in  3.5  per  cent.,  femur,  fibula  and  tibia  in  3.5 
per  cent.,  spine  in  2.3  per  cent.,  shoulder  in  1.5  per  cent.,  and  scapula, 
ulna  and  radius  in  1  per  cent.     Jaffe  finds  involvement  of  the  spine  in 


TUBERCULOSIS  OF   THE  BONES  AND  JOINTS  357 

20  per  cent.,  foot  in  21  per  cent.,  hip  in  13  per  cent.,  knee  in  10  per 
cent.,  hand  in  9  per  cent.,  and  elbow  in  4  per  cent. 

1.  Bones. — Miliary  tuberculosis  affecting  the  bones  produces  no 
symptoms.  The  spongy  ends  (epiphyses)  of  the  long  bones  are  the 
particular  seat  of  tuberculous  osteomyelitis  and  periostitis,  whence 
infection  easily  reaches  the  joints;  the  diaphyses  and  flat  bones  are 
seldom  involved.  Involvement  of  the  short  bones  of  the  fingers  and 
toes,  and  less  often  of  the  ulna,  may  cause  bulging, — the  spina  ventosa, 
which  is  seen  oftenest  at  about  five  years  of  age.  In  the  bone-marrow 
there  develops  a  grayish-red  granuloma  which  dissolves  the  bone 
(caries  sicca);  the  trabeculse  necrose  and  are  discharged  through  fistulse 
as  sequesters  or  "bone  sand,"  in  a  caseous,  pus-like  fluid.  Even  large 
foci  may  heal  by  granulating  osteitis,  in  the  same  manner  as  tubercu- 
lous adenitis  may  heal.  Infection  may  remain  unobserved  or  semi- 
quiescent  until  aroused  by  such  infections  as  pertussis  or  measles,  or 
by  trauma.  Cold  abscesses  in  the  bone  are  lined  by  granulation  tissue. 
There  may  be  nocturnal  pain,  varying  in  intensity  and  sometimes 
radiating,  stiffness,  local  tenderness,  and  fever.  Bone  lesions  are  not 
incompatible  with  seemingly  perfect  nutrition  and  otherwise  robust 
health. 

2.  Joints. — Involvement  may  occur  alone  or  follow  contiguous 
osseous  disease.  Very  often  there  is  synovial  inflammation  and  pro- 
liferation; far  less  frequently  there  are  isolated  tubercles  in  a  non- 
inflamed  synovial  sac.  Serous  or  serofibrinous  synovitis  (or  the  rice 
bodies,  corpora  oryzoidea)  may  result  from  toxins  in  a  neighboring 
focus  in  the  bone,  without  the  actual  presence  of  tubercle  bacilli  in 
the  joint,  exactly  as  toxic  pleurisy  or  pericarditis  may  result  from 
contiguous  pulmonary  or  glandular  foci.  The  symptoms,  or  onset,  may 
be  acute  or  insidious.  Pain,  especially  at  night,  contractures,  and  fever, 
may  be  noted.  In  the  later  stages  of  joint  disease,  granulation  tissue 
forms  with  large  caseous  deposits,  hydrops,  empyema  articulorum,  or 
the  tumor  albus  (so  named  because  of  the  thickening  of  the  connective 
tissue,  and  the  oedema  and  glistening  appearance  of  the  soft,  peri- 
articular structures).  The  joint  is  sometimes  quite  disorganized. 
Seventy-five  per  cent,  recover  under  such  conservative  treatment  as 
immobilization,  iodoform  or  formalin  injections,  soap  inunctions, 
cod-liver  oil,  and  sea  air. 

Within  a  few  years  Poncet  first,  and  then  Leriche,  Patel,  Trebeneau, 
Bezancon,  and  Griffon,  have  called  attention  to  a  tuberculous  pseudo- 
rheumatism,  in  which  the  incipient  arthritis  closely  resembles  genuine 
rheumatism  (rheumatisme  tuberculeuse  ankylosante) .  It  is  thought 
by  these  French  writers  that  the  exuded  leukocytes  are  strictly  of  the 
lymphocyte  type;  inoculations  have  proven  positive  in  a  number  of 
cases,  but  toxaemia  is  the  most  probable  cause  (Mohr).  It  is  most  fre- 
quent in  children.  Lejars  found  one  case  of  primary  tuberculosis  of 
the  muscles. 


358  THE  SPECIFIC  INFECTIONS 


XI.  Tuberculosis  of  the  Skin. 

1.  Lupus. — Lupus  is  the  most  frequent  form.  In  66  per  cent,  of 
the  cases  it  is  located  on  the  nose,  lips,  and  angle  of  the  eye.  It  is  often 
associated  with  tuberculosis  elsewhere ;  Besnier  found  it  with  pulmon- 
ary tuberculosis  in  21  per  cent,  and  Leloir  in  38  per  cent. ;  Sachs  and 
Bender  found  other  tuberculosis  in  62  per  cent,  and  Block  in  79  per 
cent.  It  is  typical  granulation  tissue  with  true  tuberculous  tumors, 
which  contain  few  bacilli  because  of  the  low  temperature  of  the  skin, 
and  it  often  advances  on  one  border  while  it  cicatrizes  on  another; 
Its  various  forms,  such  as  lupus  maculosus,  exulcerans,  or  hyper- 
trophicans,  need  not  be  described  in  detail. 

2.  Scrofuloderma. — Scrofuloderma,  the  subcutaneous  granuloma  of 
Neisser,  appears  as  movable,  painless,  subcutaneous  nodes,  which  later 
become  cold  abscesses  (the  so-called  scrofulous  gumma,  gomme 
scrofuleuse  of  Despres  and  Besnier);  they  discharge  a  milky  fluid 
and  leave  a  granulating  ulcer,  which  is  more  sharply  marked  than 
that  of  lupus. 

3.  Lichen  Scrofulosorum. — Lichen  scrofulosorum  is  often  but  not 
always  tuberculous;  the  eruption  originates  from  the  follicles,  is  con- 
stituted of  thick,  oily,  epidermal  cells  which  can  be  scratched  off 
without  causing  bleeding,  and  is  usually  distributed  in  sharply  marked 
groups  of  isolated  yellow  or  yellow-brown  nodules  as  large  as  a  pin- 
head. 

4.  Tuberculosis  Cutis  Verrucosa. — Tuberculosis  cutis  verrucosa  of 
Riehl  and  Pautauf  is  observed  on  the  backs  of  the  hands  and  fingers 
and  in  the  interdigital  folds,  chiefly  in  butchers,  cooks,  and  horse- 
men. 

5.  Postmortem  Tubercles. — Postmortem  tubercles  were  described 
by  Verneuil,  Verchere,  Pick,  and  Pfeiffer.  Laennec  referred  his  case 
of  pulmonary  phthisis,  though  probably  incorrectly,  to  a  postmortem 
tubercle.  Gerber  suffered  from  tuberculosis  of  the  axillary  glands 
following  a  tubercle.  They  are  observed  in  butchers,  veterinary  sur- 
geons, and  pathologists,  especially  in  those  beyond  middle  life. 

6.  Tuberculous  Ulcers. — Tuberculous  ulcers  may  develop  from  cuts 
by  broken  sputum  cups;  from  bites  of  tuberculous  subjects,  ants,  or 
flies;  from  burns,  tattooing,  skin  grafting,  or  leeches;  and  from  cir- 
cumcision when  the  wound  is  sucked  by  tuberculous  rabbis;  lupus 
has  followed  vaccination. 

Scrofula  is  tuberculosis;  however,  in  descriptions  dealing  with 
scrofula  as  a  separate  clinical  picture,  affections  of  the  mucous  mem- 
branes are  often  associated  with  the  skin  lesions  above  described, 
with  adenopathies  (q.v.),  and  with  bone  or  joint  disease.  Among 
these  may  be  mentioned  chronic  ozsena,  rhinitis,  adenoids,  friable 
carious  teeth,  otitis  media,  blepharitis,  conjunctivitis  or  keratitis,  par- 
ticularly of  the  phlyctsenular  type,  tracheobronchitis,  intestinal  catarrh, 
and  leukorrhoea. 


TREATMENT  OF   TUBERCULOSIS  359 


Treatment  of  Tuberculosis. 

(A).  Prophylaxis. — 1.  Antibaclllary. — Antibacillary  prevention  con- 
cerns the  etiological  factors  in  the  dissemination  of  the  bacillus 
and  of  the  elements  of  contagion.  Cleanliness  of  the  skin;  disinfection 
of  contaminated  faeces,  urine,  or  pus;  confiscation  of  diseased  meat; 
and  regulation  of  dairies  and  inspection  of  cows  are  important;  but 
the  destruction  of  infective  sputum  is  the  prime  indication.  It  is  well 
to  regard  all  sputum  as  dangerous,  and  to  teach  the  public  and  patients 
this  doctrine.  Tuberculous,  as  well  as  pneumonic,  grippal,  and  other 
sputa  must  be  destroyed.  An  appeal  must  be  made  to  the  conscience 
or  selfishness  of  tuberculous  patients,  setting  forth  the  risks  of  auto- 
reinfection.  Patients  should  carry  small  spit  cups,  of  which  many 
varieties  are  made,  and  the  sputum  should  be  destroyed  by  burning  or 
boiling  before  it  dries.  Spittoons,  unsesthetic  as  they  are,  should  be 
placed  conveniently  in  the  halls  and  wards  of  hospitals,  sanitoria, 
factories,  cars,  and  stations,  either  on  the  floor,  or,  better,  somewhat 
elevated  on  brackets.  The  patient  should  sleep  alone,  and  kissing  must 
be  interdicted.  The  bedclothes,  linen,  and  eating  utensils,  should  be 
carefully  steamed  or  boiled.  Rooms  should  be  cleaned  with  moist  cloths 
and  should  be  swept  with  the  windows  and  doors  open.  The  danger 
of  swallowing  sputum  must  be  clearly  set  forth,  and  the  mouth  should 
be  washed  out  with  some  antiseptic  solution  before  eating,  though  a 
few  bacilli  with  the  food  are  not  very  dangerous,  as  the  gastric  juice 
probably  destroys  them.  The  more  minute  details  are  as  impossible 
to  describe  as  those  of  consistent  surgical  asepsis,  though  they  are 
equally  logical  and  necessary.  In  Germany  the  reduction  of  mortality 
by  33  per  cent,  is  clearly  due  to  an  awakened  public  intelligence. 

2.  Governmental. — Governmental  prophylaxis, somewhat  less  promis- 
ing in  republican  than  in  autocratic  states,  is  important.  It  comprises : 
education  of  the  public  by  publication  of  the  dangers  and  preventive 
measures  in  tuberculosis,  as  in  the  recent  excellent  and  plain  pamphlets 
of  the  Illinois  State  Board;  the  establishment  of  sanitoria  for  the  poor, 
among  whom  the  mortality  is  four  times,  and  the  morbidity  many 
times,  greater  than  in  the  rich;  the  building  of  separate  hospitals,  or 
at  least  wards,  for  the  hopelessly  diseased;  and  the  regulation  of  the 
air  capacity  of  dwelling  rooms  in  tenements,  factories,  or  stores. 
Aside  from  great  suffering  and  sorrow  of  thousands  in  every  large 
community,  there  is  an  enormous  economical  waste  in  work  and 
wages,  an  enormous  cost  in  hospital  care,  and  a  great  loss  in  live 
stock, — over  62,000  cattle  and  56,000  hogs  were  condemned  in 
Prussia  alone  in  one  year.  The  comparative  sociological  damage  is 
apparent,  as  the  ravages  of  tuberculosis  involve  the  working  years  of 
life  (15  to  60),  while  94  per  cent,  of  the  deaths  from  diphtheria  occur 
under  ten  years. 

3.  Individual. — Individual  prophylaxis  includes  the  increasing  of 
physiological  resistance,  the  maintenance  of  general  health,  and  the 


360  THE  SPECIFIC  IXFECTIOXS 

aiding  of  sound  development  in  children.  "Weakly  children  should  be 
brought  up  in  the  open  air,  judiciously  fed,  watched  during  acute  infec- 
tions, kept  but  few  hours  in  school,  sent  into  the  country  during  vaca- 
tion, taught  moderation,  and,  later,  should  be  informed  as  to  the 
danger  of  alcoholism,  sexual  excesses,  and  infections. 

(B).  Hygienic  Treatment. — The  three  great  factors  are  fresh  air, 
proper  food,  and  rest.  Bodington  (1839),  in  England,  treated  cases  by 
fresh  air,  but  to  Brehmer  (1850),  in  Germany,  is  due  the  credit  of 
soundly  establishing  the  fresh-air  treatment  and  the  curability  of 
phthisis.  A  few  of  his  views  are  untenable,  but  many  of  them  are  the 
basis  of  the  modern  methods  practised  by  McCormack,  Driver,  Det- 
weiler,  Trudeau,  Knopf,  and  others.  Patients  are  treated  in  sanitoria, 
and  those  at  Nordrach,  and  Saranac,  and  many  others,  have  given  such 
excellent  results  that  institutions  of  this  class  have  increased;  they 
number  54  in  Germany,  30  in  France,  and  are  gro^^dng  in  number  in 
other  countries.  Results  depend  on  (a)  the  extent  of  the  disease;  (b) 
the  condition  of  organs  other  than  the  lungs,  as  the  pleura,  intestines, 
larvnx,  and  heart;  (c)  the  social  and  financial  status  of  the  case. 
Detweiler  states  that  30  per  cent,  of  his  cases  recovered  and  40  per 
cent,  improved;  Trudeau  brought  about  recovery  in  31  per  cent,  of 
all,  and  in  66  per  cent,  of  incipient,  cases;  Turban  considers  that  88 
per  cent,  recover;  Rumpf  followed  97  per  cent,  of  his  cases:  70  per 
cent,  of  incipient  cases  were  able  to  work — "the  best  test  of  a  cure"; 
55  per  cent,  of  those  in  the  second  stage,  and  23  per  cent,  of  those  in 
the  third,  recovered.  One  of  the  chief  values  of  sanitorium  treatment 
is  that  the  patient  learns  the  lesson  of  living  properly,  which  too  often 
in  general  practice  is  not  sufficiently  impressed  upon  him. 

1.  Fresh  Air. — This  is  the  chief  hygienic  factor  in  treatment,  at 
home,  in  sanitoria,  or  in  change  of  climate,  (a)  Treatment  at  home, 
for  financial  reasons,  is  especially  important,  as  but  5  or  10  per  cent, 
of  tuberculous  people  are  able  to  leave  home.  The  patient  should  be 
carefully  clothed  and  should  recline  in  the  sun  with  the  windows  of 
his  room  open,  or  should  lie  on  a  veranda.  He  should  be  outdoors 
for  one-quarter  to  one-half  the  sunny  hours,  according  to  the  season 
of  vear.  At  night  the  windows  should  be  kept  widely  open.  Rain, 
snow,  dampness,  and  extreme  cold,  are  no  contra-indications,  nor  are 
fever,  cough,  or  haemoptysis;  but  wind,  dust,  and  sudden  variations  in 
temperature,  are  to  be  avoided.  Very  thick  clothing,  which  is  so  fre- 
quently observed  among  the  poor,  is  unhygienic.  Acute  caseous  and 
advanced  types  should  generally  be  kept  at  home.  (6)  Sanitorium 
treatment  offers  the  advantage  of  strict  discipline,  systematic  li^-ing, 
and  the  constant  presence  of  a  physician  who  regulates  the  details  of 
every-day  life,  gives  explicit  directions,  and  cheers  the  patient.  Sani- 
toria should  be  located  near,  but  well  outside  of,  every  large  centre  of 
population,  (c)  Change  of  climate  was  once  considered  absolutely 
indispensible;  now  it  is  said  "to  be  not  without  influence."  No 
climate  is  specific.  High  altitudes  offer  the  advantage  of  purer  air, 
stimulation  of  breathing,  increase  of  vital  lung  capacity,  increase  of 


TREATMENT  OF   TUBERCULOSIS  361 

the  chest  dimensions,  growth  of  the  muscles  of  inspiration,  increase 
of  metabohsm,  and  stimulation  of  the  appetite  and  blood-making  or- 
gans. Colorado,  Arizona,  and  New  Mexico  (four  to  seven  thousand 
feet  elevation),  are  excellent  for  cure  and  for  opportunities  for  entering 
some  permanent  occupation  after  recovery;  because  of  the  emphy- 
sema which  may  be  induced,  a  return  to  the  sea  level  should  be  avoided. 
St.  Moritz,  Les  Avants,  and  Davos  (5,200  feet  elevation)  offer  a  dry, 
clear,  cold,  still  atmosphere,  where  patients  may  reside  in  summer 
and  winter;  it  resembles  the  climate  of  Colorado,  Montana  and  north- 
ern Wyoming.  There  are  also  the  Peruvian  Andes  and  numerous  other 
altitudes,  for  details  of  which  see  Solly's  Medical  Climatology.  High 
altitudes  are  best  adapted  to  suspected  cases,  to  those  with  limited  or 
incipient  lesions,  to  those  with  slight  cavity  formation  and  little  emacia- 
tion, or  to  more  advanced  but  slowly  progressing,  or  torpid,  cases. 
Slight  fever  or  slight  heemoptysis  are  not  contra-indications  to  such 
climates.  Moderate  altitudes  (2,000  to  2,500  feet)  probably  best  serve 
the  majority  of  cases,  as  Asheville  (2,250  feet),  the  Adirondacks  (2,000 
feet),  Aikin  (2,250  feet),  Summerville,  Thomasville,  etc.  The  climate 
of  Minnesota,  Nebraska  and  Dakota  (1,000  feet  elevation),  is  cool 
and  dry;  dryness  is  usually  more  desired  than  lack  of  variability. 
Moderate  elevations  do  not  induce  emphysema,  whence  return  to  the 
sea  level  is  easier.  The  sea  level  is  the  best  location  for  the  tuber- 
culous aged,  for  quiescent  cases  with  great  cicatrization  or  extensive 
damage,  for  those  with  diabetes,  albuminuria,  nephritis,  scrofula,  bone 
disease,  marked  anaemia,  repeated  haemoptysis,  emphysema,  or  rapid 
softening,  for  those  with  incurable  forms,  for  thin,  nervous  subjects, 
and  for  those  with  exophthalmic  goitre.  Sea  voyages  are  always 
somewhat  experimental,  and  Robin  holds  that  but  8  per  cent,  of  cases 
are  benefited  by  them;  those  with  incipient  forms,  or  those  with 
genito-urinary,  glandular,  or  osseous  disease,  or  with  open  wounds, 
are  often  helped.  Moist  warm  climates  (at  the  sea  level)  are  especially 
adapted  to  laryngeal  disease,— as  the  Bermudas,  Florida,  the  Madeira 
or  Canary  Islands;  patients  with  dyspepsia  and  diarrhoea  do  well 
in  Corsica,  Palermo,  and  Capri.  Warm,  dry  climates,  as  southern 
California,  Egypt,  Algiers,  or  the  Riviera,  are  good  for  catarrhal  types. 
Climate  alone,  without  proper  rest,  diet,  and  reasonable  hygiene, 
rarely  benefits. 

2.  Nutrition. — Practice  differs;  most  physicians  recommend  5  or  6 
meals  daily,  but  some  get  better  results  by  giving  but  three  meals, 
whereby  the  stomach  is  allowed  some  rest.  Feeding  varies  with 
individuals  as  to  the  amount  and  as  to  the  kind  of  food.  A  liberal 
mixed  diet  of  meat,  fatty  meats,  and  fish,  should  be  given;  well- 
cooked  leguminous  vegetables  (which  are  advantageously  given  in 
soups),  butter,  oil  on  salads,  eggs,  milk,  cream,  bread,  pastries,  and 
cakes,  are  the  chief  articles  of  diet.  Anorexia  is  a  common  obstacle 
to  full  feeding.  If  it  is  of  the  nervous  type,  patients  must  be  compelled 
to  eat,  but  long  hours  in  the  fresh  air  usually  stimulate  the  appetite. 
With  habitually  light  eaters  caution  is  necessary;  beef  juice,  milk  and 


362  THE  SPECIFIC  INFECTIONS 

koumyss,  should  be  given ;  the  amount  should  be  gradually  increased 
and  other  foods  should  be  added.  Faradization  of  the  epigastrium, 
cold  compresses  over  the  stomach,  wine,  vermouth,  the  fluid  extract 
of  condurango  tt^  xv-xxx  (Immermann),  or  strychnia  gr.  ^o  in  solution, 
half  an  hour  before  meals,  are  valuable  appetizers.  Raw  beef  (zomo- 
therapy),  which  is  especially  recommended  by  Richet  and  Hericourt, 
has  lately  come  into  use;  fresh  lean  meat  is  cut,  soaked  for  two  hours 
in  one-fifth  its  w^eight  of  water,  is  then  pressed  to  extract  the  blood 
and  fluid,  and  administered,  1  to  2  pounds  for  moderately  sick  cases 
to  twice  that  amount  for  severe  cases;  it  must  be  freshly  prepared 
each  time,  as  it  soon  becomes  tainted.  Raw  eggs  are  often  given 
between  meals,  beginning  with  1  and  increasing  to  4,  three  times  daily. 
Fever  does  not  contra-indicate  full-  or  overfeeding.  Milk  should  be 
given,  up  to  1  or  H  quarts  daily;  more  than  this  amount  promotes 
gastric  atony;  it  is  given  to  advantage  with  bread,  crackers,  or  toast,  in 
order  to  di\dde  the  curds  which  form;  it  may  be  peptonized,  disguised 
with  cocoa  or  cognac,  or  given  by  the  rectum  {v.  Gastric  Ulcer); 
cream  and  butter  are  excellent  substitutes  for  cod-liver  oil,  and  butter- 
milk is  indicated  when  the  stomach  is  weak.  Fats  and  carbohydrates 
are  necessary  to  offset  nitrogenous  waste;  the  dark  form  of  cod-liver 
oil  (u.  i.),  lipanin  (94  parts  olive  oil  and  6  parts  oleic  acid),  malt, 
honey,  cocoa,  nutrose,  eucasin,  and  somatose,  are  valuable  foods.  In 
all  forms  of  overfeeding  (Debove's  suralimentation)  the  tolerance  of 
the  stomach  must  be  considered,  for  this  is  more  important  than  the 
use  of  drugs  (creosote,  cough  syrups,  or  cod-liver  oil).  Debove's 
method  consists  of  gastric  lavage  followed  by  the  introduction  through 
the  tube  of  3  ounces  of  powdered  meat,  a  quart  of  milk,  and  one  or 
more  eggs.  Alcohol  is  at  the  present  time  administered  less  often 
and  in  smaller  amounts  than  formerly,  but  is  frequently  indicated 
symptomatically  (v.i.);  small  amounts  of  red  wine  or  cognac  and 
whiskey  in  egg-nogs  are  very  valuable  as  a  food  and  tonic.  Tobacco 
should  be  interdicted;  in  special  cases  a  cigar  or  two  daily  may  be 
allowed,  but  the  smoke  must  never  be  inhaled. 

3.  Rest. — Rest  is  one  of  the  essentials  of  Detweiler's  therapy. 
Exercise  destroys  tissue,  often  induces  anaemia,  and  irritates  the  heart; 
it  is  distinctly  contra-indicated  by  fever,  emaciation,  haemoptysis, 
rapid  pulse,  nausea,  and  coughing.  It  has  been  well  said  that  "too 
many  cases  of  phthisis  walk  into  their  graves."  Late  in  the  treatment 
graduated  exercise  may  be  taken.  Pulmonary  gymnastics  and  pneu- 
matic differentiation,  as  that  by  compressed  air,  are  clearly  injurious. 
Patients  should  lie  in  the  bright  sunshine  and  fresh  air,  and  active 
mental  occupation  should  be  carefully  avoided.  Hardening  and  exer- 
cise should  be  obtained  by  quick,  dry  rubs  with  a  large  coarse  towel, 
after  which  rapid  partial,  and  then  general,  wet  rubs  may  be  instituted; 
cold  rubs  and  hydrotherapy  are  to  be  shunned  when  there  is  any 
tendency  to  haemoptysis. 

(C) .  Specifics. — As  yet  there  are  no  specifics  for  tuberculosis.  Drugs 
are  only  of  symptomatic  value.     Parenchymatous  injections  into  the 


TREATMENT  OF   TUBERCULOSIS  363 

lungs,  of  carbolic  acid,  creosote,  iodine,  and  iodoform,  have  been  sug- 
gested by  the  surgical  results  attained  in  lesions  of  the  bones  and 
joints;  but  .they  are  not  without  danger.  Koch's  original  tuberculin, 
his  later  tuberculin  TR,  Maragliano's  serum,  and  Behring's  efforts 
to  immunize  cattle,  have  given  no  certain  results. 

(D).  Expectant  or  Symptomatic  Treatment. — 1.  Fever. — Rest, 
quiet,  digestible  food,  and  fresh  air,  or  change  of  climate,  are 
indicated  in  great  preference  to  drugs.  Brehmer  administered  strong 
wine  at  the  time  the  fever  began  to  rise;  arsenic  is  recommended  by 
Pollack  and  Powell,  but  no  remedy  in  safe  or  harmless  doses  con- 
trols fever.  Quinine  disturbs  the  digestion.  Sponging  is  fairly 
efficacious. 

2.  Cough. — A  slight  cough  serves  to  remove  secretion,  but,  if  exces- 
sive, it  begets  coughing  by  congesting  the  lungs  and  tubes ;  the  dangers 
of  excessive  coughing  are  exhaustion,  depression,  insomnia,  aspiration, 
and  vomiting,  which  necessitate  interference.  Fresh  air,  and  avoid- 
ance of  dirt,  dust,  and  smoke,  are  most  beneficial.  Rest  in  general, 
and  especially  after  eating,  should  be  enforced.  The  cough  should  be 
suppressed,  for  it  is  certainly  somewhat  under  the  control  of  the  will; 
the  comment  on  the  absence  of  coughing,  especially  at  the  table,  is 
universal  among  observers  of  sanitorium  methods;  slow  breathing, 
with  the  head  slightly  thrown  back,  moist  compresses,  or  the  sipping 
of  warm  water  (with  10  grains  of  salt),  often  aid  in  its  suppression. 
Creosote  was  discovered  by  Richenbach,  in  1832,  and  was  used  by 
Addison,  Sonnenberg,  and  Jaccoud;  it  is  not  specific,  but  often  in- 
creases the  appetite,  modifies  abundant  secretion  from  the  bronchi 
(by  which  the  drug  is  in  part  eliminated),  and  relieves  the  cough. 
Administration  in  the  fluid  form  is  better  than  in  capsules,  which  are 
often  undigested.  Beginning  with  one  drop  (well  diluted)  after  meals, 
the  dose  may  be  increased  to  ten  times  that  amount;  but  full  dosage 
often  irritates  the  stomach  and  kidneys  and  necessitates  constant 
supervision  of  the  urine;  it  should  not  be  given  in  febrile  cases  nor  in 
haemoptysis. 

Creosote  may  be  administered  in  milk,  in  water  with  the  compound 
tincture  of  gentian  (Biij),  or  in  sherry  wine. 

Creasoti 5iss. 

Glycerini ' oss. 

Tr.  gentiange  co q.s.  ad  §iv. 

M.  et  S. — One  teaspoonful  after  meals. 

Creosote  may  be  given  in  pill  form  as  follows : 

Creasoti 3iss. 

Mucilag.  acacise 3iij. 

Pulv.  althsese q.s. 

M.  et  ft.  pil.  no.  100. 
S.— One  after  meals. 

Guaiacol  carbonate  (gr.  v,  p.  c.)  is  often  better  tolerated  by  the 
stomach  than  creosote.     Cod-liver  oil,  first  used  by  Hughes-Bennett, 


364  THE  SPECIFIC  IXFECriOXS 

is  usually  given  in  doses  so  large  as  to  disturb  gastric  and  intestinal 
digestion;  the  first  dose  should  be  10  drops  and  the  amount  should  be 
gradually  increased.  It  is  more  valuable  in  tuberculosis  of  the  glands 
and  bones  than  in  the  other  types.  Eructations  can  be  avoided  by 
administering  it  one  or  two  hours  after  meals,  when  the  food  begins 
to  leave  the  stomach.  The  oil  is  readily  absorbed,  because  of  the  bile 
which  it  contains,  and  is  possibly  somewhat  alterative;  but  it  is  not 
very  superior  to  butter  or  cream,  and  is  really  more  a  food  than  a 
medicine.  Cod-liver  oil  may  be  floated  on  whiskey  or  milk,  and 
gulped  down.  Its  taste  may  be  partly  disguised  by  a  "chaser"  of 
whiskey,  or  by  floating  it  in  beer  or  porter.  Syrup  of  orange  disguises 
its  taste  fairly  well.  It  is  seldom  given  when  there  is  fever  or  indigestion. 
It  is  prepared  in  large  capsules,  which  obviate  its  unpleasant  taste. 
Opiates  may  be  used,  such  as  paregoric;  codeine  gr.  ^  with  aq.  lauro- 
cerasi  and  glycerine  aa  tijxv  and  syr.  tolutani  3j  q-i.  d.;  dionin  gr.  -j 
q.i.d.;  heroin  gr.  2'^o  q.i.d. ;  even  morphine  sulph.  gr.  ^  with  ac. 
hydrocyanic!  dil.  Tijii.  Other  remedies  are  myrtol  gr.  ii,  a.m.  and  p.m.  ; 
terpin .  hydrate  gr.  ii  to  v,  t.i.d.;  ol.  terebinthinse,  n^ij  and  for  un- 
productive coughs,  spts.  chloroformi  or  spts.  setheris  co.  3ss  in  whiskey, 
p.  r.  n.    (Various  formulee  are  given  under  Bronchitis.) 

Tr.  belladonnse oss. 

Spr.  chloroformi       oiss. 

Mucilag.  acaciae oj- 

Aquae q.s.  ad  oiij- 

M.  et  S. — -One  teaspoonful  after  meals,  or  as  indicated. 

Expectorants  are  to  be  avoided  because  of  their  nauseating  tenden- 
cies. Tr.  benzoin  co.,  and  creosote,  may  be  vaporized.  Menthol  and 
guaiacol  aa  may  be  taken  internally  in  olive  oil.  If  the  cough  is  naso- 
pharyngeal, the  mucosa  should  be  painted  with  iodine,  potas.  iodide, 
and  glycerine,  in  proportions  of  1,  10,  and  100;  if  laryngeal,  20  per 
cent,  menthol  should  be  applied  locally  (u.  Laryngeal  Tubercu- 
losis); if  due  to  enlarged  bronchial  glands,  inunctions  of  green  soap 
and  potas.  iodide  internally,  should  be  given. 

3.  Sweats. — The  room  should  be  cool  at  night,  the  windows  open, 
the  bed  not  too  heavily  covered,  and  the  body  protected  by  a  flannel 
night-gown.  A  glass  of  cold  milk,  with  5ij  of  cognac,  given  at  bed- 
time, is  often  beneficial.  Morphine  on  retiring  is  indicated  when  the 
sweats  are  associated  with  cough  and  insufficient  oxygenation.  Atro- 
pine gr.  Too  to  8^0,  and  camphoric  acid  gr.  xv  to  xxx,  at  bedtime  are 
the  most  reliable  remedies,  and  are  superior  to  aromatic  sulphuric  acid 
TT^x  to  XX,  agaricin  gr.  tV  to  A,  tr.  nucis  vomicae  npxxx,  picrotoxin 
gr.  60  and  muscarin  r\^v  of  a  1  per  cent,  solution. 

Quininae  sulph oss. 

Calcii  hypophosphitis oj. 

Extr.  nucis  vomicae gr.  v. 

M.  et  ft.  pilulae  20. 
S. — One  after  meals. 


TREATMENT  OF  TUBERCULOSIS  365 

4.  Haemoptysis. — Exertion,  loud  talking  or  singing,  and  excesses  in 
alcohol,  venery,  coffee,  or  tobacco,  must  be  shunned  in  all  cases.  It 
is  well  to  warn  patients  of  the  possibility  of  haemoptysis,  in  order  to  pre- 
vent undue  excitement,  if  it  appears.  Effusive  pleurisy  should  not  be 
tapped  in  a  subject  who  has  recently  bled  from  the  lungs,  as  thoracocen- 
tesis has  produced  fatal  haemoptysis.  The  chief  indication  is  absolute 
rest,  physical  and  mental;  the  patient  should  be  kept  in  the  semire- 
cumbent  posture;  silence  on  his  part  should  be  enforced;  massage 
and  stimulants  are  contra-indicated;  no  physical  examination  should 
be  made  except  by  auscultation,  as  percussion  is  obviously  dangerous; 
and  a  hypodermic  injection  of  morphine  should  be  given  to  lessen 
cough,  to  quiet  the  heart,  to  allay  the  excitement  attending  most  hemor- 
rhages, and  also  possibly  for  its  slight  hsemostatic  effect.  As  the  tonus 
of  the  pulmonary  vessels  is  beyond  regulation,  ergotin,  tannic  acid, 
and  other  haemostatics,  are  useless,  though  digitalis  and  fresh  supra- 
renal extract  gr.  ii  to  v  sometimes  seem  efficacious.  Salt  5  j  is  a  popular 
remedy  and  is  supposed  to  act  by  stimulating  the  vagus.  An  ice-bag 
should  be  placed  over  the  heart  and  one  over  the  lung,  if  rales  are 
heard.  Deep  breathing  seems  to  lessen  bleeding.  Ol.  terebinthinse 
vjiij  to  iij  is  considered  the  best  drug  by  Fraentzel.  In  severe  or  ob- 
stinately recurrent  hemorrhage,  bandaging  of  the  extremities  (Hip- 
pocrates), to  lessen  the  return  flow  of  blood,  injections  of  gelatin, 
induction  of  pneumothorax  by  gas  injection  or  puncture  (Murphy, 
Cayley),  or  even  emetics  to  stimulate  the  vagus  (Fraenkel)  may 
possibly  be  indicated.  Rest  and  the  administration  of  morphine, 
however,  are  usually  effective. 

5.  Pain. — Pain  may  be  pleuritic,  and  should  be  treated  by  adhesive 
straps  or  by  painting  with  iodine;  if  muscular,  it  should  be  treated 
by  codeine  to  relieve  coughing,  by  liniments,  massage,  fomentations 
or  phenacetin. 

6.  Dyspnoea. — This  is  not  common.  If  due  to  stagnant  secretion, 
moderate  movement  or  change  of  posture  aids  in  its  evacuation;  if 
asthmatic,  iodide  gr.  iij  after  meals  is  indicated  but  it  must  be 
given  with  care  lest  it  congest  the  lungs;  if  dyspnoea  results  from 
compression  of  the  vagus  by  bronchial  glands,  iodide  and  green- 
soap  inunctions  should  be  given ;  if  cardiac,  alcohol  or  strychnia  is  indi- 
cated ;  if  caused  by  pleuritis  or  pneumothorax,  these  affections  should 
be  treated. 

7.  Cardiac  Weakness. — To  relieve  cardiac  weakness,  rest,  an  ice- 
bag  over  the  precordia,  cognac,  champagne,  camphor,  or  strychnia,  are 
superior  to  digitalis  or  strophanthus. 

8.  Insomnia. — To  relieve  insomnia  the  patient  should  have  sun- 
light, and  also  fresh  air  night  and  day;  a  light,  early  evening  meal, 
a  glass  of  beer,  porter,  or  some  whiskey  on  retiring,  the  bromides, 
codeine,  morphine,  and  galvanization  of  the  neck  and  head,  are 
beneficial. 

9.  Gastro-intestinal  Symptoms. — Nervous  anorexia  is  relieved  by 
fresh  air,  forced  feeding,  electricity,  and  guaiacol   (v.s.).     Dyspeptic 


366  THE  SPECIFIC  INFECTIONS 

symptoms  necessitate  a  scant  diet  for  a  few  days,  feeding  by  rec- 
tum, and  poulticing  of  the  epigastrium.  In  gastric  atony,  frequent 
meals  of  small  volume,  limitation  of  fluids,  and  strychnia,  are  indicated. 
For  gas  formation  or  pain  the  following  are  indicated :  carbolic  acid 
gr.  j;  resorcin  gr.  iij;  fluidextract  of  gelsemium  rijij;  bismuth;  extr. 
belladonna  or  spts.  chloroformi  ttj^xx.  Pyrosis  may  be  corrected  by  sod. 
bicarb,  and  magnesia  usta  aa  gr.  xv  to  xxx.  Hyperacidity  should  be 
treated  by  milk  diet,  belladonna  and  Carlsbad  water  or  other  alkalies ; 
anacidity  is  relieved  by  easily  digested  foods,  as  somatose  or  eucasin; 
and  subacidity  by  hydrochloric  acid.  Vomiting  is  caused  by  irritation 
of  the  pharynx  (Lugol's  solution  locally,  or  gargles  [1  to  10]  of  pot. 
bromide),  the  cough,  overfeeding,  or  overmedication ;  small  doses  of 
carbolic  acid  (v.  Typhoid)  are  most  successful.  Constipation  (q.v.) 
is  treated  by  the  usual  measures.  Diarrhoea  may  be  dyspeptic,  catar- 
rhal, toxsemic,  ulcerative,  or  amyloid;  the  following  is  indicated: 
Tannic  acid  gr.  v;  opium  gr.  j;  lead  acetate  gr.  ij;  camphor  gr.  ij; 
tannigen  gr.  vij  to  xv,  or  bismuth  3j  (see  Typhoid). 

10.  Anaemia. — This  is  benefited  by  fresh  air,  change  to  a  high  alti- 
tude, full  diet,  iron  in  small  doses,  and  arsenic. 

11.  Sexual  Symptoms. — Intercourse  must  be  forbidden  in  incipient 
as  well  as  in  advanced  cases.  Two  or  three  years  after  recovery 
marriage  may  be  sometimes  allowed;  it  is  generally  less  injurious  to 
men  than  to  women.  Tuberculous  parents  may  rear  healthy  children, 
but  tuberculosis  and  scrofula  are  rather  common  in  such  families. 
In  66  per  cent,  of  pregnant  tuberculous  women  the  prognosis  is  bad, 
and  laryngeal  tuberculosis  is  almost  invariably  fatal  within  a  short 
time.  In  severe  cases  abortion  may  be  contemplated;  opinions  vary 
as  to  its  indication,  for  some  contend  that  the  mother  runs  the  greater 
risk  and  others  maintain  that  abortion  has  no  appreciable  effect  on 
the  tuberculous  process;  Kaminer  found  that  in  70  per  cent,  of  the 
cases  abortion  does  not  alter  the  clinical  course. 

12.  Treatment  of  Other  Complications. — The  treatment  of  laryngeal, 
pleural,  peritoneal,  intestinal,  glandular,  and  meningeal  complications 
(v.  s.)  is  considered  elsewhere. 


LEPROSY. 

Definition. — A  chronic  incurable  contagious  disease,  caused  by  the 
Bacillus  leprae  and  characterized  clinically  by  nodules,  which  belong 
to  the  infective  granulomata  (Lepra  tuberosa),  and  are  observed  ex- 
ternally on  the  skin  and  nasal  and  oral  mucosae,  and  internally  in 
many  organs;  or  by  a  perineuritis  leprosa,  which  causes  sensory, 
motor,  and  other  symptoms  (Lepra  maculoanaesthesia).  The  nodular 
and  anaesthetic  forms  usually  co-exist  in  some  measure,  though  in 
varying  degree. 

Distribution. — The  home  of  leprosy  is  Egypt,  where  it  existed  2,400 
years  B.C.  (Brugsch)  or  even  4,620  B.C.  (Engel-Bey).    The  leprosy 


LEPROSY  367 

of  Leviticus  probably  includes  other  diseases.  It  prevailed  in  India 
700,  and  in  China  400,  years  B.C.  Just  before  the  Christian  era,  Pom- 
pey's  soldiers  brought  leprosy  to  Italy,  whence  it  spread  over  Europe, 
and  the  Crusaders  at  the  end  of  the  thirteenth  century  further  dissemi- 
nated the  disease.  In  Europe  there  were  20,000  asylums,  but  some 
cases  were  probably  syphilis;  the  disease  has  steadily  decreased  since 
the  sixteenth  century.  It  is  estimated  that  at  present  there  are  300,000 
cases  in  the  world.  In  Europe  cases  are  found  in  Sweden,  Norway, 
Finland,  Russia,  Dalmatia,  Bosnia,  Montenegro,  Germany,  France, 
Italy,  Spain,  Portugal,  Turkey,  Greece,  and  in  some  Mediterranean 
islands;  Arning  estimates  that  there  are  3,000  cases  in  the  west  half 
of  Europe.  In  Asia  numerous  cases  are  found  in  India  (5  cases  to 
each  10,000  of  population),  China,  Malay  Archipelago,  Formosa, 
Corea,  Persia,  Turkestan,  Syria,  and  Arabia.  In  Africa  it  prevails 
in  Egypt  along  the  Nile,  in  Tripoli,  Tunis,  Algiers,  Mozambique, 
Zanzibar,  Madigascar,  and  in  the  Canaries  and  Azores.  In  Japan, 
Australia,  Oceanica,  and  Sandwich  Islands,  it  is  also  found.  In 
America  foci  exist  in  Canada  (New  Brunswick,  Nova  Scotia,  and 
British  Columbia),  in  the  United  States  (California,  Louisiana,  Minne- 
sota, North  Dakota,  Florida);  in  Mexico,  West  Indies,  Honduras, 
Columbia  (5  per  cent,  of  the  population),  Brazil  and  Paraguay. 

Bacteriology. — The  Bacillus  leproe  was  found  by  Hansen  (1871) 
and  was  fully  described  by  Neisser  (1879).  It  is  a  fine,  narrow  rod, 
measuring  |  to  |  of  a  red  cell,  and  closely  resembles  the  tubercle 
bacillus  (q.  v.)  morphologically  and  in  its  staining  properties;  both 
bacilli  contain  fat.  Inoculation  is  the  surest  differential  criterion 
between  the  two,  for  the  lepra  bacillus  is  not  inoculable.  When  in 
the  internal  viscera  it  may  exceed  the  dimensions  which  it  attains 
in  the  skin  and  mucosae  five  or  six  times  (Cornil).  It  is  motile  and 
cannot  be  cultivated.  It  is  found  in  the  typical  nodes  and  infiltrations 
of  the  skin  and  superior  mucosae,  in  the  fresh  maculae  and  in  recent 
nerve  disease,  in  the  sweat,  in  the  sebaceous  and  hair-glands,  and  it 
is  free  in  their  lumen.  It  also  exists  in  the  nerves  and  Pacinian  bodies 
of  the  skin;  in  the  brain,  cord,  eye,  lungs,  liver,  spleen,  intestine,  and 
kidney;  in  the  salivary,  pancreatic,  adrenal,  and  lymphatic  glands; 
in  the  larynx,  testis,  epididymis,  tubes,  ovaries,  and  bloodvessels; 
in  the  blood  during  fever  (metastatic  distribution),  and  in  the  nasal, 
dermal,  faecal,  lachrymal,  bronchial,  vaginal,  urethral,  and  mammary 
secretions  and  excretions.  It  is  not  known  ^hy  the  bacillus  is  found 
so  much  more  frequently  and  persistently  in  the  nodular  and  mixed 
types  than  in  the  nervous  forms;  Strieker  found  it  in  the  nasal  secre- 
tion in  96  per  cent,  of  the  nodular,  96  per  cent,  of  the  mixed,  and  in 
66  per  cent,  of  the  nervous,  type.  It  has  never  been  identified  outside 
of  the  human  body  or  of  its  secretions  and  excretions.  It  corresponds 
to  but  one  of  Koch's  criteria;  i.e.,  it  is  always  present  in  leprosy;  it 
cannot,  however,  be  cultivated,  and  the  value  of  successful  inocula- 
tions on  criminals  under  sentence  of  death  has  been  justly  criticized, 
for  these  cases  developed  in  a  leprous  community.     That  leprosy  is 


368  THE  SPECIFIC  INFECTIONS 

contagious  can  no  longer  be  doubted,  as  shown  by  its  increase  v/here 
no  restriction  is  enforced,  by  its  decrease  on  segregation,  by  its  develop- 
ment in  two-thirds  of  the  (colored)  attendants  in  lazarettos,  and  by 
other  factors.  It  is  less  communicable  than  syphilis  or  tuberculosis 
and  is  promoted  only  by  long  and  intimate  contact  with  lepers.  The 
nodular  is  far  more  dangerous  than  the  anaesthetic  type.  Infection 
may  be  direct  or  indirect  (by  infected  linen,  utensils,  etc.).  It  occurs 
chiefly  though  the  skin  and  nose,  and  possibly  also  through  the  gen- 
italia. Vaccination  has  probably  never  caused  it.  Extension  occurs  more 
by  the  lymphatics  than  by  the  bloodvessels.  Hereditary  transmission 
is  improbable;  a  predisposition  toward  leprosy  may  possibly  be  in- 
herited, but  not  the  disease,  and  only  4  per  cent,  of  children  of  leprous 
parents  acquire  it.  More  cases  occur  in  colored  than  in  white  races, 
more  in  men  than  in  women,  and  more  in  the  poorer  than  in  the  upper 
and  middle  classes.  It  most  frequently  occurs  between  the  ages  of 
fifteen  and  thirty,  and  rarely  before  the  third  year. 

The  incubation  is  long,  at  least  three  to  five,  and  sometimes  ten, 
twenty,  or  even  thirty-two,  years. 

S3maptoms. — The  chief  clinical  groups  do  not  include  the  visceral 
involvement  which  is  seen  in  every  type;  the  main  types  are  nearly 
always  somewhat  blended. 

I.  Nodular  Type  (Lepra  tuherosa  seu  tuberculosa). — The  prodromal 
toxsemic  symptoms  indicate  an  infection  which  has  already  been  estab- 
lished, but  has  escaped  recognition;  they  are  depression,  coldness, 
formication,  sweats,  pains,  vertigo,  digestive  disturbance,  temperature, 
and  sometimes  nasal  irritation.  After  months,  or  years,  maculae  appear 
on  the  face  and  extremities,  which  may  itch  or  may  be  hypersesthetic ; 
they  may  disappear,  leave  pigmentation,  or  metamorphose  into  nodules, 
which  are  present  in  75  per  cent,  of  all  cases.  The  nodule,  or  leproma, 
is  a  granuloma  and  is  very  similar  to  the  tubercle  or  gumma;  the 
nodes  are  highly  vascular  and  are  formed  of  a  scanty  fibrillar  reticu- 
lum, in  which  lie  emigrated  leukocytes,  small  round  epithelioid  cells, 
and  the  larger  multinucleated  lepra  cells  of  Virchow,  which  contain 
close  clumps  of  bacilli.  The  nodes  by  fusion  form  infiltrations  which 
are  gelatinous,  glistening,  and  yellow-red.  The  nodes  vary  in  size 
from  that  of  a  millet  seed,  to  that  of  a  hazelnut  or  walnut;  they  lie 
in  the  skin,  are  dark  red,  and  later  become  yellow-brown;  they  are 
glistening,  vascular,  slightly  desquamating,  and  at  first  soft  but  later 
become  harder.  Sensation  is  always  disturbed  in  their  vicinity.  They 
are  most  conspicuous  on  the  face  and  hands,  but  also  appear  on  the 
extensor  surface  of  the  knee,  elbow,  and  fingers,  and  very  seldom  on 
the  soles  of  the  feet,  the  palms  of  the  hands,  the  scalp,  or  penis.  When 
they  develop  on  the  face,  the  forehead,  nose,  cheeks,  chin,  lips,  and  ears, 
are  thickened,  the  nose  becomes  flatter,  the  eyebrows,  lashes  and 
the  beard  are  shed.  The  eyes  are  involved  in  over  90  per  cent,  of  the 
cases;  the  expression  is  leonine  (leoniiasis),  or,  as  the  ancients  called 
it,  faun-like  (satyriasis).  The  nodes  usually  grow  and  extend  slowly, 
and  the  lymphatic  vessels  and  glands,  of  the  neck  and  groin  especially. 


LEPROSY  369 

become  enlarged  and  tender.  Sometimes  the  progression  is  inter- 
ruptedly acute,  with  intermittent  fever  and  an  eruption  resembling 
erysipelas.^  They  may  shrink,  but  more  often  necrose,  soften,  and 
ulcerate.  At  the  same  time  or  later,  nodules  which  are  prone  to  early 
ulceration  and  infiltration,  occlude  the  nose,  roughen  the  voice  (raucedo 
leprosa),  distort  the  larynx  and  throat,  impair  mastication,  swallow- 
ing, or  respiration,  and  even  provoke  suffocation.  Cicatrization  of  the 
throat  or  face  causes  added  deformity. 

II.  Nervous  Type  (Lepra  nervorum,  anoesthetica,  maculo-anossthetica, 
sen  mutilans). — The  most  common  prodromes  are  fever  and  such 
nervous  symptoms  as  rheumatic  pains,  neuralgia,  parsesthesia,  hyper- 
sesthesia,  and  vasomotor  cerebral  congestion.  Macules  develop  on 
the  face,  neck,  trunk,  or  limbs;  they  are  pale  or  dark-red,  flat  or  slightly 
raised,  growing  peripherally  and  paling  centrally,  and  are  glistening 
or  present  a  powdered  aspect.  Histologically  they  are  identical  with 
the  nodules,  but  contain  fewer  bacilli,  are  flatter,  contain  no  large 
cells,  and  tend  more  toward  fibrous  change.  Their  distribution  is 
asymmetrical,  like  that  of  the  underlying  nerve  lesions;  they  are  often 
oversensitive,  sometimes  pigmented  (lepra  nigra),  or  leukoderma-like 
(lepra  alba).  Early  vesicles  sometimes  develop.  If  the  skin  is  pow- 
dered with  dry  methyl  violet  and  if  pilocarpine  is  then  given,  the 
sound  tissue  sweats  and  stains,  while  the  maculae  remain  uncolored 
because  they  do  not  sweat. 

Sensory  disturbances  are  due  to  lesions  in  the  nerve  trunks,  which 
are  the  seat  of  a  perineuritis  and  interstitial  neuritis  which  slowly 
compress  the  nerve  fibers.  The  connective  tissue  development  and 
the  presence  of  the  bacilli  differentiates  this  from  the  parenchymatous 
neuritides.  Unlike  the  ordinary  neuritis,  the  leprous  neuritis  affects 
the  sensory  more  than  the  motor  filaments.  There  is  an  irregular 
dissociated  anaesthesia  in  which  the  perception  of  pain  and  tem- 
perature is  usually  more  dulled  than  other  forms  of  sensation,  and 
this  occurs  mostly  in  the  peripheral  branches  in  the  arms  and  legs. 
Sensation  may  be  perverted  or  retarded,  and  anaesthesia  may  come  on 
suddenly,  which  is  considered  rather  characteristic.  Pain  may  be 
slight,  or  agonizing  as  in  a  case  of  ten  years  duration  which  was 
personally  observed.  The  nerve  trunks  are  palpable  and  are  tender 
in  many  cases;  the  ulnar  nerve  is  most  markedly  enlarged  and  in  the 
case  cited  was  thicker  than  a  lead  pencil,  but  the  auricular  nerve  is 
more  often  felt  (in  90  per  cent.,  Baelz).  Motor  weakness  and  atrophy 
are  less  common  and  are  rarely  extreme;  the  eyelids,  muscles  of  the 
mouth,  and  sometimes  the  masticatory  and  ocular  muscles,  and  also 
the  hands  and  feet,  are  paretic.  The  ulnar  and  peroneal  nerves  are 
sometimes  paralyzed,  causing  the  "claw-hand"  and  "claw-foot." 
Facial  paralysis  occurs  in  9  per  cent,  of  cases.  The  tendon  reflexes 
are  often  increased,  though  sometimes  normal  or  decreased;  there  is 
often  fibrillation  and  increased  myotatic  irritability.  Trophic  changes 
are  less  common  and  include  oedema,  glossy  skin,  " mal  perforant" 
(26  per  cent.),  loss  of  the  hair  or  nails,  dry  gangrene,  bone  resorption, 

24 


370  THE  SPECIFIC  INFECTIONS 

rheumatoid  swellings,  ankylosis,  and  pigmentation.       Great  trophic 
changes  mark  the  lepra  mutilans. 

Ill,  Mixed  Type. — This  is  a  combination  of  the  nodose  and  anaes- 
thetic types.  hi  all  developed  forms  the  internal  tissues  are  invaded: 
the  liver,  spleen,  and  lymph  glands,  are  enlarged;  the  lungs  show  peri- 
bronchial foci,  cavities,  or  induration;  and  the  intestine  is  infiltrated. 
In  both  sexes  the  sexual  functions  are  decreased  and  later  are  entirely 
lost.  Infantilism  results  in  cases  developing  before  puberty.  Cachexia 
develops,  the  patient  becomes  very  sensitive  to  cold,  the  temperature, 
except  for  intermittent  rises,  becomes  depressed,  heart  weakness  de- 
velops, and  a  degree  of  apathy  is  noted.  Abortive  or  long  localized 
forms  are  described. 

Course  and  Prognosis. — The  course  is  slow  and  progressive,  the 
outcome  invariably  fatal.  The  nodular  type  covers  eight  to  twelve 
years,  the  ansesthetic  form  fifteen  to  twenty  years,  but  either  variety 
may  endure  six  or  seven  decades.  According  to  Hillis,  38  per  cent, 
of  cases  die  of  leprosy  (exhaustion,  diarrhoea,  cardiac  weakness), 
22  per  cent,  of  chronic  nephritis,  17  per  cent,  of  lung  disease,  which 
is  more  often  leprous  than  tuberculous,  and  10  per  cent,  of  diarrhoea 
(leprous  infiltration  of  the  gut).  The  remaining  13  per  cent,  die  of 
erysipelas,  sepsis,  amyloidosis,  and  intercurrent  diseases,  for  lepers 
possess  a  decidedly  reduced  resistance. 

Diagnosis. — The  diagnosis  is  based  on  the  history  of  residence  and 
of  exposure  (which  is  often  suppressed  by  the  patient),  on  the  macules 
or  leukoderma  (which  are  found  in  90  per  cent.),  on  the  ansesthesia, 
amyotrophy,  and  mutilation,  and  on  the  finding  of  the  lepra  bacil- 
lus (necessary  for  exactness),  for  which  the  nasal  secretion,  nodes,  and 
macules,  should  be  examined  (v.  Syringomyelia). 

Treatment. — I.  Prophylaxis. — All  suspicious  cases  should  be  regis- 
tered and  all  clear  cases  should  be  sequestrated. 

II.  Therapy. — Drugs  are  useless,  though  a  few  are  helpful,  (a) 
Gurjun  oil  3ss  to  5ij  in  water  or  lime  water;  (b)  chaulmoogra  oil,  in 
milk,  beginning  with  a  few  minims  and  increasing  to  5i~iij ;  (c)  salves 
of  5  to  10  per  cent,  pyrogallol,  10  per  cent,  chrysarobin,  10  per  cent, 
ichthyol;  (d)  Calamette's  antivenin,  20  to  30  c.c,  which  was  suggested 
by  cases  which  improved  after  snake  bite;  (e)  arsenic,  salicylic  acid 
and  corrosive  sublimate;  these  are  the  most  extensively  used  remedies. 
Symptomatic  treatment  of  pain,  ulcers,  etc.,  is  also  indicated. 


FEBRICULA  371 

INFECTIONS  OF  UNCERTAIN  ORIGIN. 

(A).  FEBRICULA. 

Definition. — A  fever  of  short  duration,  due  to  a  number  of  causes. 
If  only  of  twenty-four  hours  duration  it  is  called  ephemeral  fever; 
when  it  lasts  a  few  days,  it  is  called  febricula;  when  attended  by  herpes, 
febris  herpetica;  or  when  accompanied  by  gastric  disorder,  febris  gas- 
trica. 

Febricula  is  no  morbid  entity,  and  its  varied  causes  are  not  exactly 
known.  It  embraces  (a)  benign  or  abortive  forms  of  various  acute 
infections,  such  as  rheumatism,  typhoid,  scarlatina,  tonsillitis,  and 
pneumonia;  and  (6)  febrile  dyspepsias,  especially  those  in  children. 
Gastric  fever  is  a  term  which  was  formerly  applied  to  febrile  gastritis, 
which  is  possibly  produced  by  toxins  in  the  food.  Sewer-gas  is  pop- 
ularly held  as  the  cause  of  fugitive  fever  with  gastro-intestinal  disturb- 
ance, but  Abbott  and  others  have  justly  contested  its  etiological 
significance.     Exposure  to  cold  is  also  a  possible  factor. 

Symptoms. — The  three  common  symptoms  are  (a)  chill  or  chilli- 
ness; (6)  sudden  rise  of  temperature;  (c)  a  critical  resolution,  more 
often  prolonged  than  acute.  The  onset  is  abrupt,  usually  without  pro- 
dromes. The  fever  rises  quickly  to  101°-103°,  or  higher  in  the  young, 
with  the  usual  signs  of  toxaemia  (headache,  coated  tongue,  anorexia, 
and  febrile  urine).  Herpes  is  quite  frequent.  Bronchitis,  acute  splenic 
tumor,  albuminuria,  and,  in  children,  cerebral  toxaemia,  are  sometimes 
present.  The  term  ephemeral  is  rather  inappropriate,  as  the  average 
duration  is  three  days,  with  a  slow  crisis. 

Diagnosis  and  Treatment. — The  diagnosis  is  solely  by  exclusion, 
and  the  treatment  is  expectant.  Rest  in  bed  is  advisable  as  a  precau- 
tion against  some  longer  and  insidious  malady,  such  as  typhoid;  the 
bowels  should  be  unloaded,  the  diet  restricted,  and  a  drop  or  two  of 
tincture  of  aconite  and  spts.  setheris  nitrosi  5ss  should  be  given  every 
three  or  four  hours. 

(B).  GLANDULAR  FEVER. 

Definition. — An  acute  infection  observed  in  children  and  character- 
ized by  pharyngeal  injection,  a  short  high  fever,  and  a  painful  intu- 
mescence of  the  cervical  lymph  glands.  It  was  described  as  Driisen 
fieber  by  Pfeiffer,  in  1889.  Its  etiology  is  unknown  but  it  is  evidently 
an  infection,  as  suggested  by  the  clinical  signs  and  by  its  frequent 
occurrence  in  epidemics.  It  is  usually  seen  in  children  between  five 
and  eight  years  of  age,  and  during  the  colder  months.  West  observed 
an  epidemic  of  nearly  100  cases  in  Bellaire,  Ohio. 

Symptoms. — The  symptoms  begin  without  prodromes,  with  fever 
of  100°  to  103°,  pain  in  the  head  and  neck,  redness  of  the  throat,  some 


372  INFECTIONS  OF   UNCERTAIN  ORIGIN 

dysphagia,  often  pain  in  the  hmbs,  nausea,  vomiting,  and  abdominal 
pain.  On  the  second  or  third  day  the  cervical  lymph  glands  become 
swollen  and  tender,  but  seldom  cause  redness  of  the  skin.  The  glands 
back  of  the  sternomastoid  are  most  involved.  The  inguinal  and  axil- 
lary glands  are  involved  in  75  per  cent,  of  cases,  and  the  mesenteric 
in  about  40  per  cent.  The  glands  may  reach  the  size  of  an  egg.  After 
ten  to  twenty  days  the  swelling  subsides,  having  lasted  longer  than  the 
fever.  In  some  instances  a  persistent  dry  cough  suggests  involvement 
of  the  bronchial  glands.  The  spleen  is  enlarged  in  60  per  cent,  of 
cases,  and  the  liver  in  90  per  cent.  The  fever  lasts  but  a  few  days. 
Complications  are  rare.  Suppuration  in  the  glands  is  exceptional. 
Acute  nephritis  and  otitis  media  are  occasionally  observed. 

Prognosis  and  Treatment. — The  prognosis  is  good,  though  a  relapse 
may  occur.  The  absence  of  a  rash  excludes  the  adenopathies  of 
varicella,  scarlatina,  and  measles,  and  the  generalized  glandular  swell- 
ing excludes  the  local  swelling  due  to  simple  pharyngitis.  The  treat- 
ment is  expectant. 

(C).  MILIARY  FEVER. 

Definition. — An  acute  infection,  probably  microbic,  marked  by  fever, 
profuse  sweating,  a  miliary  eruption,  nervous  symptoms,  palpitation, 
and  precordial  anxiety.  It  first  appeared  in  England  after  the  Battle 
of  Bosworth  (1486)  and  broke  out  several  times  in  the  following  cen- 
tury. It  was  known  as  the  "English  sweats"  {sudor  Anglicus),  and  its 
mortality  reached  even  50  to  80  per  cent.  In  1529  it  caused  3,000 
deaths  in  Dantzig.  There  have  been  about  200  epidemics  between  the 
epidemic  in  Picardy,  in  1718,  and  that  in  Poitou,  in  1887.  It  is 
apparently  highly  contagious  (Brouardel).  Epidemics  have  also 
occurred  in  Italy,  Switzerland,  Germany,  and  Austria,  with  a  death- 
rate  of  5  to  25  per  cent.    Fortunately  they  last  only  a  week  or  month. 

Symptoms  and  Treatment. — In  mild  outbreaks  the  chief  symptoms 
are  fever,  profuse  periodic  sweating,  and  miliary  eruptions.  The 
eruption  may  be  erythematous  or  morbilliform  (miliaria  rubra),  or 
there  may  be  no  redness  of  the  skin  (miliaria  alba  s.  crystallina) ; 
the  spleen  may  be  enlarged.  In  severe  cases  there  are  marked  cerebral 
toxaemia,  rapid  pulse,  precordial  distress,  palpitation,  extreme  pros- 
tration, and  hemorrhages  into  the  skin;  and  death  results  in  a  few 
hours  or  days.  Its  average  duration  is  one  to  two  weeks.  Desquama- 
tion is  frequent  and  convalescence  rather  tardy.  The  treatment  is 
supportive  and  expectant. 


(D).  WEIL'S  DISEASE.— (ACUTE  FEBRILE  JAUNDICE.) 

Definition. — An  acute  infection,  characterized  by  fever,  jaundice, 
herpes,  enlarged  spleen  and  liver,  sore  throat,  muscle  pains,  and 
albuminuria.    It  was  especially  described  by  Weil  (1886),  whose  name 


MILIARY  FEVER  373 

it  most  often  bears,  though  it  was  previously  mentioned  by  Mathieu, 
Bouchard,  Lancereaux,  and  Coynes.  Nicolaysen  describes  63  epidemics 
of  icterus  in  Norway  and  Sweden  in  the  last  fourteen  years;  3  to  28  per 
cent,  of  the  inhabitants  in  certain  communities  acquired  the  disease. 

Etiology. — Its  etiology  is  unknown,  whence  our  difficulty  in  stating 
whether  it  is  a  morbid  entity  or  whether  it  includes  several  diseases. 
It  occurs  largely  in  men  between  twenty-five  and  forty,  especially  in 
butchers  and  alcoholics;  it  also  occurs  in  the  warmer  seasons  and 
sometimes  in  epidemics.  The  symptoms  mentioned  above,  those 
described  below,  and  the  autopsy  findings  of  granulo-fatty  changes  and 
ecchymoses,  mark  it  as  an  infection.  It  is  either  directly  microbic  or 
toxsemic.  Bordoni,  Uffreduzzi  and  later  Jaeger  found  the  Proteus 
fluorescens,  and  Freund  a  diplococcus,  but  the  intravitam  findings 
are  usually  negative.  It  is  not  typhoid,  recurrent  fever,  sepsis,  malaria, 
or  phosphorus  poisoning,  with  which  it  has  been  sometimes  identified. 
Some  cases  have  occurred  in  this  country  (Lanphear,  Musser,  Gui- 
teras);   the  author  has  seen  eight  cases  in  Chicago. 

Symptoms. — The  symptoms  begin  suddenly  without  prodromata, 
with  fever,  chill  or  chilliness,  headache,  vertigo,  insomnia,  and  severe 
pains  in  the  limbs  and  extremities.  The  fever  may  reach  104°,  105°  or 
107°;  it  afterward  shows  remissions,  and  falls  either  by  crisis  or  by 
lysis  after  five  to  eight  days.  The  nervous  symptoms  may  include 
delirium,  sopor,  or  even  coma.  Jaundice  develops  on  about  the  third 
day,  is  probably  due  to  catarrhal  radicular  angiocholitis,  and  may  be 
slight  or  extreme;  bile  usually  appears  in  the  urine,  and  the  stools  are 
often  acholic,  though  the  author  has  twice  seen  deep  jaundice  with- 
out obstruction  of  the  bile-duct.  Muscular  pains  are  very  common  and 
intense,  especially  in  the  calves,  which  are  usually  also  tender.  Artic- 
ular pains  are  not  uncommon.  Herpes  is  very  common.  The  rapid 
pulse  is  very  marked  compared  with  the  usual  slow  pulse  of  simple 
catarrhal  icterus.  In  one  case  the  author  observed  blood-stained 
bronchitic  sputum.  Digestive  symptoms  are  common,  such  as  furred 
tongue,  nausea,  vomiting,  epigastric  pain,  abdominal  distention,  and 
diarrhoea,  with  acholic  or  bile-stained  stools.  The  liver  is  enlarged 
and  tender  in  more  than  50  per  cent,  of  the  cases,  the  spleen  in  over 
66  per  cent.,  and  the  lymph-nodes  are  frequently  affected.  The  urine 
is  albuminous  in  over  50  per  cent.;  acute  nephritis  is  frequent; 
hsematuria  occurs  occasionally,  and  uraemia  exceptionally;  the  urea 
and  the  amount  of  urine  are  decreased  during,  and  increased  after,  the 
seizure  (Chauffard's  nitrogenous  and  polyuric  crises);  glycosuria  de- 
veloped in  one  fatal  case. 

Diagnosis. — Weil's  disease  must  be  differentiated  from  recurrent 
fever  by  its  spirillum,  and  from  sepsis  and  typhoid, — in  regard  to  the 
latter  of  which  it  may  be  noted  that  icterus  may  produce  a  weak 
Widal  reaction.  Differentiation  is  more  difficult  from  suppurative 
angiocholitis  (q.v.)  and  acute  yellow  atrophy  (q.v.). 

Prognosis. — This  is  usually  good  and  convalescence  is  generally 
established  in  two  weeks;   in  one  epidemic,  11  per  cent,  of  the  cases 


374  INFECTIONS  OF   UNCERTAIN  ORIGIN 

died.  Recurrence  may  be  anticipated  if  the  splenic  tumor  has  not 
subsided  (Mathieu) ;  renal  or  hepatic  insufficiency,  pregnancy,  haemo- 
lysis with  epistaxis  and  hsematemesis,  render  the  prognosis  less  favor- 
able. 

Treatment. — The  treatment  is  directed  to  (a)  the  intoxication,  for 
which  calomel  and  salines  are  indicated;  cold  water  enemata  (KruU 
and  Chaujffard)  increase  the  renal  flow,  and,  with  it,  the  excretion  of 
toxins;  (b)  the  jaundice,  for  which  salines  should  be  given  to  lessen 
duodenal  catarrh;  (c)  the  albuminuria,  for  which  a  milk  diet  is  indi- 
cated; (d)  muscular  pains,  for  which  heat,  and  massage  with  chloro- 
form liniment,  are  most  beneficial. 


(E).  MILK  SICKNESS. 

Definition. — A  disease  acquired  by  man  from  the  milk  or  meat  of 
cattle  suffering  from  the  "trembles."  Cows  with  the  disease,  after 
being  driven  too  rapidly,  suffer  from  anorexia,  injection  of  the  eyes, 
vertigo,  trembling,  and  convulsions  ending  in  death.  Young  horses 
and  sheep  may  also  acquire  the  disease.  Milk  sickness  occurs  chiefly 
in  newly  settled  countries,  as  in  the  Southwestern  states,  and  it  is 
still  seen  in  North  Carolina.    Its  origin  and  pathology  are  unknown. 

Sjnnptoms. — In  man  the  nervous  symptoms  are  frequently  con- 
spicuous, as  restlessness,  convulsions,  or  coma,  which  appear  after  a 
few  days  of  malaise.  The  tongue  is  swollen  and  heavily  coated,  the 
breath  foetid,  the  stomach  painful  and  irritable,  the  fever  high  and 
sometimes  typhoidal.  The  issue  is  either  fatal,  in  acute  forms,  within 
a  few  days,  or  recovery  may  result  after  weeks.  Flesh,  butter,  cheese 
and  milk,  from  infected  animals  may,  even  when  boiled,  cause  death 
when  given  to  dogs. 

(F).  MOUNTAIN  FEVER. 

(a)  Some  European  cases  are  due  to  the  anchylostoma  and  are 
associated  with  anaemia.  (6)  Many  cases  are  identical  with  typhoid 
(Woodruff,  Smart,  Hoff,  and  Raymond),  (c)  Wilson  and  Chowning 
(1902)  think  that  the  disease  is  caused  by  a  red-corpuscle  protozoon 
like  that  of  Texas  fever  and  malaria,  though  not  pigmented;  Stiles 
and  Craig  could  not  confirm  their  findings.  Cases  develop  in  the 
early  spring,  and  are  marked  by  chill,  fever  of  one  to  two  weeks,  rapid 
pulse,  epistaxis,  albuminuria,  rapid  breathing,  bronchitis,  splenic 
tumor,  rapid  anaemia,  moderate  leukocytosis,  slight  icterus,  muscular 
pains,  and  widely  diffused  macular  rash, — which  develops  on  the  third 
day,  disappears  on  pressure  at  first,  but  afterwards  persists  on  pressure. 
The  liver  and  spleen  are  enlarged.  Quinine  may  be  beneficial  in 
some  cases.  The  death  rate  may  be  70  per  cent,  (d)  In  high  altitudes 
slight  fever,  associated  with  headache,  dyspnoea,  thirst,  and  malaise, 
is  known  as  mountain  sickness. 


FOOT  AND  MOUTH  DISEASE  375 


(G).   FOOT  AND  MOUTH  DISEASE, 

Definition. — Epidemic  stomatitis,  Aphthous  fever,  or  Aphthae  epizo- 
oticse  is  one  of  the  zoonoses  and  its  nature  is  unknown.  Loeffler  and 
Frosch  have  shown  that  the  virus  is  ultramicroscopic,  as  it  passes  in 
full  virulence  through  porcelain  filters.  The  disease,  first  described 
by  von  Valentini,  in  1695,  and  known,  since  the  middle  of  the  fifteenth 
century,  chiefly  affects  cattle,  sheep,  and  pigs,  but  sometimes  also 
goats,  horses,  dogs,  and  even  fowls.  In  cattle  there  is  fever,  swelling 
of  the  mouth,  salivation,  and  the  formation  of  small,  clear  vesicles 
on  the  tongue,  gums,  lips,  and  udders.  These  vesicles  soon  become 
opaque,  and  bursting,  form  small  ulcers;  emaciation  is  rapid,  and 
the  milk  becomes  yellowish  and  mucoid.  Recovery  is  usual  in  one  to 
two  weeks.  The  disease  spreads  very  rapidly.  It  is  observed  in 
Hungary,  Germany,  France,  Switzerland,  England,  and  occasionally 
in  this  country. 

Etiology  and  Symptoms. — In  man  infection  occurs  from  diseased 
milk  (as  proven  on  himself  by  Hertwig),  butter,  and  cheese,  but  not 
by  the  meat  of  the  diseased  animal.  Open  wounds  may  be  directly 
infected.  Cattle  have  been  inoculated  from  man.  The  incubation 
is  three  to  five  days.  There  are  fever,  salivation,  aphthous  ulcers, 
angina,  nausea,  vomiting,  and  vesicles  on  the  skin — which  have  caused 
confusion  with  vaccinia.  Hemorrhages  occur  in  severe  epidemics. 
Ebstein  has  suggested  that  Foot  and  Mouth  Disease  may  be  kindred 
with  the  ordinary  aphthous  stomatitis  of  nurslings,  or  pregnant  women. 
Children  are  more  endangered  than  adults.  The  death-rate  is  2.3 
per  cent.  (Hulin)  to  8  per  cent.  (Siegel).  Recovery  usually  occurs  in 
two  to  three  weeks. 

Treatment. — Prophylaxis  concerns  the  boiling  of  suspected  milk, 
the  segregation  of  diseased  animals  or  human  subjects,  and  vaccina- 
tion, as  discovered  by  LoefSer.  A  dram  of  5  per  cent,  solution  of  potas. 
chlorate,  t.  i.  d.,  should  be  given,  and  the  aphthae  should  be  touched 
with  borax  or  silver. 


SECTION  II. 


DISEASES  OF  THE  CIRCULATION. 


DISEASES  OF  THE  PERICAEDIUM. 

(A).  PERICARDITIS. 

Definition. — An  inflammation  of  the  pericardium,  usually  secondary 
to  infectious  diseases,  to  inflammation  in  contiguous  tissues,  to  other 
diseases  of  the  pericardium,  or  to  dyscrasise;  it  is  fibrinous  or  plastic, 
exudative,  or  adhesive. 

Etiology. — The  disease  is  rarely  primary,  and  final  analysis  usually 
demonstrates  that  the  so-called  primary  cases  are  tuberculous,  rheu- 
matic, or  septic.  Cold,  exposure,  and  trauma,  probably  only  reduce 
the  physiological  resistance  of  the  tissues  to  bacterial  invasion.  Peri- 
carditis is  usually  mycotic,  the  organisms  of  suppuration,  pneumonia 
and  tuberculosis,  being  most  frequently  found;  it  seems,  however,  that 
toxins  alone  may  excite  inflammation. 

Pericarditis  is  almost  invariably  secondary  (a)  to  infectious  diseases, 
of  which  rheumatism  (14,  37,  66,  per  cent.)  is  foremost,  and  it  is  most 
frequent  when  many  joints  are  involved  in  rapid  succession.  Peri- 
carditis may  be  the  only  manifestation  of  rheumatism.  Many 
"primary  "cases  are  probably  rheumatic.  It  occurs  with  recurrent  rheu- 
matism, with  endocarditis,  and  sometimes  with  chorea.  It  usually 
develops  rather  early,  within  half  a  week  to  two  weeks,  but  may  pre- 
cede arthritis,  especially  in  children.  It  is  commonly  serofibrinous, 
most  exceptionally  purulent. 

It  is  common  in  pneumonia,  septicopysemia,  puerperal  fever,  ulcera- 
tive endocarditis,  navel  infection  in  babes,  osteomyelitis,  scarlatina, 
and  more  rarely  in  other  exanthemata,  and  in  tuberculosis  (pulmonary, 

377 


378  DISEASES  OF  THE  CIRCULATION 

multiple  serous  inflammations,   pleuritis,  peritonitis).     In   children, 
scarlatina  and  rheumatism  are  most  important. 

(6)  It  is  secondary,  by  contiguity,  to  adjacent  affected  organs;  to 
pleurisy,  pneumonia,  and  aneurysm;  to  disease  of  the  ribs,  sternum, 
bronchial  glands,  spine,  oesophagus,  stomach  (ulcer  and  cancer),  spleen, 
liver  (abscess),  peritoneum,  myocardium,  and  endocardium;  and  to 
cervical  cellulitis  (diphtheria,  mediastinitis).  Trauma  of  these  parts, 
from  without  or  within,  such  as  penetration  of  foreign  bodies,  may  be 
included  under  this  class. 

(c)  It  is  secondary  to  certain  diseases  of  the  pericardium,  as  tubercu- 
losis, carcinoma,  and  other  processes.  In  30  per  cent,  of  Matter's 
"cryptogenetic  "  cases,  tuberculosis  was  found  at  autopsy. 

(d)  It  is  secondary  to  cachexies  or  dyscrasice,  gout,  diabetes,  car- 
cinoma, to  nephritis  (3  to  10  per  cent,  of  cases,  especially  those  of  con- 
tracted kidney),  to  alcoholism,  blood  diseases,  and  scurvy;  and  often, 
as  a  terminal  infection,  to  reduced  physiological  resistance,  in  which 
case  it  may  easily  escape  recognition  clinically.  This  class  is  usually 
found  in  adults.  Though  encountered  at  any  age  from  foetal  life  to 
old  age,  it  is  most  frequent  between  the  fifteenth  and  thirtieth  years. 


Fibrinous  (Plastic)  Pericarditis. 

A  strict  di^^sion  into  dry  (plastic)  and  exudative  (effusive)  pericar- 
ditis is  impossible,  because  the  forms  are  very  often  combined.  Dry 
(plastic,  fibrinous)  pericarditis  is  circumscribed  over  the  base  and  large 
vessels,  or  is  diffuse,  and  consists  pathologically  of  vascular  injection, 
punctate  ecchymoses,  loss  of  the  smooth,  glistening,  mirror-like  ap- 
pearance of  the  serous  membrane,  and  exudation  of  plastic  lymph  in 
small  particles  or  irregular  lamellse,  which  may  appear  smeared  as 
with  butter,  spongy,  shaggy,  or  hairy  (cor  villosum).  Some  fluid  is 
usually  found  in  the  meshes  of  fibrin.  Stripping  off  of  the  fibrin  may 
reveal  tubercles.  The  subjacent  myocardium  often  suffers  infiltration 
and  degeneration  in  the  more  intense  or  protracted  cases. 

Symptoms. — Symptoms  are  lacking  in  most  cases;  pain  is  incon- 
stant, and,  when  present,  is  by  no  means  characteristic. 

Physical  Findings. — Inspection  and  percussion  are  usually  negative. 
The  writer  has  seen  a  strong  apex  beat  where  the  autopsy  revealed  a 
fibrin  deposit  which  was  an  inch  in  thickness.  Palpation  may  disclose 
a  friction  fremitus,  usually  over  the  sternum,  which  may  be  obtained 
as  frequently  as  is  friction  on  auscultation  {described  under  Pericarditis 
with  Effusion, to  ivhich  refer  also  for  diagnosis ,  prognosis ,  and  treatment). 


Pericarditis  with  Effusion. 

This  form  has  been  called  the  second  stage,  the  fibrinous  or  dry  form 
being  the  first  stage.    The  fluid  may  be  serous  with  much  or  little  cellu- 


PERICARDITIS  WITH  EFFUSION  379 

lar  or  fibrinous  admixture  (sero-fibrinous) ;  it  may  be  hemorrhagic, 
this  type  being  observed  in  the  aged,  in  the  dyscrasise  (such  as  those 
having  scurvy  or  cancer),  in  cases  of  tuberculosis,  in  those  having  pur- 
pura, hemorrhagic  exanthemata,  or  Bright 's  disease;  the  exudation 
may  be  tinged  with  fresh  or  with  darker  altered  blood ;  it  may  be  puru- 
lent, and  is  then  usually  sero-fibrinous  rather  than  purely  purulent, 
and  is  often  associated  with  pyaemia  or  contiguous  suppuration;  it 
may  be  putrid,  when  caused  by  pyaemia,  carcinoma  of  the  oesophagus 
or  stomach,  or  by  lung  cavities.  (Sixty-seven  per  cent,  of  pericarditis 
cases  are  sero-fibrinous,  19  per  cent,  are  hemorrhagic,  and  14  per  cent. 
are  purulent  [Breitung].)  The  pathological  sequences  of  pericarditis  are 
fatty  and  cloudy  degeneration,  inflammatory  infiltration,  or  actual  exul- 
ceration  of  the  heart  muscle;  rupture  of  a  purulent  exudation  exter- 
nally into  the  tissues  of  the  chest,  or  possibly  into  neighboring  organs  or 
cavities;  inflammatory  extension  outside  of  the  pericardium  {pericar- 
ditis externa)  and  thence  to  other  tissues,  such  as  the  mediastinum  or 
pleura;  formation  of  polypi,  which,  becoming  detached,  may,  in  rare 
cases,  produce  foreign  bodies  in  the  pericardium;  complete  resorption 
of  the  exudate  and  restitutio  ad  integrum,  which  is  a  rather  uncommon 
issue;  the  formation  of  hard  plaques,  maculce  tendinece,  which  are 
usually  not  inflammatory  in  origin;  organization  of  connective  tissue, 
either  as  local  adhesions,  which  are  mostly  observed  near  the  fixed 
base  of  the  heart,  because  the  heart's  movements  probably  detach 
apical  adhesions,  or  as  general  obliteration  of  the  sac  (concretio  peri- 
cardii); and,  finally,  desiccation  of  the  exudate,  leaving  a  cheesy  mass 
which  may  become  tuberculous  or  may  calcify.  Coincident  endocar- 
ditis is  less  a  sequence  than  an  associate  or  cause  of  pericarditis. 

Symptoms. — All  symptoms  are  frequently  absent  (Latham,  Graves, 
Stokes),  and  no  symptom  is  diagnostic.  Leudet  found  total  latency 
of  symptoms  in  55  per  cent,  of  his  cases.  Daily  examination  of  the 
heart  in  those  diseases  which  are  most  likely  to  cause  pericarditis  is 
the  only  certain  method  of  avoiding  diagnostic  errors.  Fever  may 
exist  from  the  disease,  or  from  the  causal  affection,  but  is  irregular 
(Wunderlich).  It  is  often  absent,  especially  in  secondary  pericarditis, 
and  the  temperature  may  be  subnormal,  even  in  purulent  effusions. 
High  fever  is  infrequent  even  in  rheumatic  cases. 

Dyspnoea,  or  thoracic  oppression  occur.  Oppolzer  observed  cyano- 
sis without  dyspnoea  when  the  pulmonary  circuit  remained  intact. 
Dyspnoea  is  due  largely  to  heart  compression  by  the  exudate  or  exten- 
sion of  inflammation  to  the  myocardium,  and  is  less  frequently  due 
to  vagus  irritation,  phrenic-nerve  inflammation,  venous,  pulmonary, 
arid  arterial  compression.  It  is  remarkable  that  patients  may  some- 
times walk  into  the  hospital  with  enormous  pericardial  effusions.  The 
respirations  are  increased. 

Pain  is  variable,  is  often  absent  (in  secondary  pericarditis),  and  is 
said  to  be  more  common  in  small  effusions.  Severe  pain  oftener  indi- 
cates pleurisy  than  pericarditis  (Bouillaud).  Epigastric  pain  may 
precede  pain  elsewhere  (Gueneau  de  Mussy).    Anginal  pain  (Andral), 


380  DISEASES  OF   THE  CIRCULATION 

radiating  to  the  shoulder,  arm,  and  neck,  is  rare.  Precordial  tender- 
ness is  at  times  present,  and  palpitation  is  common. 

Cerebral  Sympioms. — Delirium,  anxiety,  restlessness,  insomnia, 
mania,  choreiform  movements,  convulsions,  psychoses  (Burrows  and 
Flint),  or  even  coma,  may  be  due  to  pericarditis,  or  to  complicating 
uraemia  or  endocarditis.  The  symptoms  may  be  suggestive  of  gas- 
tritis, while  pericarditis  is  found  on  examination.  Vomiting,  singul- 
tus, dysphagia,  recurrent  nerve  paralysis,  and  tracheal  cough,  are 
symptoms  of  pericardial  pressure. 

Physical  Findings.— The  definite  diagnosis  depends  on  the  physical 
findings.    These  are  obtained  as  follows: 

1.  Inspection. — Precordial  prominence,  voussure,  first  noted  by 
Louis,  may  occur  when  the  chest  is  plastic,  as  in  women  and  children, 
and  when  the  intercostal  muscles  are  paretic  from  inflammatory 
oedema.  The  left  chest  often  moves  less  than  the  right,  since  the  left 
lung  is  usually  compressed.  An  epigastric  tumor-like  bulging  of  the 
luxated  liver  was  noted  by  Auenbrugger  and  Corvisart.  The  apex- 
beat  is  somewhat  lower  when  exudation  depresses  the  diaphragm;  it 
is  more  horizontal,  more  to  the  left,  and  the  dulness  transcends  the  apex 
to  the  left.  The  greater  the  effusion,  the  weaker  the  apex  becomes,  and 
disappearance  of  the  previously  distinct  apexheat  is  all-important.  There 
may  be  only  an  indefinite,  diffuse  cardiac  impulse.  On  bending  for- 
ward the  apex  beat  or  cardiac  impulse  usually  reappears.  The  inter- 
spaces may  bulge.  Collateral  oedema  of  the  chest  wall  (Rendue)  is 
most  rare.  Undulatiori,  described  by  Senac,  is  not  due  to  the  exudate, 
but  to  the  heart  itself.  Graves  and  Stokes  described  tumor-like  extru- 
sion of  the  compressed  lung  above  the  cla"sacle.  According  to  Ewart, 
the  upper  edge  of  the  first  rib  can  be  felt  as  far  as  its  sternal  attach- 
ment, being  separated  from  the  clavicle  ("first  rib  sign").  The  veins 
of  the  thoracic  wall  are  large.  During  convalescence  the  apex  may 
retract  during  the  systole.  The  decubitus  is  usually  dorsal,  or  left- 
sided,  rarely  right-sided,  for  this  compresses  the  sound  lung;  the  head 
and  shoulders  are  usually  elevated,  and  the  attitude  is  fixed  and  rarely 
changed.    The  knee-hand  position  was  noted  in  Zehetmayer's  case. 

2.  Palpation. — Palpation  confirms  the  location  of  the  apex.  The 
friction  rub  is  often  felt.  In  Fuller's  cases  of  palpable  rub,  there  was 
always  external  pericarditis  which  favored  conduction  of  the  pericar- 
dial friction.  Disappearance  of  an  apex  heat  previously  observed,  and 
the  presence  of  a  strong  radial  pulse,  is  very  important,  because  mere 
absence  of  the  apex  is  observed  in  many  conditions.  Epigastric  tender- 
ness on  either  side  of  the  ensiform,  or  tenderness  between  the  attach- 
ments of  the  sterno-mastoid,is  due  to  inflammation  of  the  phrenic  nerve 
(Gueneau  de  Mussy  and  Peter).    Fluctuation  is  practically  never  felt. 

3.  Percussion. — Three  to  five  ounces  of  fluid  are  usually  necessary 
to  produce  distinct  physical  signs,  though  Fraentzel  has  detected  the 
presence  of  one  and  one-half  ounces.  There  are  two  complementary 
recesses  in  the  pericardium:  one  over  the  basal  vessels,  where  the  fluid 
may  accumulate,  in  which  case  it  is  early  revealed  by  a  triangular  dul- 


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PERICARDITIS  WITH  EFFUSION  381 

ness,  whose  apex  is  directed  downward  (Skoda,  von  Dusch,  Oppolzer), 
which  may  compress  the  large  veins  or  arteries;  and  the  other  in  the 
fifth  right  intercostal  space  (Rotch,  Ebstein),  where  the  fluid  exudate 
replaces  the  relative  liver  dulness,  and  is  most  easily  recognized  by 
palpatory  percussion.  Extensive  exudates  produce  an  outline  usually 
designated  as  triangular,  with  the  blunted  apex  upward,  or  as  pyri- 
form  with  the  base  directed  downward.  The  dulness  may  even  reach 
the  interclavicular  notch,  the  right  nipple,  or  the  left  axilla,  and  may 
impinge  on  Traube's  semilunar  space,  extend  beyond  the  left  lobe  of 
the  liver,  compress  the  lungs,  and  markedly  depress  the  diaphragm 
and  liver.  The  dulness  is,  at  times,  trapezoidal  (see  Plate  VIII,  Fig.  F.) 
rather  than  triangular.  Very  massive  exudates  may  be  mistaken  for 
pericarditis  plus  pleurisy  with  effusion.  Though  the  outline  is  roughly 
triangular,  the  right  border  is  more  vertical  than  the  oblique  left  border, 
which  is  beyond  the  apex  beat,  if  the  latter  remains  visible  (Skoda). 
The  apex  beat  is  dislocated  abnormally  when  the  patient  lies  on  his 
side,  because  the  pericardial  sac  is  larger  than  normal,  and  permits 
greater  cardiac  movement.  German  writers  hold  that  the  heart  falls 
back  in  the  fluid,  but  the  French  think  it  comes  forward.  The  dulness 
varies  with  fluctuations  in  the  effusion  and  with  resorption.  When  the 
patient  is  in  the  erect  posture,  the  dulness  may  be  one-third  to  one-half 
as  broad  again  as  when  he  is  in  the  dorsal  position;  it  also  is  not  so 
high  (Gerhardt).  This  is  not  invariable,  because  the  lung  borders 
must  be  normal  and  the  exudate  freely  movable  to  allow  free  shifting 
of  the  fluid.  Sahli  also  found  increase  in  dulness  when  the  subject  was 
in  the  sitting  posture  in  case  of  an  enlarged  heart,  and  in  valvular  disease; 
this  he  explains  as  caused  by  depression  of  the  diaphragm,  or  by  the 
emptying  of  the  blood  from  the  auricles.  He  thinks  the  lateral  more 
important  than  the  upper  border.  Sitting  is  usually  unnecessary  and 
often  dangerous  to  the  patient.  Change  of  the  dulness,  especially 
when  the  patient  lies  on  the  right  side  (Rosenbach),  is  important,  for 
this  is  uncommon  physiologically,  whereas  the  shifting  of  dulness  in 
the  left  decubitus  is  of  minor  value. 

Dulness  may  persist  from  cardiac  dilatation,  or  from  pulmonary 
retraction.  The  effusion  may  be  enormous  (10  quarts,  Kyber;  or 
8  pounds,  Corvisart),  and  may  lead  to  a  diagnosis  of  pleurisy,  or 
pleurisy  plus  pericarditis.  As  the  normal  pericardial  sac  holds  only 
two-thirds  to  three-quarters  of  a  quart  (650  to  800  c.c),  the  pericardium 
must  be  greatly  relaxed  by  the  inflammation,  to  allow  such  large  effu- 
sions. The  pericardial  dulness  may  not  be  typical  when  the  effusion 
is  largely  covered  by  emphysematous  lungs,  or  when  the  borders  of  the 
lung  are  adherent  and  cannot  be  pushed  back  by  the  effusion. 

4.  Auscultation. — Auscultation  reveals  the  chief  and  most  reliable 
diagnostic  sign,  the  pericardial  friction  due  to  attrition  of  the  inflamed 
pericardial  surfaces,  (a)  It  is  usually  a  'Ho-and-jro"  rubbing  which 
is  not  exactly  synchronous  with  either  the  systole  or  diastole,  which 
character  is  most  clear  when  the  heart  is  slow.  It  is  less  often  single, 
and  occurs  mostly  late  in  the  systole;  it  may  be  triple,  i.e.,  presystolic, 


382  DISEASES  OF   THE  CIRCULATION 

systolic,  and  diastolic.  It  is  often  absent  in  fibrinous,  hemorrhagic,  or 
purulent  inflammation.  In  contradistinction  to  pleurisy,  where  the 
effusion  of  fluid  abolishes  the  primary  friction,  it  may  be  present,  even 
with  great  exudation  (Stokes),  especially  at  the  base,  since  here  the 
heart  may  displace  the  fluid  and  touch  the  parietal  pericardium.  A 
certain  consistence  of  the  fibrin  seems  necessary  to  friction,  for  the 
latter  is  absent  in  very  soft  fibrinous  deposits.  (6)  In  quality,  it 
may  be  harsh,  soft  like  a  gentle  and  interrupted  scratching  of  the 
ear  with  the  finger,  whistling,  creaking,  crunching,  musical,  or 
even  metallic  (resonance  from  the  stomach  or  intestines).  (c)  In 
location,  it  is  most  often  heard  over  the  base  or  the  tricuspid  region, 
where  it  is  especially  significant.  It  may  also  be  heard  over  the  apex. 
Sears  describes  a  case  in  which  the  friction  was  heard  most  clearly 
at  the  angle  of  the  left  scapula,  (d)  It  is  very  superficial,  and  close 
to  the  ear,  not  deep  as  in  endocardial  murmurs.  Superficiality  of 
the  friction  sound  is  absent  when  partial  adhesions  exist  anteriorly, 
and  the  fluid  accumulates  behind  the  heart.  (e)  Its  propagation 
is  not  wide  (il  nait  et  meurt  sur  place,  Jaccoud),  though  it  has  been 
heard  at  a  distance  of  nine  feet.  In  children  it  may  be  heard  over  the 
whole  chest,  and  the  author  has  once  seen  the  same  in  an  adult.  Coin- 
cident hydrothorax  (Graves)  has  been  thought  to  favor  its  propagation, 
and  cardiac  hypertrophy,  iDy  bringing  the  heart  closer  to  the  chest 
wall,  propagates  the  friction  more  widely  (Stokes).  The  murmur 
usually  ceases  abruptly  when  the  stethoscope  has  been  removed  a 
short  distance.  It  does  not  follow  the  same  lines  of  propagation  as  it 
does  in  valvular  heart  disease.  Propagation  along  the  sternum  is  not 
uncommon.  (/)  Inspiration  usually  increases  the  murmur  (Traube), 
and  this  is  due  to  the  closer  apposition  of  the  pericardial  leaves,  caused 
by  the  movable  wedge  of  expanding  lung.  (Sometimes  it  is  more 
marked  during  expiration  [Lewinski,  Paul],  particularly  when  adhe- 
sions exist  between  the  heart  and  lung  [Riegel].)  {g)  Moderate  pres- 
sure usually  increases  the  friction,  especially  in  plastic  chests,  though 
pressure  may  also  accentuate  valvular  murmurs,  and  much  pressure 
may  inhibit  the  cardiac  action  (Friederich).  Change  of  posture  (Cor- 
rigan,  Stokes),  e.  g.,  leaning  forward,  often  makes  the  murmur  clearer. 
(h)  The  murmur  is  variable,  now  present,  now  absent,  now  systolic, 
or  again  systolic  and  diastolic,  varying  in  acoustic  properties,  or  chang- 
ing with  change  of  posture;  it  is  often  short  lived,  lasting  sometimes 
but  two  to  six  hours.  It  is  frequently  stated  that,  as  exudation  in- 
creases, the  friction  disappears,  but  returns  again  during  absorption. 
"It  increases  upward  during  exudation,  and  downward  during  absorp- 
tion" (Sibson).  Nevertheless,  friction  often  persists  when  there  are 
large  exudations,  if,  indeed,  its  persistence  is  not  invariable  (Walshe). 
Balfour  claims  that  friction,  once  heard,  is  never  effaced  by  even  the 
greatest  effusion.  It  is  not  dependent  on  the  intensity  of  the  inflamma- 
tion, but  rather  upon  the  accidental  quality  of  the  effused  lymph  and 
its  location.  Disappearance  of  the  rub  is  explained  by  (i)  regression; 
(ii)  exudation;   (iii)  adhesions;   (iv)  weak  heart. 


PERICARDITIS  WITH  EFFUSION  383 

As  a  rule,  the  heart  tones  gradually  become  more  or  less  weakened 
and  distant. 

The  x-rays  outline  the  pericardial  effusion. 

Secondary  Physical  Signs. — There  may  be  evidences  of  cardiac 
incompetence,  which  is  due  to  the  mechanical  hindrance,  by  the  fluid, 
of  the  diastole,  especially  of  the  auricles;  it  is  also  due  to  myocardial 
inflammation  or  degeneration,  or  to  coincident  cardiac  disease.  The 
signs  of  cardiac  incompetence  are  hepatic  and  renal  stasis,  ascites, 
oedema,  cyanosis,  dyspnoea,  cerebral  anaemia  (syncope),  distention 
and  pulsation  in  the  jugular  veins,  and  oedema  of  the  lungs.  The  pulse 
at  first  undergoes  irritative  acceleration,  but  a  lasting  frequency  in- 
dicates myocardial  change.  It  may,  in  exceptional  cases,  be  normal, 
or  even  slow  (to  36),  as  a  result  of  compression.  There  is  no  charac- 
teristic pulse;  dicrotism  is  frequent;  there  may  be  the  pulsus  para- 
doxus (weakening  or  intermitting  with  each  inspiration  [Traube]).  A 
very  strong  or  water-hammer  pulse  may  suggest  underlying  valvular 
disease.  Irregularity  is  occasional,  as  is  the  pulsus  differens  and 
difference  in  the  pupils.  Lung  coTnpression  is  frequent.  Bamberger 
observed  a  small  area  of  compression,  the  size  of  a  dollar,  at  the  angle 
of  the  left  scapula,  where  bronchial  breathing,  dulness  (or  tympany), 
and  increased  fremitus,  are  noticed;  the  compression  clears  up  when 
the  patient  assumes  the  knee-chest  posture  (Pins).  Pleural  puncture 
excludes  the  possibility  of  fluid  in  doubtful  cases,  and  the  absence  of 
crepitant  rales  excludes  pneumonia.  Bamberger's  sign  occurred  in 
cases  of  hsemopericardium  (Allbutt).  There  may  be  tympany  (or 
dulness)  under  the  left  clavicle  and  to  the  left  (and  sometimes  to  the 
right)  of  the  heart  in  cases  where  there  is  a  fair-sized  effusion.  Ewart 
describes  tubular  breathing  near  the  right  mamma. 

Thrombosis  of  the  innominate  veins  may  result  from  compression. 
Walshe  observed  tracheal  compression.  The  second  pulmonic  sound 
may  be  accentuated,  which  Warthin  regards  as  an  early  sign.  The 
second  tone  may  be  split  (Skoda),  Metallic  heart  tones  may  be  due 
to  an  adjacent  cavity,  to  pneumothorax,  or  to  the  stomach  and  intes- 
tines. A  systolic  non-valvular  murmur  over  the  aorta  has  been  explained 
by  pressure  on,  or  inflammatory  relaxation  of,  the  vessels,  thus  inter- 
fering with  their  normal  vibration.  Organic  valvular  or  accidental 
murmurs  may  occur. 

Diagnosis. — Differentiation  rests  upon  (1)  the  friction,  and  (2)  the 
dulness,  or  on  both,  with  constant  attention  to  (3)  the  apex  beat.  Sub- 
division into  types,  such  as  acute  or  chronic,  fibrinous,  serofibrinous, 
seropurulent,  purulent,  ichorous,  or  hemorrhagic,  is  inadvisable,  as 
puncture  alone  reveals  the  character  of  the  exudate.  Fibrin  forma- 
tion and  serous  exudation  usually  coexist  (Latham), 

1.  The  Pericardial  Rub. —  The  pericardial  rub  is  practically  patho- 
gnomonic of  pericarditis  (Von  Dusch).  (It  has  resulted  on  rare  occa- 
sions in  cholera  from  tissue  dryness,  in  tubercles,  cancer,  soldier's  spots, 
hemorrhage,  hypertrophied  heart,  and  inflammation  of  the  diaphragm 


384  DISEASES  OF  THE  CIRCULATION 

or  of  the  peritoneum,  in  which  cases  the  heart  beats  against  the  in- 
flamed surface.) 

(a)  In  distinguishing  it  from  endocardial  murmurs,  the  acoustic  qual- 
ity, superficial  character,  lack  of  rhythmic  precision,  variability,  slight 
propagation,  palpatory  difference  in  the  rub,  the  basal  location,  and  in- 
crease of  the  pericardial  friction  by  pressure  or  inspiration  are  most 
decisive.  Sometimes  pericardial  friction  obscures  a  concomitant  or 
preexisting  endocarditic  bruit.  The  distinction  is  sometimes  difficult, 
between  an  aortic  to-and-fro  murmur  and  pericardial  friction. 
Valsalva's  experiment — i.  e.,  a  long  inspiration  with  closed  glottis  fol- 
lowed by  expiration  with  tense  abdominal  muscles — intensifies 
pericardial  friction  and  decreases  endocardial  murmurs.  Bearing  in 
mind  the  great  frequency  with  which  pericarditis  is  a  complication 
(or  coordinate  phenomenon)  of  endocarditis,  this  special  point  neces- 
sitates reserve  in  the  prognosis,  because  the  valvular  disease  remains 
after  the  pericarditis  subsides. 

(6)  It  must  be  differentiated  from  pi  euro  pericardial  friction  (pseudo- 
or  extrapericardial)  originating  in  the  inflamed  pleura,  where  friction 
depends  not  only  on  respiration,  but  also  on  the  heart's  action.  The 
usual  distinction  lies  (i)  in  the  close  connection  of  the  pericardial  rub 
with  the  cardiac  activity,  which  persists  during  expiration,  and  (ii)  in 
the  location  of  the  pleuropericardial  friction  in  the  sinus  mediastino- 
costalis  (along  the  lingual  lobe),  in  its  intimate  relation  to  respiration 
and  in  its  usual  cessation,  either  at  extreme  inspiration  or  expiration 
(Stokes,  Addison).  This  method  of  differentiation  is  not  infallible, 
for  inspiration  also  augments  true  pericardial  friction,  which  is, 
however,  increased  by  bending  forward.  Valsalva's  test  {v.  s.)  is  also 
useful.  Pericardial  friction  toward  the  base  or  sternum  is  less  often 
confused  with  pleural  friction.  Rosenbach  finds  differentiation  most 
difiScult  when  the  basal  vessels  come  in  contact  with  a  tuberculous 
cavity  or  pneumonia. 

(c)  Differentiation  from  precordial  emphysema  is  possible  on  account 
of  the  crackling  sounds  of  interstitial  emphysema  (air)  in  the  anterior 
mediastinum.  The  sounds  resemble  rales,  but  are  closely  associated 
with  the  heart's  action  and  are  often  metallic.  The  condition  of  the 
heart  tones  is  decisive. 

(d)  Differentiation  from  pericardial  splashing  (see  Pneumoperi- 
cardium). 

(e)  Crepitant  rales  are  easily  differentiated. 

2.  The  Dulness  of  Pericardial  Exudation, — typically  pyriform  or  trian- 
gular,— is  modified  by  pleural  or  pericardial  adhesions,  and  by  pulmo- 
nary emphysema.  The  relative  cardiac  dulness  (which  may  be  markedly 
increased)  should  be  considered  rather  than  the  absolute  dulness 
(which  is  often  little  altered). 

(a)  Hydropericardium  and  effusive  pericarditis  may  be  confused, 
because  stasis  with  hydrops  pericardii  may  intervene  in  pericarditis, 
the  friction  may  be  absent  or  disappear,  and  fever  may  be  lacking 
(chronic  pericarditis).      Hydropericardium  shows  its  etiological  fac- 


PERICARDITIS  WITH  EFFUSION  385 

tors.  These  are  local  pericardial  changes  or  a  general  cause  for  hy- 
drops, and  are  differentiated  by  previous  anasarca  or  hydrothorax, 
which  alnSost  always  develops  first,  by  lower  dulness,  by  resorp- 
tion under  digitalis  and  purges,  by  absence  of  friction,  and  by  para- 
centesis, which  reveals  the  usual  differences  between  exudates  and 
transudates  in  their  opacity,  specific  gravity,  and  percentage  of 
albumin  (see  Pleurisy). 

(&)  HcBmopericardium,  resulting  from  trauma  and  rupture  of  a  coro- 
nary artery,  or  from  ventricular  or  aneurysmal  rupture,  is  usually  sud- 
den, is  attended  by  syncope,  and  blood  is  removed  by  puncture. 

(c)  Pneumopericardium  (q.v.).  (d)  From  cardiac  dilatation  the  differ- 
entiation may  be  most  difficult,  especially  when  there  is  dilatation  plus 
hydrops  pericardii,  in  which  case  drastics,  digitalis,  friction,  the  history 
and  evolution  only,  may  decide.  In  dilatation  the  dulness  is 
rarely  triangular  but  rather  is  increased  laterally,  the  shock-like  im- 
pulse of  the  heart  is  more  marked  and  often  contrasts  sharply  with  the 
weak  radial  pulse,  compression  of  the  lung  is  much  more  uncommon,  and 
the  heart  tones  are  more  clear  and  "snappy."  The  very  distinctive  re- 
lation between  the  apex  and  the  outer  dulness  to  the  left  is  rarely  fallible 
{v.  s.).  If  the  pulse  is  strong  and  the  apex  weak,  pericarditis  is  present 
(with,  of  course,  the  typical  dulness);.  but  compression  or  weakness  of 
the  heart  in  pericarditis  necessitates  a  weak,  rapid  pulse.  In  both  af- 
fections the  heart's  dulness  is  increased  by  leaning  forward;  but  this 
may  clearly  demonstrate  the  apex  within  the  dulness  of  the  exudate. 
When  the  patient  lies  on  his  right  side  the  apex  in  pericardial  effusion 
becomes  visible  (Rosenbach),  which  does  not  obtain  in  cases  of  en- 
larged heart.  In  children  the  diagnosis  of  pericardial  effusion  is  often 
made  incorrectly ;  the  dulness  is  equally  often  a  dilatation,  (e)  When  there 
is  retraction  of  the  left  lung  away  from  the  heart,  the  diaphragm  is  high, 
the  apex  and  outer  cardiac  dulness  coincide,  the  spleen  is  high,  the  pul- 
monary artery  is  exposed,  and  the  proper  signs  of  pulmonary  contrac- 
tion are  elicited  (Leube).  (/)  In  cases  of  mediastinal  tumor  the  dulness 
is  irregular;  there  is  no  variation  of  dulness  on  postural  change;  the 
signs  of  increased  conduction  and  bronchial  breathing  are  noted  with 
the  absence  of  the  cardinal  signs  of  pericarditis,  (g)  From  aneurysm 
the  differentiation  is  usually  possible,  as  well  as  from  marginal  infil- 
tration of  the  lung;  callous  pleura,  encapsulated  pleurisy,  superabun- 
dant fat  (Walshe);  and  anterior  mediastinitis  (usually  with  friction, 
but  with  more  vertically  elongated  dulness). 

Diagnosis  of  the  Character  of  the  Exudate.— The  fluid  is  serofibrin- 
ous in  rheumatism;  ichorous  in  perforation  from  hollow  viscera;  hem- 
orrhagic in  scurvy,  carcinoma,  tuberculosis,  hemorrhagic  exanthemata, 
and  alcoholism;  and  purulent  in  sepsis  and  empyema.  Paracentesis 
is  the  only  certain  test.  Tuberculous  pericarditis,  even  in  clearly 
tuberculous  cases,  can  be  diagnosticated  positively  only  by  detection  of 
tubercle  bacilli  in  the  aspirated  exudate;  a  chronic  pericarditis  is  prob- 
ably tuberculous.  In  children  30  per  cent,  of  pericarditides  are  suppur- 
ative and  17  per  cent,  are  tuberculous  (Baginsky). 

25 


386  DISEASES  OF  THE  CIRCULATION 

Course. — The  clinical  course  is  variable;  exudation  may  follow  the 
friction  in  a  short  time  or  only  after  many  days.  The  exudate  may  be 
rapidly  absorbed  in  a  few  days  or  may  endure  for  weeks  or  months. 
The  average  duration  is  one  or  two  weeks.  In  convalescence  the  heart 
may  long  remain  irritable  on  exertion. 

Prognosis. — The  prognosis  depends  largely  upon  the  physiological 
resistance,  the  causal  disease,  and  the  character  and  quantity  of  the 
fluid;  it  is  usually  good  in  rheumatic  and  serofibrinous  cases.  Septic, 
purulent,  putrid,  or  hemorrhagic  types,  are  more  serious.  The  pneu- 
mococcic  form  is  fatal  in  50  to  7-5  per  cent.  Pericarditis  is  most  danger- 
ous in  the  very  young  or  aged.  Death  may  be  rapid  in  hemorrhagic 
cases;  it  usually  is  due  to  cardiac  exhaustion,  especially  in  cases  of 
long-standing,  and  results  from  myocarditis  rather  than  from  simple 
pressure.  The  prognosis  is  more  favorable  in  men  than  in  women  and 
children. 

Treatment. — 1.  The  hygienic  treatment  should  be  managed  as  it  is 
in  any  acute  infection  with  cardiac  involvement. 

2.  Absolute  rest  in  bed  is  indicated,  in  order  to  spare  the  heart, 
even  during  convalescence.  The  patient  should  never  be  allowed  to 
sit  up  or  leave  the  bed,  even  to  urinate  or  defecate,  for  severe  or  fatal 
syncope  may  follow  the  effort.    . 

3.  Laxatives  should  be  given,  for  constipation  jper  se  may  increase 
the  heart  action,  and  difiicult  bowel  movements,  with  the  attendant 
straining,  weaken  or  paralyze  the  heart.  Sod.  phosphate  5ss.  to  ij,  is 
an  excellent  laxative. 

-  4.  The  diet  should  be  light  or  fluid,  and  tea  and  coffee,  which  excite 
the  heart,  should  be  avoided.  Alcohol  may  be  given  when  a  septic 
process  prevails  or  when  the  patient  is  accustomed  to  its  regular 
use. 

.5.  Local  antiphlogistic  measures  should  be  employed.  An  ample  ice- 
bag  upon  the  precordia  quiets  and  regulates  the  heart-rate,  and 
relieves  palpitation  and  pain.  The  author  believes  that  it  is  often  a 
better  cardiant  and  sedative  than  drugs.  Leeches  may  be  applied 
after  drawing  some  blood  by  small  scratches  over  the  heart;  their 
action  is  regulated  by  applying  salt,  which  causes  them  to  release  their 
hold.  A  Spanish-fly  blister,  as  large  as  the  hand,  often  not  only  relieves 
pain  but  stimulates  resorption.  It  must  be  dressed  carefully  with 
weak  carbolic  salve  and  gauze.     Cupping  may  be  of  service. 

6.  The  cause  should  be  treated.  Therapy  of  the  underlying  disease 
is  indicated, — such  as  the  use  of  salicylates,  in  the  rheumatic  form. 

7.  Heart  stimulation  is  indicated  when  the  pulse  is  irregular,  fast, 
or  small,  for  this  is  due  to  early  cardiac  irritation  or  to  later  mechanical 
compression  of  the  heart  and  lungs  by  the  exudate  (see  Treatment 
OF  Valvulae  Diseases).  Alcohol  should  frequently  be  given  (see 
Typhoid  Fever  and  Pneumonia  for  its  action  and  indications). 
Strychnia,  coffee,  and  camphor,  operate  more  quickly  than  digitalis; 
they  can  also  be  used  to  follow  up  its  action.  Cardiac  depressants, 
such  as  aconite,  are  to  be  carefully  avoided. 


ADHESIVE  PERICARDITIS  387 

8.  Treatment  of  the  fever  depends  on  the  basic  disease.  Hydro- 
therapy is  preferable  to  the  use  of  antipyretics. 

9.  Compression  symptoms,  such  as  dyspnoea,  insomnia,  and  vomit- 
ing, when  mild  in  degree  or  not  of  long  standing,  are  met  by  the 
judicious  use  of  morphine  hypodermatically.  Tardy  resorption  of 
large  exudates  or  sudden  or  severe  symptoms  therefrom  necessitate 
tapping  of  the  pericardial  sac,  under  the  general  precautions  observed 
in  pleural  aspiration.  The  puncture  is  made  in  the  fifth  left  (or  right) 
interspace  about  an  inch  from  the  sternum,  where  the  sac  is  not  covered 
by  the  pleura.  Care  and  gentleness  in  passing  the  trocar  enable  us 
to  feel  the  giving  way  of  the  parietal  pericardium  and  to  avoid  cardiac 
trauma.  Removal  of  but  a  small  quantity  frequently  provokes  absorp- 
tion by  relaxation  of  the  vessels  in  the  tense  pericardium,  although 
results  are  sometimes  disappointing.  Sudden  or  extreme  cardiac  embar- 
rassment may  necessitate  free  venesection. 

10.  Special  indications  in  various  forms  of  the  disease  are  encoun- 
tered. Ergot  is  indicated  in  the  hemorrhagic  type,  alcohol  in  drinkers, 
and  care  of  the  kidneys  in  nephritis. 

11.  Delayed  absorption  is  treated  by  potassium  iodide  gr.  x  to  xx,  by 
diuretin  60  to  90  gr.  per  diem,  and  by  small  doses  of  calomel  followed 
by  salines.  Hot  packs,  alcohol  sweats,  and  pilocarpine,  should  be  most 
cautiously  employed  or  entirely  avoided,  for  with  their  use  symptoms  of 
collapse  occur  quite  frequently. 

12.  Early  pericardiotomy  is  indicated  in  suppurative  or  putrid 
forms  when  the  causal  disease  permits  it.  About  one-half  of  the  cases 
recover. 

Adhesive    Pericarditis. 

(Pericardial  Concretion  [Synechia];  Cicatricial  [Callous]  Mediastino- 

Pericarditis.) 

Though  pericarditis  may  resolve  completely,  local  adhesions  within 
the  sac  or  more  extensive  bands  to  the  chest  wall,  pleura,  spine  or  other 
structures,  are  frequent.  They  develop  in  41  per  cent,  of  cases  of  peri- 
carditis (Breitung)  and  are  found  in  6  per  cent,  of  autopsies  (Leudet). 
In  one  group  of  cases,  complete  obliteration  of  the  sac  may  occur  with 
absolute  clinical  latency;  the  heart  may  beat  itself  loose  from  fresh  or 
lax  adhesions,  especially  when  they  are  located  about  the  apex. 
In  a  second  group,  there  are  undistinctive  evidences  of  cardiac 
insufficiency.  In  a  third  series,  distinctive  physical  signs  exist. 
Adhesions  most  frequently  follow  serofibrinous  pericarditis.  A  clear 
history  or  the  actual  observation  of  a  previous  pericarditis  is  one  of  the 
strongest  points  in  the  diagnosis. 

Symptoms. — 1.  Cardiac  insufficiency  is  caused  by  pressure  on  the 
coronary  arteries,  by  myocardial  fibrosis  and  degeneration,  but  more 
often  by  dilatation  or  atrophy.  Though  severe  heart  symptoms  in 
advanced  life  without  valvular  disease  are  indicative  of  myocardial 


388  DISEASES  OF   THE  CIRCULATION 

degeneration,  in  the  young  they  suggest  pericardial  adhesions 
(Wilks).  Evident  failure  of  the  right  ventricle  without  valvular, 
renal,  or  pulmonary  disease,  or  with  sudden  break  in  compensation 
in  the  usual  valvular  lesions,  directs  attention  to  possible  pericardial 
adhesions.  Weiss  and  Pick  have  called  attention  to  an  isolated  ascites 
which  is  not  found  in  simple  cardiac  incompetency,  but  is  usually 
associated  with  large  liver  and  somtimes  with  fibrous  peritonitis;  it  is 
probably  due  to  the  extension  of  inflammation  along  the  vessels  from 
the  pericardium  to  the  peritoneum.  Sudden  death  is  sometimes  due 
to  pericardial  synechise  (Aran). 

2.  Systolic  retraction  of  the  interspaces  at  the  apex  may  occur 
even  with  slight  basal  adhesions  which  hinder  the  systolic  descent  of 
the  heart,  while  diffuse  adhesions  other  than  basal  often  produce  no 
symptoms.  It  is  especially  significant  when  the  normal  systolic  pro- 
trusion has  been  gradually  replaced  after  pericarditis  by  systolic 
retraction,  for  retraction  of  the  apex  also  occurs  in  other  conditions. 
Systolic  retraction  is  merely  an  expression  of  impaired  locomotion  of 
the  heart  and  of  lack  of  space  at  the  apex.  It  is  best  seen  on  deep  in- 
spiration and  disappears  when  the  heart  grows  weak.  Retraction  of 
the  apex  can  be  seen,  and  can  also  be  felt. 

3.  Retraction  (not  merely  of  the  apex  but)  of  the  sternum,  epi- 
gastrium (Oppolzer),  diaphragm,  and  lower  chest  wall,  may  be  observed 
when  adhesions  also  exist  outside  of  the  pericardium  in  the  mediasti- 
num (Skoda) ;  it  is  indicative  of  indurative  mediastinitis,  which  attaches 
the  heart  anteriorly  to  the  chest  wall  and  posteriorly  to  the  spine,  and 
necessitates  retraction  unless  cardiac  weakness  develops.  Broadbent's 
sign  is  a  systolic  retraction  of  the  eleventh  and  twelfth  ribs  posteriorly 
and  on  the  left  side. 

4.  The  diastolic  recoil  (Friedreich),  due  to  rebound  of  the  retracted 
diaphragm  and  chest  wall,  is  recognized  by  palpation  and  by  ausculta- 
tion as  a  dull  vibration  which  may  cause  the  second  tone  to  appear 
doubled. 

5.  Diastolic  collapse  of  the  cervical  veins  (Skoda)  is  of  great  diag- 
nostic value,  and  is  due  to  their  aspiration  by  the  heart;  it  is  some- 
times dicrotic  and  may  produce  diastolic  pallor  of  the  face.  The  cervical 
veins  often  swell  with  the  systole. 

6.  The  pulsus  paradoxus  (a  pulse  intermitting  with  inspiration) 
strongly  suggests  cicatricial  mediastinopericarditis,  particularly  when 

Fig.  21. 


Pulsus  paradoxus  (Kussmaul);  E,  beginning  of  expiration,  and  J,  of  inspiration. 

observed  with  the  signs  previously  mentioned.  It  is  observed  to  a 
moderate  extent  physiologically  and  is  sometimes  seen  in  other  condi- 
tions which  lessen  the  entrance  of  air  into  the  lungs  or  render  the  heart 
sensitive,  especially  in  myocarditis  (Riegel).    It  is  due  in  mediastino- 


ADHESIVE  PERICARDITIS  389 

pericarditis  to  inspiratory  stretching  of  the  great  vessels  by  well- 
attached  mediastinal  adhesions,  which  shuts  off  the  blood  supply  to 
the  extrenaities.  It  is  a  mediastinal  symptom,  and  occurs  (a)  when  the 
arterial  system  is  poorly  filled,  and  hence  is  more  important  when  the 
heart  tones  are  normal  or  stronger  than  normal,  and  (6)  when  the 
return  venous  flow  is  retarded.  Schreiber  holds  it  pathognomonic  when 
(i)  it  appears  without  forced  inspiration,  (ii)  when  the  radial  and  all 
other  pulses  are  completely  suspended  by  inspiration,  (iii)  when  the 
heart's  action  is  regular  and  (iv)  when  it  is  combined  with  inspiratory 
swelling  of  the  cervical  veins  (v.  i.).  Struempell  observed  slowing  of 
the  pulse  during  inspiration.  This  was  explained  by  him  as  irritation 
of  the  vagus  by  the  mediastinal  connective  tissue. 

7.  Inspiratory  swelling  of  the  neck  veins  (Kussmaul),  which  nor- 
mally collapse  during  inspiration,  is  due  to  the  same  mechanism 
as  the  pulsus  paradoxus.  Inspiration  stretches  the  mediastinal  bands, 
which  constrict  the  large  venous  trunks  and  interrupt  the  return 
venous  flow.     Cyanosis  may  occur  with  each  inspiration. 

8.  Other  signs  are  fixation  of  the  heart  by  adhesions,  which  gives 
no  change  of  dulness  by  change  of  posture  (von  Dusch);  absence  of 
respiratory  excursion  over  the  heart;  decrease  of  Traube's  semilunar 
space  by  pleural  adhesions  (Jaccoud);  decreased  movement  of  the 
left  half  of  the  epigastrium  (diaphragmatic  adhesion  to  heart) ;  expira- 
tory weakening  of  the  apex  by  pleural  adhesions  (Tuczek-Riegel); 
weak  right  heart  with  no  accentuation  of  second  pulmonic  tone;  loud, 
even  musical,  murmurs, especially  in  the  aged;  systolic  emptying  of  the 
veins  of  the  thorax  due  to  systolic  dilatation  of  the  internal  mammary 
veins  (Broadbent);  a  rumbling  presystolic  murmur  (Fischer,  Hale 
White)  at  the  apex,  especially  in  children,  without  signs  of  mitral 
stenosis;  precordial  creaking  (Perez)  when  the  patient  moves  the  arm; 
and  other  mediastinal  symptoms,  e.g.,  left  recurrent  laryngeal  paralysis, 
venous  thrombosis  in  arm,  etc. 

Diagnosis.— In  the  diagnosis,  two  groups  of  symptoms  are  observed: 
first,  the  myocardial  (dilatation,  hypertrophy,  relative  tricuspid  in- 
sufficiency); and  second,  the  mediastinal  (pulsus  paradoxus,  etc.) 
(See  Pick's  Pericarditic  Pseudocirrhosis,  under  Diagnosis  of 
Hepatic  Cirrhosis.) 

Prognosis. — The  heart  must  suffer  to  a  varying  extent  when  its 
movement  is  impaired,  whence  the  prognosis  depends  upon  the  condi- 
tion of  the  myocardium. 

Treatment. — The  treatment  is  identical  with  that  of  valvular 
disease  {q.  v.)  or  of  mj ocardial  insufficiency  in  general.  Brauer  advo- 
cates surgical  solution  of  the  adhesions  (cardiolysis) ;  about  a  dozen 
operations  are  reported.  The  heart  muscle  must,  however,  be  in  good 
condition  to  warrant  surgical  interference. 


390  DISEASES  OF   THE  CIRCULATION 


PNEUMOPERICARDIUM. 

The  presence  of  gas  or  air  in  the  pericardium  is  very  infrequent; 
James  (1904)  could  collect  but  38  cases. 

Etiology. — It  results  (a)  from  trauma,  such  as  perforating  wounds; 
(b)  from  perforative  processes  from  cavities  or  viscera  containing  air  or 
gas,  such  as  pulmonary  cavities;  from  gangrene,  pneumothorax, 
oesophageal  ulcers  or  neoplasms;  gastric  ulcer,  liver  abscesses,  or 
caseated  bronchial  glands.  There  is  almost  always  fluid,  which  may  be 
ichorous,  hemorrhagic,  purulent  (pyopneumopericardium),  or  more 
rarely  serous  (hydropneumopericardium).  (c)  Exceptional  instances 
of  spontaneous  gas  development  without  solution  of  continuity  have 
been  observed,  due  to  the  Bacillus  aerogenes  encapsulatus. 

Diagnosis. — On  inspection,  there  is  precordial  bulging  and  absence 
of  the  apex  beat,  though  this  may  reappear  upon  leaning  forward.  On 
falpation,  the  vocal  fremitus  about  the  heart,  and  the  apex  beat  are 
gone,  friction  and  occasionally  splashing,  churning,  gurgling  sounds 
may  be  felt.  On  percussion,  when  the  patient  is  sitting,  a  tympanitic 
or  even  metallic  note  is  obtained  above  or  indeed  over  the  entire 
heart,  especially  when  percussion  is  made  with  the  plessimeter  and 
the  hard  part  of  the  percussion  hammer  or  the  finger-nail.  Fluid 
is  usually  detected  when  the  patient  is  in  the  sitting  or  lateral 
decubitus. 

The  tympanitic  note  heard  above,  and  the  fluid  below,  is  present  only 
when  no  adhesions  are  present  and  varies  during  the  systole  and  dias- 
tole; it  becomes  higher  in  the  erect  posture  and  varies  with  the  amount 
of  exudation.  The  change  in  note  on  change  of  posture  and  the  con- 
dition of  the  apex  depend  upon  hydrostatic  laws,  as  is  the  case  in 
pneumothorax.  The  lung  is  compressed.  On  auscultation,  the  heart 
tones  vary  with  the  fluid,  being  loud  if  there  is  no  great  effusion,  and 
usually  metallic  or  musical,  like  a  sound  from  a  zither.  The  same  is 
true  of  the  quality  of  the  friction  (for  pericarditis  is  almost  invariably 
present).  The  tones,  the  metallic  tinkling  or  splashing,  the  falling- 
drop  sound,  the  mill-wheel  churning  and  succussion,  may  be  heard  at 
a  distance.  They  may  keep  the  patient  awake  and  may  be  heard  in  an 
adjacent  room,  as  in  cases  of  Stokes,  Laennec,  and  Graves. 

Differentiation  is  required  from  cavities  or  encapsulated  pyopneu- 
mothorax near  the  heart.  Consideration  of  the  heart  dulness,  even 
though  it  be  dislocated, and  of  the  apex  beat,  renders  the  diagnosis  easy. 
Confusion  with  distention  of  the  stomach,  which  imparts  a  metallic 
note  to  the  heart  tones,  is  similarly  excluded. 

Prognosis. — Death  occurs  in  70  per  cent,  of  the  cases  and  usually 
results  within  two  weeks,  from  the  causal  disease  and  from  cardiac 
insufficiency.    Recovery  is  most  probable  in  the  traumatic  cases. 

Treatment. — Treatment  is  the  same  as  in  pericarditis.  Puncture  to 
void  the  gas,  and  operation  for  putrid  or  purulent  processes,  are  indi- 
cated. 


H^MOPERICARDIUM  391 


HYDROPERICARDIUM  (HYDROPS  PERICARDII.) 

Hydropericardium  is  always  secondary  to  (a)  circulatory  disturhances , 
such  as  heart  or  pulmonary  lesions,  or  local  obstruction  in  the  peri- 
cardial veins;  the  latter  is  infrequent;  or  (6)  cachectic  conditions  pro- 
ducing blood  alteration  and  transudation,  such  as  Bright's  disease,  or 
carcinoma. 

Sjnnptoms. — They  are  much  the  same  as  in  pericarditis,  except  that 
friction  is  absent.  The  heart  region  is  sometimes  prominent,  the  apex 
beat  is  lost,  the  heart  tones  are  distant,  the  fluid  changes  with  change  of 
posture,  the  dulness  is  clearly  triangular  or  trapezoidal  since  no  adhe- 
sions exist.  In  most  autopsies  a  small  amount  of  fluid  is  found  which 
transudes  during  the  death  agony  or  after  death.  In  hydropericardium, 
the  fluid *is  yellow-green,  and  is  sometimes  slightly  tinged  with  blood. 
Cholestearin  crystals  are  sometimes  found.  Evidences  of  inflammation 
are  absent.  The  fluid  is  alkaline,  contains  some  albumin,  sugar,  and 
urea,  and  is  of  low  specific  gravity.  Chyle-like  effusions  (chyloperi- 
cardium)  are  very  rarely  seen. 

Diagnosis. — The  signs  of  fluid  are  the  same  as  they  are  in  pericardi- 
tis {q.  V.  for  differentiation),  but  there  is  no  temperature,  tenderness, 
nor  friction  murmur.  Dilatation  of  the  heart  causes  the  most  frequent 
diagnostic  confusion  and  is  differentiated  as  it  is  in  pericarditis.  The 
etiological  diagnosis  is  most  important,  such  as  finding  a  cardiac  lesion 
in  the  first  and  renal  lesion  in  the  second  group. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  depend 
wholly  on  the  cause.  Cardiac  stimulants,  blisters  over  the  heart,  la.x- 
atives,  etc.,  are  indicated. 


H-ffiMOPERICARDIUM. 

Blood  tinges  the  exudate  in  certain  forms  of  pericarditis.  A  large 
quantity  of  blood  may  escape  into  the  sac  in  trauma  of  the  heart  or 
of  the  sac,  rupture  of  the  heart  (q.  v.)  or  of  aneurysms  (q.  v.). 

The  symptoms  and  physical  signs  relate  to  (a)  the  acute  ancBmia,  with 
pallor,  syncope,  and  rapid  pulse,  which  usually  ends,  in  a  few  hours  or 
possibly  a  few  days,  in  death;  (b)  signs  of  fluid  in  the  pericardial  sac. 
The  prognosis  is  favorable  only  in  the  traumatic  cases.  The  treatment 
is  expectant;  the  heart  should  be  stimulated  and  salt  solution  should 
be  infused. 


392  DISEASES  OF  THE  CIRCULATION 

DISEASES  OF  THE  ENDOCAEDIUM. 

ENDOCARDITIS. 

Definition. — Inflammation  of  the  endocardium.  Its  clinical  impor- 
tance attaches  to  the  fact  that  the  valves  of  the  heart  are  involved. 
Two  main  varieties  are  distinguished,  the  acute  and  the  chronic. 

I.  Acute  Endocarditis. 

This  is  practically  always  a  secondary,  general  disease,  and  is  mycotic 
in  origin  (excepting  atheromatous  endocarditis).  Two  main  clinical 
varieties  are  described:  (a)  Malignant  or  ulcerative  endocarditis,  and 
(6)  simple  or  verrucose  endocarditis.  They  differ  only  in  degree. 
Litten  divides  endocarditis  into  (a)  the  benign  forms  produced  by 
rheumatism,  chorea,  gonorrhoea,  scarlatina,  measles,  variola,  typhoid, 
diphtheria,  pneumonia,  tuberculosis,  grippe,  and  traumatism;  and  (b) 
malignant,  (i)  non-suppurative,  caused  by  rheumatism,  chorea,  or 
gonorrhoea,  and  (ii)  suppurative  or  septicopyaemic. 

(A).  Malignant  Endocaeditis. 

This  variety  is  also  known  as  ulcerative  or  septic. 

Etiology. — The  heart  lesion  is  either  (1)  secondary  to  some  clearly 
causal  infection  or  disease,  as  furuncles,  dysentery,  typhoid,  empyema, 
abscess  or  gangrene  of  the  lungs,  pneumonia,  tuberculous  foci  with 
mixed  infections,  hepatic  abscess,  suppuration  of  the  gall  bladder, 
pylephlebitis,  pyonephrosis,  cystitis,  gonorrhoea,  calculi,  diseases  of  the 
prostate,  puerperal  or  other  infections  of  the  female  genitalia,  middle- 
ear  disease,  and  to  osteomyelitis  or  such  specific  infections  as  scar- 
latina or  more  rarely  typhoid,  rheumatism,  diphtheria,  smallpox,  or 
malaria;  or  (2)  cryptogenetic,  when  the  causal  infection  is  not  apparent. 
Care  in  examination  and  at  autopsy  usually  reveals  an  obscure  cause 
and  thus  decreases  the  number  of  these  cases. 

The  disease  is  more  common  in  women  than  in  men,  even  excluding 
the  cases  resulting  from  puerperal  infections;  it  is  most  frequent 
between  the  years  of  twenty  and  forty.  Its  frequency  is  2  per  one 
thousand  patients.  Seventy-five  per  cent,  of  cases  develop  upon  an  old 
valvular  lesion  by  which  the  physiological  resistance  is  lessened,  or  in 
a  hypoplastic  aorta.  The  literature  contains  11  cases  of  ulcerative 
endocarditis  involving  a  patent  ductus  Botalli  (Hart,  1904). 

Pathology. — Malignant  endocarditis  most  often  involves  the  Ze//  heart, 
because  it  is  far  more  frequently  the  seat  of  previous  lesions  and  its 
arterial  blood  favors  the  growth  of  microorganisms,  although  the 
right   heart  is  involved  more  frequently  than  it  is  in  other  types  of 


MALIGNANT  ENDOCARDITIS  393 

endocarditis.    Lenhartz  found  the  left  heart  affected  in  86  per  cent., 
the  right  in  12  per  cent.,  and  both  sides  in  2  per  cent.,  of  his  cases. 

Thougli^the  process  may  involve  the  walls  (parietal  or  mural  endo- 
carditis), it  most  frequently  attacks  the  valves  (valvular  endocarditis), 
which  are  often  already  indurated  by  previous  simple  endocarditis, 
are  most  washed  by  the  circulating  blood,  and  are  subject  to  greater 
mechanical  activity.  The  endocardium  becomes  opaque,  and  irregular 
deficits  occur  on  the  under  surface  of  the  aortic  or  the  auricular 
surface  of  the  mitral  valves;  and  later  there  is  a  grayish  deposit  sur- 
rounded by  some  swelling  and  injection  of  the  endothelial  coat.  Exu- 
dation is  abundant  on  the  mitral  valves,  but  is  late  or  scanty  on  the 
less  vascular  aortic  or  pulmonary  valves.  Thrombi  and  excrescences 
develop  on  the  erosions,  whose  removal  discloses  subjacent  ulceration. 
The  thrombi  consist  of  lamellated  fibrin  and  bacteria.  The  vegetations 
may  attain  the  size  of  a  walnut  and  often  extend  from  one  valve  to 
another  by  contact  infection. 

Some  thrombi  are  apparently  purely  mechanical  deposits  of  fibrin, 
but  genuine  endocarditis  is  probably  always  mycotic.  Heiberg  first 
found  microorganisms  (1869)  and  Weichselbaum  first  obtained  pure 
cultures. 

Efi^orts  to  classify  endocarditis  by  the  bacteriological  findings  are 
more  or  less  impracticable.  The  following  bacteria  have  been  found : 
Streptococcus,  staphylococcus,  pneumococcus,  and  less  frequently  the" 
gonococcus,  colon,  diphtheria,  infiuenza,  tubercle,  and  typhoid  bacillus, 
meningococcus,  a  long  bacillus  (Alchame),  Bacillus  endocarditidis 
griseus  and  encapsulatus.  Micrococcus  endocarditidis  rugatus.  Bacillus 
pyogenes  foetidus,  Bacillus  foetidus  immobilis,  and  Bacillus  pyocya- 
neus.  The  same  organism  may  produce  either  the  benign  or  malig- 
nant form. 

Bacteria  may  cause  the  endocarditis  or  may  only  be  deposited 
from  the  blood  upon  vegetations  of  other  origin,  for  mixed  infections 
are  common.  Experimental  endocarditis  (Wyssokowitch,  Ribbert) 
has  been  produced  by  inoculations  of  various  organisms,  usually 
after  wounding  the  valves  by  a  sound  introduced  through  the  cer- 
vical vessels,  but  also  without  trauma.  The  pyogenic  organisms  are 
said  to  attack  more  frequently  the  mitral,  and  the  pneumococcus 
rather  selects  the  aortic  valves.  The  mitral  valves  in  general  are 
more  often  involved  than  are  the  aortic.  The  process  may  invade  the 
aorta,  the  pulmonary  artery,  or  the  lung.  Destructive  changes  by 
ulceration  through  one  leaf  of  the  valve  may  produce  acute  valvular 
aneurysm,  which,  when  aortic,  projects  toward  the  ventricle,  and  when 
mitral,  projects  toward  the  auricle.  If  the  necrosis  destroys  both 
lamellae  of  the  valve,  the  perforation  leads  to  valvular  insufficiency. 
Ulceration  of  the  chordae  tendine£e,  or  papillary  muscles,  also  produces 
valvular  insufficiency;  necrosis  of  the  parietes  results  in  a  "heart 
ulcer,"  which  sometimes  leads  to  communication  between  the  ven- 
tricles, or  to  rupture  of  the  heart.  Dislodgment  of  tissue  particles, 
thrombi,  or  bacteria,  occurs  frequently,  and  usually  in   the  arterial 


:394  DISEASES  OF  THE  CIRCULATION 

circuit.  The  effects  vary  with  the  location  of  the  infarct  (See  Symptom- 
atology) and  with  the  character  of  the  microbes;  i.  e.,  they  act 
mechanically  and  infectively.  Streptococci  are  said  to  produce  anajmic 
infarcts,  while  staphylococci  result  in  suppuration.  Pathological 
changes  in  other  organs  are  those  of  (a)  general  sepsis,  such  as  par- 
enchymatous degeneration,  or  splenic  tumor,  (6)  embolism,  mechan- 
ical or  infective,  (c)  stasis  when  the  heart  fails,  and  (d)  the  primary 
disease. 

Symptoms. — The  clinical  features  vary  to  such  an  extent,  according 
to  the  basic  disease,  the  special  visceral  involvement  by  embolism 
and  the  virulence  of  the  microorganisms,  that  a  general  description 
is  impossible.  The  onset  may  be  violent  or  most  insidious  during 
convalescence  from  the  primary  disease.  The  autopsy  findings  in  the 
latent  cases  may  be  surprising,  as,  for  example,  the  discovery  of  a 
mural  gonorrhoeal  endocarditis  in  a  case  which  clinically  resembled 
septicopysemia.  In  the  majority  of  cases,  the  septic  element  prevails. 
The  various  types,  somewhat  artificial  though  convenient  for  descrip- 
tion, are: 

1.  The  Typhoid  Form. — ^The  toxsemic  symptoms,  such  as  apathy, 
delirium,  dry  tongue,  distended  abdomen,  splenic  tumor,  diarrhoea, 
and  albuminuria,  are  suggestive  of  typhoid.  The  resemblance  may 
be  heightened  by  hemorrhage  of  the  bowels,  rose-like  spots,  and  the 
response  of  the  urine  to  the  diazo  reaction.  Dilatation  of  the  right 
heart,  and  cardiac  murmurs,  so  important  in  endocarditis,  are  not 
uncommon  in  typhoid.  Obvious  embolism  helps  to  establish  the 
diagnosis.  The  pneumococcus  is  often  the  cause  of  this  type.  In 
the  skin  embolism  appears  as  spots  with  a  white  or  yellow  centre  and 
hemorrhagic  periphery,  or  as  pemphigus,  gangrene,  or  suppurative 
foci.  Analogous  areas  may  be  seen  in  the  upper  air-passages.  Infarcts 
may  sometimes  occur  in  the  conjunctiva,  but  in  the  retina  simple  spots 
of  hemorrhage  or  actual  infarcts  with  yellow  centres  are  frequently 
detected.  The  entire  eyeball  may  suppurate.  The  frequent  splenic 
infarction  is  characterized  by  sudden  pain,  tenderness,  enlargement, 
and  sometimes  perisplenitic  friction.  Embolism  is  often  accompanied 
by  fever,  chill,  and  vomiting.  Renal  infarction  is  very  frequent,  and 
is  attended  by  pain  in  the  loins,  hsematuria,  albuminuria,  and  some- 
times anuria  or  dysuria.  Staphylococci  may  be  found  in  renal  ab- 
scesses. Severe  nephritis  is  common.  Cerebral  embolism  usually 
occurs  in  the  left  Sylvian  artery,  and  results  in  the  usual  shock  and 
hemiplegia  with  aphasia.  Pulmonary  infarcts  are  caused  by  lesions 
of  the  right  heart  or  by  auricular  thrombi,  and  occasion  sudden  pleu- 
ritic pain,  dyspnoea,  hsemoptoe,  temperature,  and  possibly  a  small  area 
of  crepitant  rales,  pleural  friction,  or  consolidation.  Embolism  also 
occurs  in  the  liver,  in  the  mesenteric  artery  (with  enterorrhagia  and 
peritonitic  symptoms),  in  the  muscles  and  joints,  testes,  and  parotid; 
in  the  heart,  and  the  various  mucosae;  in  the  meninges,  pleurae,  peri- 
cardium, peritoneum,  and  in  the  peripheral  arteries,  sometimes  causing 
gangrene,  or  embolic  aneurysm. 


MALIGNANT  ENDOCARDITIS  395 

The  course  may  be  peracute  (two  to  four  days),  acute  (a  few  weeks), 
or  chronic  (several  months).  Death  occurs  from  the  typhoid  state, 
from  emboHsm,  or  from  cardiac  failure. 

2.  The  Septic  or  Intermittent  Type. — This  form  has  an  irregular 
fever-curve,  with  chills  and  drenching  sweats;  and  the  spleen  is  en- 
larged. Heart  symptoms  may  be  absent  or  indeterminate,  the  mod- 
erate relaxation  of  the  right  heart  and  the  murmur  being  often  called 
functional.  The  paroxysms  are  more  irregular  than  in  malaria  and 
no  response  to  quinine  is  obtained.  The  streptococcus  is  often  causal. 
Cardiac  findings,  embolism,  or  clearly  septic  manifestations,  may  estab- 
lish the  diagnosis.  The  course  is  usually  several  weeks  but  may  cover 
months. 

3.  The  Visceral  Forms. — These  forms  embrace  the  cases  in  which 
some  one  organ  is  especially  involved.  In  the  cardiac  form,  anaemia 
exists  and  the  heart  murmur  seems  accidental,  until  a  typical  valvular 
lesion  develops,  or,  if  one  already  be  present  from  older  valvular  dis- 
ease, until  another  appears  as  a  diastolic  following  a  systolic  murmur. 
The  diagnosis  may  be  difficult  even  when  chronic  valvular  disease  is 
present.  In  the  cerebral  form,  meningitis,  apoplexy,  coma,  or  psychoses, 
may  dominate  the  clinical  picture.  The  symptoms  referable  to  any 
organ  which  is  the  seat  of  embolism  (lung  pericardium,  etc.),  may 
seem  to  indicate  a  primary  disease.  In  this  way  acute  yellow  atrophy, 
cholera,  etc.,  have  been  incorrectly  diagnosticated. 

Special  Sjrtnptoms. — (1)  All  types  of  fever,  from  intermittent  to 
continuous,  have  been  noted,  although  it  may  be  absent  for  a  long 
time  or  may  not  develop  at  all,  (2)  The  heart  is  always  somewhat 
disturbed  in  its  action,  cardiac  unrest  being  common.  Its  action  is 
usually  more  frequent,  but  is  quite  variable,  now  being  rapid,  again 
slow,  and  often  irregular.  The  heart  seems  to  beat  harder  and  the 
pulse  may  throb  although  the  irritable  overaction  is  attended  by  low 
arterial  tension.  The  heart  tones  are  dulled.  Palpitation  is  frequent. 
Cyanosis  is  not  common.  (3)  Respiration  is  always  increased,  from 
toxsemic  centric  stimulation,  or  from  pain  or  respiratory  complica- 
tions (septic  pneumonia,  infarcts,  pleurisy,  pneumothorax,  or  gan- 
grene). (4)  The  digestive  tract  may  be  affected.  Anorexia  is  not 
invariable.  Nausea,  vomiting,  and  diarrhoea,  may  occur  from  the  gen- 
eral sepsis.  Embolism  has  been  mentioned.  The  liver  is  enlarged, 
may  be  tender,  or  may  be  the  seat  of  friction.  Icterus  may  be  marked, 
is  ominous  and  is  referable  to  duodenal  catarrh  or  to  oversecretion  of 
bile  (polycholia).  (5)  The  spleen  is  almost  always  palpably  enlarged 
from  sepsis  or  embolism.  (6)  The  urine  shows  evidences  of  the 
sepsis  or  stasis  by  albuminuria  with  or  without  cylindruria,  of  the 
"blood  dissolution,"  and  of  the  embolism  by  hsematuria.  Malignant 
endocarditis  may  run  a  course  similar  to  that  of  subacute  nephritis, 
which  is  present  in  33  per  cent,  of  all  cases  of  the  ulcerative  type. 

(7)  The  nervous  system  may  be  irritated  or  dulled  by  the  sepsis  toxins, 
or  embolic  lesions,  such  as  meningitis  or  encephalitis,  may  intervene. 

(8)  The  motor  system  is  often  affected.     The  muscles  are  frequently 


396  DISEASES  OF  THE  CIRCULATION 

tender  and  actually  inflamed,  and  may  undergo  suppuration.  The 
bones  are  often  tender  and  the  joints  tender  or  swollen,  although  the 
swelling  is  more  frequently  peri-articular  than  intra-articular.  Bac- 
teria are  seldom  found,  and  this  may  heighten  the  resemblance  to 
rheumatism.  (9)  The  skin  may  be  the  seat  of  embolism  (v.  s.)  or 
of  eruptions,  such  as  sudamina,  urticaria,  erythema,  purpura,  poly- 
morphous septic  rashes  from  bacteria  or  their  products  in  the  circu- 
lation. Bullae,  gangrene,  phlegmons,  or  bed  sores,  are  also  observed. 
(10)  The  blood  is  also  affected.  There  is  usually  marked  anaemia; 
when  there  are  no  heart  findings,  the  anaemia  and  splenic  tumor 
have  been 'confused  with  pseudoleukaemia.  The  leukocytes  are  often 
but  not  always  increased.  Bacteria  may  be  cultivated  from  the  blood 
by  modern  methods  of  inoculation  from  a  large  quantity  of  blood  in 
much  bouillon.  The  latter  and  other  points  are  considered  under 
Septicopyemia  (q.  v.). 

Bacteriological  Forms. — (a)  Streptococcic  Endocarditis. — The  ordi- 
nary streptococcus  is  the  usual  cause  of  rapidly  fatal  and  of  chronic 
ulcerative  endocarditis,  both  with  severe  repeated  chills  and  high 
irregular  fever.  Acute  cases  may  result  from  the  small  streptococcus, 
which  is  said  to  usually  cause  moderate  fever,  (h)  Staphylococcic 
endocarditis  is  less  frequent.  The  course  is  nearly  always  acute 
and  is  attended  by  high  fever,  pustules  in  the  skin,  dissemin- 
ated hemorrhages,  and  septic  infarcts,  especially  in  the  kidneys. 
(c)  Pneumococcic  endocarditis  (see  Pneumonia)  is  usually  acute; 
frequently  follows  pneumonia,  less  often  cholecystitis;  begins  with 
gradual  fever  rise  associated  commonly  with  chills;  and  is  often  at- 
tended by  suppurative  meningitis.  (d)  Gonococcic  endocarditis 
(Ricord,  1847)  may  result  from  Neisser's  coccus  or  from  mixed 
infection  with  the  strepto-,  staphylo-,  or  pneumococcus.  Cases  of 
recovery  are  instanced. 

Diagnosis. — Bamberger's  remark  of  half  a  century  ago  still  holds: 
"The  diagnosis  of  acute  endocarditis  is  seldom  easy,  is  usually  difficult, 
and  often  impossible."  Unless  there  are  physical  changes  in  the  heart, 
the  diagnosis  is  only  presumptive.  A  proper  etiology,  temperature, 
signs  of  cardiac  insufficiency,  such  as  blue  nails  or  cold  extremities, 
irregular  weak  pulse  with  apparently  strong,  cardiac  shock  and 
dilatation  are  very  suggestive  and  may  be  confirmed  by  continued 
observation,  by  embolism,  by  change  in  the  valvular  murmur,  and  by 
blood-cultures.  Actual  hypertrophy  of  the  heart  not  only  requires  time 
for  development  but  adequate  nutrition,  of  which  the  disease  seldom 
admits.  In  37  per  cent,  of  cases,  the  heart  is  negative,  in  44  per  cent, 
the  murmur  is  systolic  and  in  5  per  cent,  diastolic.  Absolute  certainty 
rests  upon  our  ability  to  diagnosticate  by  physical  signs,  the  presence 
of  a  mitral  regurgitation  (q.  v.)  which  is  the  most  frequent  form,  or 
of  an  aortic  regurgitation  (q.  v.)  plus  the  signs  of  sepsis  of  which  the 
disease  is  a  part  ("arterial  pyaemia").  The  valvular  murmur  may  dis- 
appear after  embolism.  Confusion  with  typhoid  or  malaria  is  possible 
(see  Typhoid,  differential  table). 


{VERICOSE  OR)   BENIGN  ENDOCARDITIS  397 

Diastolic  murmurs  are  very  rarely  functional,  and  their  appearance 
is  therefore  especially  suggestive.  Myocarditis  may  produce  a  systolic 
murmur,  15ut  is  usually  attended  by  marked  early  muscular  insuffi- 
ciency, weak-heart  shock  and  irregular  pulse,  weak  systolic  murmur 
and  a  moderately  accentuated  second  pulmonary  tone. 

Recurrent  endocarditis  shows  not  only  the  fever  and  other  symptoms 
caused  by  the  fresh  lesions,  but  also  the  hypertrophy  of  the  older 
valvular  lesion.  An  aortic  diastolic  or  a  mitral  presystolic  murmur 
is  more  likely  to  indicate  an  old  lesion.  With  repeated  examinations, 
fresh  murmurs  may  be  heard  in  addition  to  the  old  ones. 

Prognosis. — The  prognosis  is  almost  always  unfavorable;  Herrick 
(1902)  collected  22  cases  of  recovery.  It  depends  on  the  strength  of 
the  heart,  the  bacteriology,  the  number  of  infarcts  and  their  location, 
the  variability  of  the  heart  murmurs  (which  may  entail  danger  of 
embolism),  and  the  intensity  of  the  sepsis.  Recovery  from  the  gonor- 
rhoeal  form  is  relatively  frequent.  Musical  murmurs  with  fever  are 
usually  regarded  as  ominous.  Apparently  light  cases  of  endocarditis 
may  become  severe.  The  course  paay  be  rapid  or  severe;  of  but  a 
few  days  duration;  or  it  may  have  a  slower  evolution  of  even  a  year 
and  a  quarter.  « 

Treatment. — (See  Benign  Endocarditis  and  Septicopyemia.) 


(B).   (Verrucose  or)  Benign  Endocarditis. 

This  variety  is  more  frequent  (1.5  per  cent,  of  clinical  cases)  and 
is  always  secondary.  (See  general  prefatory  remarks  to  Ulcerative 
Endocarditis.) 

Etiology. — (a)  Rheumatism  (q.  v.)  is  the  most  frequent  cause,  and 
60  to  85  per  cent,  of  the  cases  can  be  referred  to  it.  Twenty  per  cent,  or 
more  of  cases  of  rheumatism  suffer  from  endocarditis.  It  occurs  in 
the  more  severe  rheumatic  cases.  In  children  it  is  very  frequent, 
for  in  them  the  heart  "resembles  an  articulation."  Muscular  rheu- 
matism, angina,  or  erythema  nodosum,  may  occasion  endocarditis. 
Chronic  rheumatism  predisposes  to  it.  (6)  Chorea  is  frequently  com- 
plicated by  endocarditis  (30  per  cent,  of  clinical  and  82  per  cent,  of 
fatal  cases).  By  some  writers  chorea  is  considered  rheumatic  but  the 
majority  hold  that  it  is  only  correlated,  (c)  Of  other  specific  injec- 
tions, scarlatina  ranks  first,  (10  per  cent,  of  the  cases  becoming  in- 
volved). Endocarditis  is  far  more  uncommon  after  typhoid,  diphtheria, 
tonsillitis,  measles,  erysipelas,  gonorrhoea,  variola,  grippe,  tuberculosis, 
or  parotitis,  {d)  Occasionally  it  is  associated  with  trauma,  burns, 
syphilis,  cancer,  Bright's  disease,  gout,  or  diabetes,  (e)  It  is  more 
common  in  males  between  the  years  of  twenty  and  thirty. 

Pathology. — The  vegetations  are  verrucose,  wart-like,  papular,  or 
even  pedunculated,  are  usually  small,  and  occur  at  or  above  the  lines 
of  closure  of  the  valves,  whereby  their  function  is  interfered  with  and 
valvular  insufficiency  or  stenosis  results.     At  times  the  vegetations  are 


398  DISEASES  OF  THE  CIRCULATION 

cauliflower-like,  or  resemble  condylomata.  They  are  grayish,  gelatin- 
ous, and  transparent;  they  become  whiter  and  firmer  with  age,  and 
consist  of  two  strata,  the  deeper  being  granulating  endocardium  and 
subendocardial  tissue  and  the  superficial  layer  consisting  of  thrombi 
from  the  coagulable  elements  of  the  blood.  The  signs  of  active  inflam- 
mation, such  as  redness  or  swelling,  are  usually  lacking,  redness 
being  sometimes  confused  with  post-mortem  imbibition  of  haemoglobin 
from  the  blood.  Vegetations  must  not  be  confused  with  Albini's 
nodes,  which  are  seen  in  infants  and  children.  The  vegetations  are 
at  an  early  stage,  quite  cellular  from  leukocytic  exudation  and  tissue 
proliferation  and  usually  contain  bacteria  (see  Ulcerative  Type). 
Becoming  detached,  the  outgrowths  form  emboli  and  produce  mechani- 
cal hemorrhagic  or  anaemic  infarcts,  not  suppurative  infarcts  as  in  the 
ulcerative  type.  The  fate  of  the  vegetations  is  (a)  embolism;  (6) 
organization  with  the  bare  possibility  of  restoration  to  normal;  (c) 
organization  with  valvular  lesions  resulting  from  retraction,  and  from 
induration  and  calciflcation ;  (d)  being  a  place  of  slight  resistance, 
recurrent  endocarditis  may  be  observed;  (e)  the  intensity  of  the  in- 
flammation may  increase,  leading  to  malignant  endocarditis. 

Location. — As  in  the  first  type,  the  vegetations  are  largely  in  the 
left  heart,  because  of  its  greater  physiological  activity  and  its  arterial 
blood,  although  these  same  conditions  in  foetal  life  predispose  to  endo- 
carditis of  the  right  heart,  either  on  the  valves  or  on  foetal  openings 
or  defects.  In  general,  the  mitral  valves  are  most  affected  (50  per  cent, 
of  the  cases  alone  or  80  per  cent,  when  combined  with  other  lesions), 
next  the  aortic  (13  per  cent,  alone  or  40  per  cent,  when  combined  with 
other  lesions),  and  far  less  frequently,  the  tricuspid,  the  pulmonary, 
and  the  walls  of  the  heart,  chordae  or  parietes — (1)  wall  of  left,  or  (2) 
of  right  auricle,  (3)  of  left  or  (4)  of  right  ventricle. 

Sjmaptoms. — The  symptoms  are  not  characteristic  and  a  diagnosis 
is  impossible  or  only  presumptive  unless  the  valves  are  considerably 
involved.  Simple  endocarditis  therefore  is  found  far  more  frequently 
at  autopsy  than  at  the  bedside;  i.  e.,  it  is  very  often  latent.  With  such 
heart  symptoms  as  increased  rate  or  palpitation,  it  is  diflficult  or  im- 
possible to  determine  whether  they  are  caused  by  a  valvular  lesion  or 
a  myocarditis,  though  the  latter  is  the  more  likely  cause.  Systematic 
daily  examination  of  the  heart  in  such  diseases  as  rheumatism  may 
reveal  the  gradual  involvement  of  the  endocardium  with  moderate 
fever,  and  dyspnoea,  cardiac  unrest,  oppression,  palpitation,  or  insufla- 
ciency.  Pain  is  more  often  pleuritic  or  pericarditic.  The  diagnosis 
depends  on  the  valvular  bruit,  which  often  follows  muffling  or  irregu- 
larity of  the  cardiac  sounds,  and  is  still  later  followed  by  the  signs  of 
mitral  or  aortic  insufficiency  (q.  v.).  The  infrequent  diastolic  mur- 
murs are  more  distinctive  than  the  systolic,  for  they  are  rarely  func- 
tional. Embolism  is  very  distinctive,  as  it  is  in  the  first  type,  and  is 
important  mechanically  rather  than  bacteriologically.  It  also  occurs 
in  parietal  endocarditis;  embolism  may  be  so  minute  or  undistinctive 
as  to  escape  recognition. 


(VERRUCOSE  OR)   BENIGN  ENDOCARDITIS  399 

Diagnosis. — Conservatism  in  making  the  diagnosis  is  necessary, 
because  acute  benign  endocarditis  is  much  too  often  diagnosticated. 
The  murmurs  are  mistaken  for  functional  murmurs  accompanying 
febrile  relaxation  of  the  heart-chambers.  (See  Mitral  Insuffi- 
ciency.)    Confusion  with  pericardial  rub  (q.  v.)  is  possible. 

Prognosis. — -(a)  As  to  life,  the  outlook  is  generally  good,  unless  (i) 
emboli  lodge  in  important  structures,  such  as  the  basilar  or  coronary 
arteries,  or  (ii)  the  process  becomes  malignant,  (b)  As  to  complete 
recovery,  (i)  valvular  lesions  are  usual  and,  (ii)  fresh  recurrent  endo- 
carditis is  very  common. 

Treatment. — The  treatment  of  the  two  forms  of  endocarditis  is 
considered  together,  (a)  Prophylaxis  resolves  itself  into  the  treat- 
ment of  the  causal  acute  infection,  such  as  rheumatism  or  sepsis. 
Preventive  treatment,  such  as  the  administration  of  salicylates  and 
alkalies  in  rheumatism,  is  uncertain  except  that  they  shorten  the  rheu- 
matic attack.  (6)  Rest  spares  the  heart  and  probably  lessens  the 
percentage  of  cases  involved.  Complete  rest,  psychical  and  physical 
(cardiac),  is  the  prime  essential,  and  cardiac  stimulants  are  to  be 
avoided,  at  least  in  the  early  stages.  Rest  in  bed  must  be  enforced  for 
weeks  after  temperature  and  signs  of  heart  weakness  have  wholly 
disappeared.  Should  relative  recovery  occur,  the  general  care  of 
the  heart's  strength  must  be  insisted  upon  as  in  chronic  valvular 
disease,  and,  with  intercurrent  affections  or  with  the  appearance  of 
temperature,  the  patient  must  be  confined  to  bed.  (c)  The  sepsis  is 
treated  by  alcohol  (see  Pneumonia);  quinine,  gr.  x  to  xv,  once  or 
twice  daily,  with  three  ounces  of  red  wine  every  hour  or  two,  is  recom- 
mended by  Fraentzel ;  bichloride  of  mercury  and  other  antiseptics  are 
futile;  for  pure  or  dominating  streptococcic  infections  Marmoreck's 
antistreptococcus  serum  is  indicated  in  doses  larger  than  those  usually 
prescribed,  and  should  be  frequently  repeated,  (d)  The  irritable  heart 
may  be  quieted  and  slowed  by  the  use  of  the  ice-bag.  Sinapisms 
sometimes  act  favorably  but  blisters  are  to  be  avoided.  Cardiac 
stimulants  should  be  employed  with  caution,  and  only  coffee,  am- 
monia, or  brandy,  should  be  given.  Digitalis  is  usually  to  be  avoided, 
but  it  is  indicated  when  very  tumultuous  heart  action  threatens  to 
induce  embolism. 

(e)  Symptomatic  Treatment. — For  nervous  symptoms,  sodium  brom- 
ide is  indicated.  Sulphonal  and  trional  are  to  be  avoided  when  the 
heart  weakens.  For  the  fever,  hydrotherapy,  aside  from  simple 
sponging,  is  inadvisable,  for  the  joints  and  muscles  are  very  tender,  and 
movement,  on  account  of  the  possibility  of  embolism,  is  dangerous. 
Diarrhoea  of  septic  origin  should  not  be  checked  at  once,  because  it 
is  nature's  effort  at  derivation  and  elimination.  Fluid  diet  should  be 
given  because  of  the  fever.  Potassium  iodide  is  usually  administered 
as  a  resolvent  after  the  acute  stage  has  passed. 


400  DISEASES  OF  THE  CIRCULATION 


II.  Chronic  Endocarditis.    Chronic  Valvular  Disease. 

Etiology. — Valvular  heart  disease  constitutes  2  to  9  per  cent,  of 
all  diseases.  It  often  develops  from  (a)  acute  verrucose  endocarditis, 
and  therefore  has  the  same  etiology.  Some  cases  develop  without 
symptoms  and  are  apparently  primary  or  possibly  hereditary;  they 
are  seen  mostly  in  young  or  adolescent  subjects  and  in  women.  (6) 
Atheroma  is  also  an  important  cause;  it  is  promoted  by  overexertion 
(as  in  the  working  classes),  by  advanced  years,  or  by  chronic  nephritis, 
gout,  diabetes,  syphilis,  alcoholism,  and  lead  poisoning.  It  is  a  more 
common  cause  in  males.  Though  chronic  valvular  disease  may  develop 
from  other  causes  than  chronic  endocarditis,  both  topics  can  well  be 
considered  together.  Valvular  lesions  less  often  result  from  (c)  rup- 
ture of  the  valves;  this  occurs  most  often  in  the  aortic  valves  during 
supreme  physical  efforts,  and  is  promoted  of  course  by  previous  val- 
vular lesions,  although  it  is  sometimes  observed  in  perfectly  normal 
valves.  Healing  is  most  rare,  (d)  Relative  valvular  insufficiency  is 
a  condition  in  which  the  normal  valves  are  unable  to  close  the  orifices 
to  which  they  belong  because  the  heart  is  dilated.  It  is  most  com- 
monly tricuspid  and  mitral,  although  it  also  occurs  in  the  aortic  and 
pulmonary  valves.  Relative  stenosis  is  not  clearly  established,  (e) 
Other  rarer  causes  are  aortic  aneurysms,  neoplasms,  valvular  aneu- 
rysms, and  cardiac  thrombi  or  trauma. 

Pathology. — Small  grayish-red  swellings  are  sometimes  seen  in  the 
early  stages;  they  somewhat  resemble  atheroma  plaques.  Foci  of 
endocardial  thickening  and  retraction  (endocarditis  retrahens)  are  seen, 
in  which  calcification  and  even  ossification  of  the  valves  may  be  pres- 
ent. The  valves  become  less  translucent,  are  not  infrequently  rigid, 
unable  to  unfold,  adherent  to  each  other  or  distorted  by  their  own 
thickening  and  retraction  or  that  of  the  chordse  or  papillary  muscles. 
Mural  changes  are  unimportant,  except  when  associated  with  myo- 
carditis. Acute  exacerbations  may  occur  and  the  ordinary  vegetations 
appear.  Embolism  occurs  in  about  30  per  cent,  of  the  cases.  The 
myocardial  changes  are  hypertrophy,  dilatation,  and  myocarditis.  The 
valves  most  often  involved  are  the  mitral  (78  per  cent.),  especially  in 
adolescence,  then  the  aortic  (20  per  cent.),  which  are  especially  subject 
to  change  in  arteriosclerotics,  and  finally  the  tricuspid  (1  per  cent.), 
and  the  pulmonary  valves.  Combined  valvular  lesions  occur  in  33 
per  cent,  of  cases.  The  process  often  extends  by  continuity  of  surface 
from  the  mitral  to  the  aortic  valves.  In  foetal  cases  {v.  Congeni- 
tal Valvular  Disease)  the  valves  of  the  right  heart  are  more 
frequently  involved.  When  one  valve  is  but  moderately  involved, 
the  others  of  the  same  valvular  orifice  may  compensate  by  stretch- 
ing in  order  to  cover  the  defect,  especially  in  aortic  disease. 

Valvular  insufficiency  is  usually  caused  by  (a)  thickening  and  retrac- 
tion or  even  calcification  of  the  valves  and  also  of  the  chords  ten- 
dinese  and  of  the  papillary  muscles;     {h)   massive  vegetations;     (c) 


AORTIC  INSUFFICIENCY.      {CORRIGAN'S  DISEASE)  401 

growing  together  of  the  valves,  or  of  the  valves  with  the  wall  of  the 
heart  or  aorta;  or  adhesions  between  the  papillary  muscles  and  ten- 
dons; (d)  valvular  aneurysm,  perforation,  rupture,  or  tearing  of  the 
tendons  or  muscles.  Valvular  stenosis  (stenosis  of  the  orifice)  results 
from  (a)  adhesions  between  the  valves,  (b)  retraction,  calcification, 
fibrosis  of  valves  or  ring  of  insertion,  (c)  vegetations.  Combined  val- 
vular insufficiency  and  stenosis  in  one  valvular  mechanism,  especially 
the  mitral,  is  most  common. 

Symptoms. — The  symptoms  of  valvular  disease  are  (a)  the  cardiac 
findings  peculiar  to  each  lesion,  which  will  be  first  considered,  and  (6) 
the  general  sym^ptoms  more  or  less  common  to  all  forms  of  cardiac 
insufficiency,  the  description  of  which  will  follow  the  individual  lesions. 


III.  Aortic  Insufficiency.    (Corrigan's  Disease.) 

Etiology. — 1.  Endocarditic  Form. — The  sinuses  of  the  valves  may 
fuse,  vegetations  are  present,  or  the  valves  grow  together  at  their 
margins  and  shrink;  this  is  more  frequent  than  valvular  perforation 
or  ulceration,  which  is  rapidly  fatal.  If  calcification  develops,  there 
may  be  coincident  stenosis.  This  form  usually  follows  a  previous 
mitral  lesion.  The  endocarditic  may  be  combined  with  the  atherom- 
atous form. 

2.  Atheromatous  Form. — Atheroma  may  be  slight  in  the  aorta,  and 
located  mostly  on  the  valves.  It  is  a  slow,  degenerative  process  (see 
Arteriosclerosis)  with  marginal  valvular  retraction;  it  is  caused 
by  excessive  use  of  alcohol,  by  continued  hard  work  or  athletics,  and 
by  syphilis,  which  may  dilate  the  aortic  ring  (syphilitic  aortitis), 
even  without  directly  involving  the  valves.  It  is  often  therefore  seen 
in  middle-aged  men.  A  relatively  slight  anatomical  lesion  may 
produce  disproportionate  symptoms.  The  atheromatous  process  may 
overlie  or  actually  invade  the  coronary  orifices.  This  is  obviously 
dangerous.  The  valves  may  become  adherent  to  the  aorta.  TJieir 
edges  are  rounded,  and  are  not  the  seat  of  endocarditic  •  masses. 
Coincident  stenosis  is  infrequent.  Relative  insufficiency  and  con- 
genital defects  are  less  frequent. 

3.  Relative  Insufficiency. — This  form  occurs  mostly  in  cases  of  aor- 
titis, aneurysm,  and  arteriosclerotic  dilatation  of  the  root  of  the  aorta, 
which  is  a  more  or  less  physiological  process,  as  the  aorta  usually 
relaxes  one  centimeter  in  circumference  after  the  fortieth  year.  It 
may  also  occur  in  cases  of  dilatation  of  the  left  ventricle,  resulting  from 
idiopathic  hypertrophy,  from  myocarditis,  or  from  renal  disease. 

4.  Cong3nital  Defects. — These  are  rare;  absence  of  a  valve  may  be 
in  part  compensated  for  by  the  others,  though  anatomical  anomalies 
pre(lis])o>o  to  sclerosing  endocarditis.  Valvular  fenestration  is  unim- 
piirianl  c'inically  iiiid  pathologically. 

5.  Trauma. — This  is  a  most  uncommon  cause,  only  25  cases  being 
recorded  (Trcvisanello,  10^4). 


402  DISEASES  OF  THE  CIRCULATION 

Mechanism. — From  aortic  valvular  incompetence,  a  diastolic  regur- 
gitation of  blood  into  the  left  ventricle  takes  place  from  gravity  and 
contraction  of  the  aorta.  Blood  currents  and  vibrations  are  caused  by 
the  blood  flowing  (normally  from  the  left  auricle  and  pathologically 
from  the  aorta)  into  the  left  ventricle,  thereby  producing  the  diastolic 
murmur.  The  left  ventricle  becomes  hypertrophied,  because  it  must 
propel  the  normal  plus  the  regurgitated  blood,  and  becomes  dilated  to 
accommodate  its  added  volume.  The  size  of  the  left  heart  becomes 
enormously  increased,  and  may  even  weigh  50  ounces,  whence  the 
name  "ox-heart," — cor  bovinum.  The  hypertrophied  left  ventricle 
suddenly  forces  an  unusually  large  amount  of  blood  into  the  arteries, 
and  thus  causes  the  many  arterial  phenomena. 

Physical   Signs. -i—l.  Inspection. — (a)  Precordial  prominence  is  ob- 
served chiefly  in  plastic  chests,  and,  therefore,  is  most  common  in 
women   and  children.     Mensuration  may  confirm  the  prominence, 
although  the  right  chest  normally  measures  nearly  an  inch  more  than 
the  left,     (b)  The  heart  shock  is  powerful  and  diffuse,     (c)  The  apex 
beat  is  dislocated  downward  (6th,  7th,  8th  interspace)  and  outward, 
beyond  the  nipple  or  anterior  axillary  line.    The  apex  lies  low  in  arte- 
riosclerotics, from  relaxation   of  the  aorta.     It  is  heaving,  pulsating, 
and  superficial.      The  lung  is  pushed  back  and  some  slight  rotatory 
systolic  retraction  of  the  chest  wall  is  seen.      These  findings  are  re- 
ferred to  the  dilated  and  hypertrophied  left  heart,     (d)  Pulsation  in 
the  first  and-  second  right  intercostal  spaces  is  usually  dynamic,  be- 
cause the  extra  volume  of  blood  thrown  with   extra  force  into  the 
aorta  causes  dilatation  of  the  aortic  arch,     (e)  The  peripheral  vessels 
pulsate  with  unusual  violence,  and  the  carotids  hop;  pulsation  in  the 
jugular  fossa,  or  in  the  abdominal  aorta,  may  simulate  aneurysm,  and 
the    temporals    and    radials    often    attract    attention  before  the  pa- 
tient   undresses   for  examination;   these    are    all    caused    by    ven- 
tricular hypertrophy    and  the   extra  volume   of  blood    thrown    into 
the  vessels.      Pulsation  may  also  be  seen  in  the  retina,  either  spon- 
taneously or  by  pressure  on  the  eyeball,  as  occurs  also  in  Basedow's 
disease.      The   liver   may   pulsate,    though    this    is  rare  because   a 
strong    heart  action  with  stasis  is    necessary.      The  liver  also   pul- 
sates  in    cases   of   tricuspid  incompetency,  but  this  throb  is  due  to 
venous    filling  of  the  organ  during  the  systole.      Pulsation  also  oc- 
curs in  the  spleen,  palate,  and  penis.      (/)  The  capillary  (Quincke's) 
pulse,  occurs  in  over  80  per  cent,  of  the  cases,  but  is  not  pathog- 
nomonic, for  it  is  also  seen  in  health  and  in  fevers  or  anaemias.    It  is 
a  symptom  of  overfilling  of  the  arteries  and  capillary  dilatation,  and 
is  best  observed  when  the  hypertrophy  exceeds  the  dilatation;   it  dis- 
appears when  the  heart  weakens.    It  is  elicited  by  exerting  slight  pres- 
sure on  the  tips  of  the  finger  nails,  on  the  lips  by  a  glass  slide,  or  by 
rubbing  the  forehead  until  it  is  red;   there  is  a  systolic  reddening  and 
a  diastolic  paling  in  these  parts.    It  is  sometimes  found  in  the  retina, 
in  the  palate,  or  in  cases  of  complicating  erysipelas,     (g)  The  passing 
over  of  the  blood  from  the  arteries  into  the  veins  may  produce  the 


AORTIC  INSUFFICIENCY      {CORRIGAN'S  DISEASE)  403 

centripetal  venous  pulse.  This  is  seen  most  advantageously  in  the  fore- 
arm, and  is  caused  by  (i)  relaxation  of  the  vessels,  as  in  fevers,  some 
nervous  lesions,  and  chlorosis;  (ii)  by  delicate  skin;  and  (iii)  full  heart 
action,  (h)  The  arteries  are  actually  lengthened,  (i)  Patients  often  as- 
sume the  dorsal  decubitus,  for  gravity  increases  the  leakage;  subjects 
with  mitral  insufficiency  usually  sit. 

2.  Palpation. — (a)  The  hand  corroborates  the  results  of  inspection, 
— as  the  heaving,  throbbing  apex.  (6)  A  diastolic  thrill  over  the  base  is 
infrequent,  but  when  present  is  usually  proportionate  to  the  degree  of 
leakage,  (c)  In  the  jugulum,  especially  in  arteriosclerotics,  the  widened 
aorta  can  be  felt,  (d)  The  pulse  findings  may  seem  paradoxical,  but  it 
must  be  noted  that  (i)  the  arteries  are  filled  violently  (the  pulsus  durus), 
though  (ii)  the  tone  of  the  vessel  wall  is  less  than  normal. 

Fig.  22. 


Sphygmogram  of  case  of  uncomplicated  aortic  leakage. 


The  radial  artery  is  suddenly  filled  ("pistol  pulse"),  the  pulsus 
celer;  this  is  due  to  hypertrophy  of  the  left  ventricle.  The  condition 
of  the  heart  muscle,  and  therefore  of  the  pulse,  depends  largely  on  the 
type  or  etiology  of  the  case;  hypertrophy  is  usual,  and  marked  in  the 
endocarditic  form,  though  in  the  atheromatous  type  coronary  athe- 
roma and  fibrous  myocarditis  lessen  the  myocardial  activity,  render 
the  pulse  atypical,  and  make  the  prognosis  less  favorable.  The  sphyg- 
mographic  tracing  shows  the  high  up-stroke  with  an  acute  apex  (the 
pulsus  altus).  The  dicrotic  wave  is  ill-marked,  and  the  pulse  rapidly 
recedes  (the  ''collapsing  pulse"),  due  to  the  inability  of  the  aortic 
valves  to  hold  the  receding  blood.  The  falling  away  of  the  pulse  is 
sometimes  increased  by  lifting  the  arm.  The  pulse  is  not  absolutely 
characteristic,  because  it  also  occurs  in  fevers  or  anaemias,  but  it  is 
strongly  suggestive.  The  typical  findings  are  altered,  (a)  when  athe- 
roma of  the  aorta  or  vessels  occurs;  (6)  when  other  valvular  lesions  de- 
velop, as  aortic  stenosis  or  mitral  regurgitation;  (c)  when  the  heart  is 
weak  or  degenerated.  When  the  pulse  findings  precede  the  murmur  it 
is  claimed  that  the  lesion  is  due  to  disease  of  the  aorta.  Thrills  may 
be  felt  over  various  peripheral  vessels.  The  peripheral  pulse  is  delayed 
in  about  half  of  the  cases,  because  the  regurgitation  continues  into  the 
first  part  of  the  systole. 

3.  Percussion. — (a)  The  heart  area  is  oval,  and  is  increased  down- 
ward and  to  the  left,  as  could  well  be  anticipated  from  the  mechanism. 


404  DISEASES  OF  THE  CIRCULATION 

Dulness  reaches  the  second  or  third  ribs  to  the  left  of  the  sternum  (See 
Plate  VIII,  Fig.  C).  The  heart  is  somewhat  more  horizontal  than 
normal.  The  dulness  extends  slightly  beyond  the  apex  and  is 
largely  due  to  dilatation  of  the  left  ventricle.  Because  physical  laws 
demand  its  equal  dilatation  in  all  directions,  it  is  not  surprising  that 
the  right  heart  may  be  somewhat  crowded  to  the  right,  and  the  left 
auricle  upward,  although  dulness  to  the  right  of  the  sternum  is  infre- 
quent. The  papillary  muscles  are  found  jflattened  and  even  thickened 
at  autopsy,  from  the  pressure  of  the  regurgitant  blood.  (6)  A  small 
area  of  dulness  in  the  first  and  second  right  interspaces  denotes  mechan- 
ical dilatation  of  the  arch,  which  results  from  the  cardiac  hypertrophy. 
4.  Auscultation. — (a)  A  diastolic  murmur  is  heard  over  the  sternum 
at  the  level  of  the  second  or  third  rib.  It  is  caused  by  the  retrograde 
blood  passing  through  the  incompetent  valves  into  the  left  ventricle. 
"When  heard  over  the  so-called  "pulmonic  area,"  it  is  increased  down- 
ward along  the  sternum,  for  the  regurgitant  column  follows  this  direc- 
tion (Plate  A  III,  Fig.  C).  It  has  a  bloiving,  deep,  and  less  often  sawing, 
musical  or  whistling  sound  (which  latter  suggests  a  relative  aortic 
leakage).  When  slight,  it  may  easily  escape  recognition,  but  when 
well  developed  it  is  very  characteristic,  sounding  like  the  word  "who." 
It  sometimes  disappears  before  death  when  the  heart  is  weak  and  the 
lesion  is  great,  but  generally  corresponds  to  the  degree  of  leakage.  It 
rarely  reaches  the  neck  or  abdomen.  Cases  of  valvular  rupture  have 
produced  a  murmur  which  could  be  heard  at  a  distance,  (b)  A  slight 
systolic  murmur  over  the  valves  or  aorta  is  not  uncommon,  but  the  too 
frequent  diagnosis  of  aortic  stenosis  (see  Pulse  and  Thrill  under  this 
topic)  is  not  justified.  It  is  soft  in  the  atheromatous,  and  often  harsh  in 
the  endocarditic  type.  Its  various  explanations  are:  Rough  aorta  or 
valves,  physiological  stenosis  (the  rigid  valves  lying  between  a  wide  aorta 
and  a  dilated  ventricle);  ^dbration  of  the  aorta;  or  leakage  continuing 
into  the  beginning  of  the  systole,  (c)  Weakness  or  absence  of  the  second 
aortic  tone  is  explained  by  imperfect  closure  of  the  valves.  Because  the 
second  tone  is  normally  heard  over  the  carotid  artery  it  should  be 
listened  for  there,  because  it  is  removed  from  the  murmur  and  the 
second  pulmonic  tone.  If  it  is  present,  the  usual  conclusion  is  that  one 
or  more  valves  are  closing,  though  possibly  imperfectly.  By  lifting 
the  stethoscope  a  little  from  the  skin  over  the  aortic  region,  the  second 
sound,  which  was  pre\dously  obscured  by  the  bruit,  may  be  heard. 
(d)  The  first  mitral  tone  is  often  weak,  or  lost,  because  the  papillary 
muscles  are  flattened  and  indurated  by  the  regurgitant  column.  If 
the  change  is  pronounced,  a  mitral  systolic  murmur  may  be  heard  in 
place  of  the  first  tone,  (e)  An  apical  presystolic  (Flint's)  murmur  is 
heard  in  50  per  cent,  of  the  cases,  and  is  due  to  aortic  leakage  continued 
in  the  systole,  or  to  pressure  on  the  mitral  valves,  which  hinders  the 
flow  of  b'ood  from  the  left  auricle  into  the  left  ventricle.  Thayer  found 
it  in  CO  per  cent,  of  74  cases,  and  in  less  than  one-quarter  of  these  was 
there  a  mitral  stenosis.  (/)  Arterial  tones  and  murmurs  may  result  from 
vibration  of  the  vessel  wall ;  these  tones  may  become  murmurs,  when 


AORTIC  STENOSIS  405 

there  is  great  difference  in  tension.  The  systoHc  vessel  tone  is  in- 
creased from  the  larger  volume  of  blood  and  increased  ventricular 
action,  and  is  most  plain  when  the  vessels  are  not  sclerotic.  It  is  also 
found  in  anaemia.  Over  the  femoral  artery,  a  systolic  tone  is  heard 
which  is  convertible  into  a  murmur  on  pressure.  Traube's  double 
femoral  sounds  consist  of  two  spontaneous  (i.  e.,  produced  without 
pressure)  tones,  which  are  variously  explained,  probably  most  satis- 
factorily by  sudden  change  in  tension.  They  are  heard  best  when  the 
heart  is  strong  and  the  vessels  soft.  They  occur  in  other  conditions 
and  in  valvular  lesions,  and  may  be  confused  with  the  double  venous 
(Friedreich's)  tones,  which  are  heard  over  the  vein  in  tricuspid  leakage. 
Duroziez's  double  murmur  is  analogous,  but  consists  of  two  murmurs, 
which  may  be  elicited  by  slight  pressure  and  are  due  to  the  progress 
and  recession  of  blood  in  the  artery.    It  also  occurs  in  other  conditions. 

Diagnosis. — Physical  examination  by  inspection,  palpation,  per- 
cussion, and  auscultation,  in  the  order  named,  prevents  many  errors  in 
the  interpretation  of  murmurs.  The  cardinal  findings  are :  (a)  Dilata- 
tion and  hypertrophy  of  the  left  ventricle;  (&)  the  'pulsus  celer  and 
alius;  (c)  the  arterial  phenomena ;  and  (c^)  the  diastolic  murmur. 

Relative  aortic  regurgitation  (see  Etiology)  is  difficult  to  differentiate 
from  the  valvular;  the  murmur  is  not  the  typical  protracted  diastolic 
bruit,  but  rather  a  short  presystolic  (or  postdiastolic)  murmur  (Rosen- 
bach)  which  produces  a  short  "huff"  after  the  second  aortic  tone. 
This  character  is  said  to  be  almost  pathognomonic.  The  pulse  in  rela- 
tive regurgitation  is  frequently  small,  tardy,  and  tense,  but  not  quick. 
Hypertrophy  of  the  left  ventricle  is  not  very  great.  The  murmur 
varies  from  time  to  time ;  it  is  sometimes  short,  then  longer,  sometimes 
blowing,  and  again  coarse,  or  it  may  be  difficult  to  fix  as  to  systole  or 
diastole. 

Diastolic  murmurs  are  rarely  anaemic  {cardiopulmonary  or  func- 
tional). Clear  instances  exist,  however,  of  bruits  in  the  cava  and  other 
veins.  These  murmurs  are  uneven,  and  are  stronger  in  the  beginning 
of  the  diastole.  Aortic  aneurysm  (q.  v.)  may  cause  confusion.  In 
mitral  lesions,  the  capillaries  are  poorly  filled  and  the  skin  is  cyanotic; 
in  aortic  regurgitation  the  arterioles  are  overfilled  and  the  skin  is  red. 
In  mitral  disease,  congestion  of  the  lung,  brown  induration,  and  dila- 
tation of  the  right  heart  obtain;  these  are  absent  in  aortic  leakage;  a 
hemorrhagic  nephritis  takes  the  place  of  the  analogous  brown  indura- 
tion of  the  lungs  of  mitral  lesions. 

Relative  healing  by  vicarious  stretching  oi  sound  valves,  by  growing 
stenosis,  and  by  calcification,  is  possible  but  infrequent. 

IV.    Aortic  Stenosis. 

Aortic  stenosis  is  the  most  infrequent  of  left-heart  lesions.  It  may 
occur  congenitally,  in  which  case  the  conus  arteriosus  is  often  con- 
stricted   (Dittrich's    genuine    heart    stenosis).      It    occurs,    however, 


406  DISEASES  OF   THE  CIRCULATIOX 

largely  in  the  aged.  The  valves  become  interadherent  or  thickened, 
and  calcarious  masses  or  retraction  at  their  insertion  obstruct  the  ori- 
fice. Acute  endocarditis,  with  massive  vegetations,  may  produce  some 
stenosis.  It  is  usually  associated  mth  aortic  incompetency,  although 
aortic  double  lesions  are  far  less  common  than  mitral.  Stenosis  of  the 
aortic  orifice  is  a  better  term  than  aortic  stenosis. 

Mechanism. — The  rigid  valves  make  the  orifice  narrow,  and  at  the 
obstruction  a  systolic  murmur  originates.  The  resistance  to  the 
onward  flow  of  blood  from  the  left  ventricle,  leads  to  its  hyper- 
trophy.    The  pulse  becomes  small  and  slow  because  of  obstruction. 

Physical  Signs. — 1.  Inspection. — Some  precordial  prominence  may 
be  seen  in  yielding  chests.  The  apex  beat  is  sometimes  strong,  and  at 
times  somewhat  dislocated  to  the  left,  but  often  no  apex  is  seen,  either 
on  account  of  coincident  emphysema  or  because  the  heart's  recoil  is 
lessened  or  absent.  The  apex  sometimes  retracts  during  the  systole 
from  lack  of  tension  in  the  aorta  and  from  lessened  systolic  dislocation 
of  the  heart. 

2.  Palpation. — (a)  A  most  pronounced  systolic  thrill  is  often  felt 
over  the  second  right  interspace,  and  sometimes  is  propagated  over  the 
heart  and  into  the  cer^acal  vessels.     (6)  The  -pulse  is  infrequent  (pulsus 

Fig.  23. 


Pulse  tracing  in  stenosis  of  the  aortic  orifice. 

rams),  because  the  systole  is  prolonged  and  the  coronary  arteries  are 
not  well  filled;  it  is  small  (p.  parvus),  from  obstruction  to  its  flow;  it 
is  tense  (p.  durus),  from  hypertrophy  of  the  left  ventricle,  and  from 
arteriosclerosis;  and  it  is  exceedingly  slow  (p.  tardus)  with  tardy  up- 
and-down  stroke  and  some  retardation,  as  compared  with  the  apex 
beat.  A  strong  apex  heat  and  a  iveak  radial  pulse  suggest  aortic 
stenosis. 

3.  Percussion. — This  may  be  wholly  negative.  Concentric  h^'per- 
trophy  (i.  e.,  hypertrophy,  with  the  left  heart  chamber  smaller  than 
normal),  is  very  frequent.  Concentric  and  simple  hypertrophy,  which 
are  the  more  common,  as  the  stenosis  is  purer,  naturally  give  no  change 
on  percussion.  Dilatation  is  sometimes  present,  giving  slight  dulness 
to  the  left,  especially  with  aortic  regurgitation,  renal  contraction,  or 
atheroma.  In  rare  instances,  hypertrophy  and  dilatation  are  both 
absent. 

4.  Auscultation. — Auscultation  gives  (a)  a  systolic  murmur  over 
the  aortic  area,  which  is  sometimes  soft  but  more  often  long,  saT\'ing, 
whistling,  or  musical,  and  is  transmitted  with  the  blood  current  into 
the  aorta,  the  descending  aorta  in  the  back,  and  its  vessels  (Plate  VIII, 
Fig.  A).  It  is  frequently  heard  over  the  entire  heart,  and  at  times  is 
heard  at  some  distance  from  the  chest.  It  is  not  proportionate  to  the 
intensity  of  the  lesion,  and  disappears  with  broken  compensation. 
(b)  The  second  aortic  sound  is  weak,  from  poor  filling  of  the  aorta  and 
weak  closure  of  the  altered  valves,  or  it  is  absent,  when  combined  with 


MITRAL  INSUFFICIENCY  407 

aortic  regurgitation;  (c)  when  the  second  aortic  sound  is  absent,  the 
second  mitral  tone,  or  indeed  all  the  heart  tones,  are  weak  or  absent. 
(d)  A  systolic  tone  is  heard  over  the  aorta. 

Diagnosis. — The  lesion  may  be  a  favorable  sign,  because  it  is  some- 
times a  healing  of  an  aortic  regurgitation.  Aortic  stenosis  is  a  fre- 
quent surprise  at  autopsy,  having  run  a  latent  course.  The  cardinal 
symptoms  are  (a)  systolic  murmur  with  propagation  into  the  large 
vessels,  which  is  frequently  heard  over  the  entire  heart;  (b)  a 
systolic  fremissement  over  the  aortic  area;  (c)  the  small,  tardy, 
slow  pulse,  in  contrast  to  the  strong  apex  beat.  A  diagnosis  should 
be  reserved  unless  these  signs  are  present.  As  the  lesion  is  uncom- 
mon, its  frequent  diagnosis  implies  confusion  with  (i)  accidental  mur- 
murs, which  are  variable  but  which  may  resemble  a  slight  stenotic 
murmur,  (ii)  Acute  endocarditic  vegetations;  these  usually  give  a  soft 
murmur  which  becomes  harsher  if  actual  stenosis  ensues,  (iii)  Athe- 
roma of  the  aorta,  or  acute  aortitis,  where  the  murmur  is  more  localized 
over  the  aorta,  the  second  aortic  tone  is  ringing  or  metallic,  and  the  pulse 
is  generally  proportionate  to  the  apex  beat.  Atheroma  is  the  most 
frequent  cause  of  diagnostic  error;  it  is  very  common,  while  experi- 
enced clinicians  see  few  cases  of  pure  aortic  stenosis,  (iv)  Aneurysm 
(q.  v.),  which  is  often  distinguishable  by  its  pressure  symptoms. 


V.    Mitral  Insufficiency. 

Mitral  insufficiency  (incompetency,  regurgitation)  is  the  most  fre- 
quent valvular  lesion.  It  is  (a)  valvular,  from  adhesions  between  the 
valves  or  chordae  or  ventricular  wall,  from  vegetations,  from  thickening 
with  retraction,  from  valvular  aneurysm  or  perforation,  or  from  shrink- 
age or  rupture  of  the  papillary  muscles  or  chordae;  or  it  is  (6) 
muscular,  from  relative  insufficiency  due  to  such  relaxation  of  the 
ventricular  muscle  that  the  valves  will  not  cover  the  orifice;  it  is  most 
common  in  hypertrophy  with  dilatation,  resulting  from  hard  work, 
atheroma,  nephritis,  syphilis,  alcoholism,  myocarditis,  adherent  peri- 
cardium, and  exophthalmic  goitre;  (c)  rupture  of  the  mitral  cusps  is 
very  uncommon.  Barie  collected  35  cases  of  valvular  rupture,  of  which 
45.7  per  cent,  were  aortic,  45.7  per  cent,  were  mitral,  and  8.6  per  cent, 
were  tricuspid. 

Mechanism. — During  the  systole,  a  backward  flow  occurs  through 
the  incompetent  valves  into  the  left  auricle,  which,  as  it  also  receives 
blood  from  the  lung  veins,  must  first  dilate  and  later  hypertrophy,  as 
far  as  its  slight  musculature  can  admit.  The  left  ventricle  dilates  be- 
cause it  receives  in  the  diastole  more  blood  than  normal  (i.  e.,  the  usual 
inflow  plus  the  already  regurgitated  blood),  and  it  hypertrophies  be- 
cause its  work  is  increased.  In  aortic  lesions,  the  first  and  greatest 
strain  is  felt  in  the  left  ventricle,  but  mitral  lesions,  by  congesting  the 
lungs,  throw  the  most  work  on  the  right  heart.  The  stasis  in  the  left 
auricle  is  transmitted  to  the  pulmonary  veins,  capillaries,  and  arteries, 


408  DISEASES  OF  THE  CIRCULATION 

thus  leading  to  increased  engorgement  and  blood  pressure  in  the  pul- 
monary circuit,  because  (a)  of  this  backward  pressure,  and  (b)  of  the 
onward  pressure  from  the  right  ventricle,  which  hypertrophies.  The 
lungs  are  enlarged  and  engorged,  their  vessels  dilate  and  may  become 
atheromatous,  possibly  causing  infarcts  in  the  lung,  and  connective 
tissue  development  (brown induration).  When  the  final  inevitable  weak- 
ening of  the  right  ventricle  occurs  from  dilatation,  i.e.,  broken  compen- 
sation, the  right  auricle  is  engorged  and  relative  tricuspid  leakage  {v.  i.) 
follows  from  dilatation.  The  venous  system  is  overloaded,  and  this 
results  in  stasis  and  cyanotic  induration  of  the  viscera,  liver,  and  kid- 
neys, and  often  in  oedema. 

Physical  Signs. — 1.  Inspection. — (a)  The  a'pex  may  be  normally 
located  or  displaced  to  the  left — even  into  the  axilla  when  there  is  much 
dilatation.  The  heart  may  then  lie  lower  than  normal.  The  normal 
force  of  the  apex  beat  in  mitral  insufficiency  is  evidence  of  hypertrophy. 
(6)  Systolic  pulsation  in  the  seco7id  left  interspace  indicates  a  wide 
pulmonary  artery  from  increased  tension  or  stasis,  and  (c)  a  diastolic 
shock  there  is  due  to  closure  of  its  valves;  (d)  precordial  prominence 
occurs  in  yielding  chests  from  marked  cardiac  dilatation;  (e)  pulsa- 
tion, either  epigastric  or  to  the  right  of  the  sternum,  results  from  dilata- 
tion and  hypertrophy  of  the  right  ventricle.  (/)  The  veins  are  enlarged 
and  pulsate  during  the  diastole  from  stasis,  and  sometimes  during  the 
systole  from  tricuspid  incompetency  {q.  v.)  or  patency  of  the  foramen 
ovale. 

2.  Palpation.- — (a)  The  apex  is  dislocated  to  the  left;  (b)  the  pulmonary 
pulsation  is  felt;  (c)  the  diastolic  shock  of  the  forcibly  closing  pul- 
monary  valves  is  very  often  palpable  by  placing  one  finger  over  the 
valves  and  another  over  the  apex  whereon  the  two  shocks  alternate; 
{d)  pulsation  is  felt  to  the  right;  (e)  a  systolic  apical  thrill  is  often 
palpable  after  physical  or  psychical  excitement,  or  when  the  patient  lies 
on  his  left  side,  but  it  is  not  pathognomonic.  (/)  In  pure  cases  the  pulse 
is  of  about  normal  tension  in  compensation,  or  becomes  lessened  with, 
rupture  of  compensation.  Irregularity  is  not  very  common  and  the 
sphygmographic  tracing  is  not  characteristic. 

3.  Percussion. — This  shows  (a)  dilatation  of  the  right  ventricle  in 
compensated  cases,  which  is  commonly  followed  by  hypertrophy. 
Dilatation  shows  dulness  and  palpatory  resistance  to  the  right  of  the 
sternum  (See  Plate  VIII,  Fig.  B).  Hypertrophy  without  dilatation  is 
usually  found  in  the  early  and  well  compensated  lesion.  It  should  be 
remembered  that  the  right  heart  bears  the  stress  of  this  lesion,  (b) 
The  left  ventricle  usually  but  not  always  dilates  to  respond  to  the 
increased  amount  of  blood,  and  hypertrophies  because  of  increased 
work  or  because  of  the  raising  of  arterial  pressure  by  carbon  dioxide. 

4.  Auscultation. — (a)  The  systolic  murmur  is  due  to  abnormal 
eddies  in  the  left  auricle  or  to  the  vibrations  caused  by  them  in  the 
mitral  valves;  it  most  often  gives  a  bloiving  sound,  is  best  heard  over 
the  apex,  which  is  less  covered  by  the  lung,  but  at  times  is  best  recog- 
nized over  the  pulmonary  area  or  auricle,  where  it  really  originates  and 


MITRA  L .  INS UFFICIENCY  409 

where  it  is  heard  especially  in  early  lesions.  It  is  transmitted  chiefly 
towards  the  left  interscapular  region,  and  to  the  left;  and  more  rarely  to 
the  aorta,  carotids,  and  abdomen  (See  Plate  VIII,  Fig.  B) ;  it  is  at  times 
heard  intermittently,  in  certain  postures  only,  and  it  may  disappear 
with  weakening  of  the  heart.  In  very  rare  cases  it  is  entirely  absent 
(latent).  (6)  The  first  mitral  tone  is  usually  absent  because  the  valves 
cannot  vibrate;  if  present  it  is  referable  to  conduction  from  the  tri- 
cuspid valve  or  to  contraction  of  the  ventricle.  When  obscured  by  the 
murmur,  it  may  sometimes  be  heard  by  lifting  the  stethoscope  a  little 
from  the  chest  wall.  In  cases  of  extreme  leakage,  the  murmur  replaces 
all  tones,  (c)  The  second  pulmonic  sound  is  accentuated,  "hammer- 
like," and  is  a  measure  and  result  of  the  right  ventricular  hypertrophy 
(Skoda).  It  sometimes  reaches  the  vessels  of  the  neck.  When  the 
tricuspid  valves  become  relatively  insufficient,  it  usually  weakens; 
accentuation  is  absent  in  those  rare  cases  where  the  right  ventricle  does 
not  hypertrophy.  The  second  tone  at  the  base  is  sometimes  split,  (d) 
A  systolic  murmur  over  the  pulmonary  area  is  usually  propagated  from 
the  apex  or  is  due  to  vibrations  in  the  distended  pulmonary  artery. 

Diagnosis. — The  cardinal  features  are  (a)  the  systolic  murmur,  (6) 
the  accentuated  second  pulmonic  tone,  and  (c)  the  right-heart  changes. 

Excepting  the  etiological  diagnosis,  there  are  no  positive  criteria  by 
which  we  can  differentiate  a  muscular  (relative)  from  a  valvular  in- 
sufficiency, though  in  the  former  the  murmur  is  more  variable,  lessens 
with  digitalis,  and  is  not  associated  with  a  diastolic  murmur  which  is 
common  in  valvular  incompetency.  Pure  insufficiency  is  very  excep- 
tional, being  usually  combined  with  some  mitral  stenosis  into  which 
insufficiency  may  eventually  pass.    (A  cure  is  thus  sometimes  effected.) 

From  the  functional,  accidental,  hsemic,  or  cardiopulmonary  mur- 
mur, the  diagnosis  is  usually  easy.  This  murmur  is  inconstant,  is  often 
basal,  often  depends  on  posture  and  coughing  efforts,  is  circumscribed, 
sometimes  disappears  on  pressure,  is  not  typically  transmitted,  follows 
fever,  anaemia,  and  emphysema,  is  often  associated  with  the  venous 
hum  in  the  neck,  but  is  never  associated  with  typical  mitral  changes  in 
the  heart  tones  and  right  ventricle.  The  intensity,  timbre,  or  fremisse- 
ment,  of  the  murmur  must  not  alone  be  depended  upon.  So-called 
"  functional "  murmurs  are  usually  systolic. 

In  chlorosis,  we  may  obtain  a  hsemic  murmur,  apparently  large  heart 
(because  the  lungs  are  poorly  expanded),  and  a  displaced  apex,  since  the 
diaphragm  stands  high  in  chlorosis;  deep  breathing  rapidly  decreases 
the  heart's  dulness. 

Pericardial  friction  (q.  v.)  may  simulate  any  endocardial  murmur 
(Skoda),  though  most  clinicians  find  little  difficulty  in  distinguishing 
them. 

Fraentzel's  general  rules  are  excellent  and  aid  in  accuracy :  (1)  Never 
make  a  diagnosis  just  before  death.  (2)  Remember  the  great  infre- 
quency  of  right-heart  lesions.  (3)  Avoid  complicated  diagnoses.  (4) 
Murmurs  are  subordinate  in  value  to  physical  findings  by  inspection, 
palpation,  and  percussion. 


410  DISEASES  OF  THE  CIRCULATION 


VI.     Mitral  Stenosis. 

Pure  stenosis  of  the  mitral  orifice  is  rare  and  is  an  almost  constant 
anatomical  associate  of  mitral  leakage.  The  mitral  valves  are  so  grown 
together  or  the  ring  so  constricted  as  to  well  justify  the  name  used  by 
Corrigan,  "  the  button-hole  contraction. "  The  orifice  in  extreme  cases 
is  funnel-shaped.  It  is  more  frequent  in  the  young  and  in  women  (76 
per  cent,  of  the  cases). 

Mechanism. — The  stenosis  obstructs  the  diastolic  passage  of  the 
blood  into  the  left  ventricle  from  the  left  auricle,  which  consequently 
dilates  and  later  hypertrophies.  The  enlarged  auricle  may  compress 
the  adjacent  bronchus  or  recurrent  laryngeal  nerve.  The  stasis  is  pro- 
pagated backward  through  the  lungs  to  the  right  ventricle,  whose 
dilatation  and  hypertrophy  cause  the  large  right  heart  and  the  in- 
creased pressure  in  the  lesser  circulation.  The  effects  on  the  right 
heart  and  lungs  are  more  severe  than  in  mitral  insufficiency.  The  right 
auricle  also  dilates  when  the  later  venous  stasis  follows.  Thrombi  in 
either  auricle  may  dislodge  and  produce  pulmonary  or  arterial  infarc- 
tion.   The  arterial  system  is  naturally  filled  but  poorly. 

Physical  Signs. — 1.  Inspection. — This  reveals  (a)  precordial  dis- 
tention, (b)  epigastric  pidsation,  and  (c)  a  diffuse  cardiac  shock;  (d)  the 
apex  beat  may  in  comparison  be  small,  and  (e)  two  impulses  or  shocks 
may  be  seen  in  the  second  left  interspace;  one  is  systolic,  from  systolic 
filling  of  the  pulmonary  artery,  and  the  other  is  diastolic,  from  pul- 
monary valve  closure  under  high  tension.  All  these  findings  depend 
on  changes  in  the  right  heart. 

2.  Palpation. — Palpation  confirms  the  above,  especially  (a)  the  apex 
beat,  which  is  often  weak  in  comparison  with  the  diffuse  heart  impulse, 
(6)  the  snap  of  the  second  pulmonic  sound,  (c)  the  pulsating  right  heart, 
and  also  (d)  a  presystolic  (more  rarely  diastolic)  thrill  {fremissement 
cataire)  which  is  usually  limited  to  the  apex,  ends  with  the  snappy  first 
apex-tone,  and  is  felt  sometimes  only  in  the  left  lateral  posture,  after 
exertion  or  when  the  arms  are  raised.  Its  mechanism  is  identical  with 
that  of  the  murmur  (q.  v.).  (e)  The  pidse  is  often  irregidar  even  with 
good  compensation,  especially  in  cases  of  pure  stenosis,  and  is  usually 
small  and  of  low  tension,  because  the  aorta  is  poorly  filled.  It  some- 
times seems  hard,  and  at  times  its  weakness  contrasts  conspicuously 
with  the  active  heart  impulse.  The  pulse  is  not  pathognomonic 
but  merely  suggestive;  the  sphygmograph  confirms  the  palpatory 
findings. 

3.  Percussion. — (a)  The  right  ventricle  in  the  earlier  stages  may  be 
only  hypertrophied,  which  does  not  show  on  percussion.  Dilatation 
without  hypertrophy  exists  in  few  cases  fortunately,  for  the  prognosis 
is  then  poor.  Most" commonly  hypertrophy  and  dilatation  coexist,  the 
latter  giving  increased  dulness  to  the  right,  as  is  the  case  in  mitral  in- 
sufficiency. (6)  The  left  ventricle  in  many  cases  of  dominant  stenosis 
shows  concentric  atrophy,  so  that  at  autopsy  it  looks  like  a  mere  appen- 


MITRAL  STENOSIS  411 

dage  to  the  huge  right  heart.  It  is  sometimes  both  hypertrophied  and 
dilated,  for  which  the  following  reasons  have  been  assigned :  Marked 
concomitant  mitral  leakage;  stasis  with  increase  in  the  blood  of  car- 
bon dioxide,  which  raises  the  blood  pressure;  coincident  adherent 
pericardium,  nephritis,  atheroma,  or  aortic  disease,  all  of  which  lead 
to  changes  in  the  left  ventricle,  (c)  The  auricles  are  distended,  much 
of  the  dulness  under  or  beyond  the  sternum  being  due  to  the  dilated 
right  auricle  and  that  above  and  to  the  left,  to  the  left  ventricle. 
(The  right  conus  arteriosus  and  the  pulmonary  trunk  are  found 
widened  at  autopsy.)  Increased  dulness,  due  apparently  to  dilatation 
of  the  various  chambers,  is  often  caused  merely  by  their  dislocation  by 
the  wide  right  ventricle. 

4.  Auscultation. — (a)  An  apical  presystolic  murmur  is  important. 
It  occurs  at  the  end  of  the  diastole  just  before  the  ventricular  systole, 
i.  e.,  during  the  auricular  systole  which  forces  the  blood  through  the 
narrowed  ring  or  rigid  adherent  valves.  Corresponding  with  the  energy 
of  that  chamber,  it  is  loudest  at  the  incipiency  and  ending  of  the 
murmur.  It  so  closely  precedes  the  ventricular  systole  that  it  is  often 
called  systolic  by  physicians  and  is  almost  invariably  mistaken  by 
students.  It  is  rarely  a  blowing  sound,  but  usually  snoring,  rolling, 
sounding  like  R-R-R-P,  after  which  comes  the  loud  first  tone.  It  is 
poorly  propagated  as  a  rule,  corresponding  to  the  localized  thrill 
{v.  s.),  but  may  in  exceptional  cases,  be  heard  in  the  axilla  or  back. 
It  is  most  variable,  often  being  absent  even  with  great  stenosis,  and 
appearing  again  only  after  exertion ;  it  is  absent  when  the  heart  weakens 
and  before  death,  whence  the  importance  of  Rule  4  of  Fraentzel  (see 
Diagnosis  of  Mitral  Insufficiency).  It  is  rarely  diastolic.  (6)  Marked 
accentuation  of  the  second  pulmonic  sound  is  the  proof  and  measure  of 
hypertrophy  of  the  right  ventricle  from  pulmonary  congestion.  Its 
absence  is  a  poor  prognostic.  It  usually  weakens  when  relative  tri- 
cuspid leakage  intervenes  and  thereby  lessens  the  tension  in  the  lungs. 
The  accentuation  rarely  reaches  the  cervical  vessels.  (c)  Splitting  or 
reduplication  of  the  second  pulmonic  sound  is  due  to  difference  in 
tension  in  the  two  arterial  trunks,  the  aortic  valves  closing  first  and 
more  weakly.  The  doubling  is  best  heard  at  the  base  and  is  often 
propagated  into  the  neck  or  axilla,  id)  The  usually  loud  first  mitral 
tone  is  explained  in  various  ways;  viz.,  by  difference  in  tension  of  the 
valves  during  the  systole  and  diastole  or  by  a  vigorous  contraction  of 
the  left  ventricle  upon  little  blood.  It  is  sometimes  heard  at  a  distance 
of  several  feet,  (e)  The  second  mitral  tone  is  weak  because  of  poor 
filling  of  the  aorta  or  because  the  right  heart  comes  forward  more  than 
usual.  This  tone  may  be  split  at  the  apex  (the  "postman's  knock"), 
and  may  be  present  early  in  this  lesion;  the  cause  of  the  splitting  is 
the  subject  of  variant  discussion. 

Diagnosis. — The  cardinal  signs  are  (a)  the  presystolic  thrill  and 
bruit;  (b)  the  involvement  of  the  right  heart;  (c)  the  accentuated 
second  pulmonic  sound ;  (d)  the  small  pulse,  which  is  less  important 
and  (e)  loud  first  apical  tone. 


412 


DISEASES  OF  THE  CIRCULATION 


The  thrill  and  bruit  are  also  found  in  other  conditions,  as  in  aortic 
insufficiency  (Flint's  murmur),  in  which  the  vascular  phenomena  and 
the  involvement  of  the  left  heart  are  sufficiently  distinctive,  though  one 
out  of  every  three  cases  of  aortic  leakage  is  complicated  by  mitral 
stenosis.  The  bruit  has  also  been  heard  in  lesions  leading  to  dilatation 
of  the  left  ventricle,  such  as  adherent  pericardium,  whence  the  rule  that 
the  diagnosis  of  mitral  stenosis  must  be  conservative  when  there  is  a 
clear  history  of  pericarditis  or  where  the  left  ventricle  is  dilated. 

When  the  thrill  and  murmur  are  absent,  the  diagnosis  can  very  often 
be  made  by  the  other  cardinal  symptoms. 

It  has  been  held  that  (a)  an  absence  of  the  murmur  indicates  a  slight 
lesion,  as  also  does  (b)  a  presystolic  murmur;  (c)  a  diastolic  murmur 
indicates  a  severe  stenosis ;  and  (d)  absence  of  the  murmur  with  irregu- 
larity is  indicative  of  the  most  serious  lesion. 

Differential  Table  of  the  Common  Chhonic  Valtulae  Lesions. 


Aortic 
Insufficienct. 


Aortic 
Stenosis. 


Mitral 
Insufficiency. 


Mitral 

Stenosis. 


ETioLoaT. 


Pulse. 


Left  Ventricle. 


Right  Ventricle. 


Murmur. 


First  Mitral 
Tone. 


Second  Aortic 
Tone. 


Second     Pulmon- 
ary Tone. 


Peripheral 

Vessels. 


Arteriosclerosis 
chiefly. 

Pulsus   celer. 

Water-hammer, 

collapsing. 

Hyjpertrophied 
and  dilated 
greatly;  heaving 
apex. 

No  change. 


Diastohc;  blowing 
over  sternum  near 
second  rib;  prop- 
agated toward 
apex. 

Usually  weak. 


Weak  or  absent. 
Not  accentuated. 


Violent    pulsation; 
capillary  pulse; 
arterial  tones;  skin 
red. 


Often  arterioscler- 
otic. 

Pulse,  small,  slow, 
tense. 


Hypertrophy, 
usually  concentric. 


No  change. 


Harsh  systohc 
murmur  over  aor- 
tic area  with  sj's- 
toUc  thrill;  prop- 
agated into  neck. 


Strong     usually. 

Weak  only. 

Not  accentuated. 

Absent. 


Endocarditis 
chiefly. 

No  characteristic 
alteration — often 
normal. 

Some  hypertrophy 
and  dilatation. 


Hypertrophy    and 
dilatation  marked. 


Ditto. 


Small    and     often 
irregular. 


No    essential    nor 
regular    change; 
may  be  smaU. 


Both  marked,  also 
in  auricles. 


Systolic  at  apex,  Presystohc  (often- 
blowing,  transmit-  er  than  diastolic), 
ted  into  axilla  and  apical,  accom- 
behind  scapula.  panied  by  presys- 
tohc thrill,  fairly 
locahzed. 


Usually  present, 
perhaps  covered 
by  murmur. 


Somewhat  weak. 


Loudly  accent- 
uated,   and    often 
palpable. 

Absent. 

Skin  cyanotic. 


Loud  and  sharp, 
clearly    palpable 
and  following  mur- 
mur. 

Somewhat  weak. 


Ditto;    often  split, 
reduplicated. 


Absent. 
Skin  cyanotic 


In  conjunction  with  this  table,  Plate  VIII  should  be  consulted. 


VII.  Pulmonary  Insufficiency. 


Pulmonary  insufficiency,  of  which  Barie  has  collected  58  cases,  is 
most  uncommon  and  is  often  combined  with  pulmonary  stenosis  or 
other  rare  right-heart  anomalies.    It  is  (a)  congenital,  resulting  from 


PULMONARY  STENOSIS  413 

foetal  endocarditis  or  from  supernumerary,  or  rudimentary  valves; 
(6)  acquired  from  rheumatism,  from  sepsis,  which  destroys  the  valves 
by  ulceration  or  from  atheroma;  or  it  is  very  rarely  (c)  relative  from 
extreme  intrapulmonary  blood  pressure,  or  from  embolism  of  the 
pulmonary  trunk  or  its  branches. 

Mechanism. — The  mechanism  is  analogous  to  that  of  aortic  insuffi- 
ciency except  that  the  right  heart  suffers  instead  of  the  left  and  the 
arterial  phenomena  are  manifest  in  the  area  of  the  pulmonary  artery. 

Physical  Signs. — 1.  Inspection. — The  right  heart  is  dilated  and 
hypertrophied,  and  pulsates  under  and  to  the  right  of  the  sternum. 
It  may  slightly  dislocate  the  apex  to  the  right.  A  systolic  dynamic 
pulsation  may  be  seen  over  the  pulmonary  trunk,  which  is  also 
dilated. 

2.  Palpation. — This  determines  the  diffuse  right-heart  impulse  in 
20  per  cent,  of  cases,  and  a  diastolic  thrill  over  the  pulmonic  area, 
though  the  apex  beat  is  normal  or  weak  and  the  radial  pulse  is  practically 
normal. 

3.  Percussion. — Percussion  confirms  the  schematic  expectation  that 
the  right  ventricle  should  be  dilated  because  of  the  backward  fall  of  the 
regurgitant  column  of  blood  and  should  be  hypertrophied  to  maintain 
the  onward  flow  under  this  burden.  The  left  ventricle  is  normal  or 
sometimes  atrophic.      (See  Plate  VIII,  Fig.  E.) 

4.  Auscultation. — A  diastolic  murmur  is  heard,  which  is  propagated 
down  the  sternum  over  the  right  ventricle.  This  bruit  may  be  confused 
with  that  of  aortic  leakage,  aneurysm,  a  dislocated  aorta,  functional 
venous  murmurs, congenital  anomalies  of  the  vessels,  or  patent  foramen 
ovale.  The  second  pulmonic  and  the  second  tricuspid  tones  are  weak 
or  absent  and  are  replaced  by  the  murmur.  The  bruit  is  but  rarely 
heard  in  the  neck  and  the  normal  second  arterial  tone  is  heard  over  the 
carotids  (see  Aortic  Insufficiency).  A  systolic  murmur  (heard  in  25 
per  cent,  of  cases)  over  the  pulmonary  trunk  is  due  to  vibrations  in 
its  walls  or  to  coincident  stenosis  of  the  pulmonary  ring.  A  double  tone 
has  been  heard  over  the  lung,  as  well  as  variation  in  the  respiration 
during  the  systole, — a  capillary  pulse  in  the  pulmonary  vessels. 

VIII.  Pulmonary  Stenosis. 

The  etiology  will  be  considered  under  diagnosis  and  under  congen- 
ital heart  lesions. 

Mechanism  and  Physical  Signs. — 1.  Inspection.— Inspection  shows 
precordial  bulging  over  the  right  heart;  it  also  discloses  a  diffuse  heart 
shock  from  hypertrophy  and  dilatation  of  the  right  heart.  The  apex 
beat  is  often  weak  or  absent. 

2.  Palpation. — Palpation  confirms  the  above  and  reveals  a  systolic 
thrill  in  the  left  second  interspace.    The  pulse  is  negative  or  weak. 

3.  Percussion. — Percussion  shows  an  area  of  increased  dulness  over 
the  right  heart  from  dilatation. 


414  DISEASES  OF  THE  CIRCULATION 

4.  Auscultation. — On  auscultation,  a  loud  and  usually  whistling  or 
musical  systolic  murmur,  caused  by  the  stenosis,  is  often  but  not  al- 
ways heard  and  the  first  and  second  pulmonic  tones  (and  hence  also  the 
second  tricuspid)  are  weak  or  absent  from  poor  filling  of  the  pulmonary 
vessel  and  from  valve  alteration.     (See  Plate  VIII,  Fig.  E.) 

Diagnosis. — The  most  frequent  form  is  (a)  the  congenital,  which  is 
due  to  malformation,  myocarditis,  or  endocarditis,  and  is  usually  asso- 
ciated with  other  kindred  lesions  {e.  g.,  open  ductus  Botalli  or  foramen 
ovale).  The  obstruction  may  be  below  the  valves,  from  myocarditic 
scars  narrowing  the  conus  arteriosus,  in  which  case  the  second  pulmonic 
sound  is  accentuated;  or  it  may  be  at  the  valves  or  in  the  trunk  of  the 
artery.  Congenital  cyanosis  and  acquired  pulmonary  tuberculosis  are 
common.  The  murmur  may  be  heard  in  the  neck.  (6)  The  acquired 
valvular  form  is  rare.  Atheroma  or  gummata  maybe  causal.  The  thrill 
is  also,  though  far  less  frequently,  felt  in  accidental  murmurs  and  a 
murmur  over  this  area  is  most  common,  because  the  walls  of  the  artery 
are  so  thin  and  compressible  as  to  vibrate  easily.  These  "functional" 
murmurs  are  so  common  in  this  locality  as  well  to  justify  Fraentzel's 
rule  to  observe  extreme  caution  in  the  diagnosis  of  right-heart  lesions  in 
the  adult.  Functional  murmurs  may  occur  (i)  in  health;  (ii)  after 
fevers;  (iii)  in  ansemia;  (iv)  as  the  cardiopulmonary  murmur.  The 
organic  murmur  rarely  reaches  the  jugular  or  cervical  vessels.  The  left 
heart  is  frequently  atrophic.  When  the  acquired  stenosis  is  beyond  the 
valve  in  the  pulmonary  trunk  or  lungs,  the  murmur  is  heard  most  ad- 
vantageously beside  the  right  border  of  the  sternum  or  in  the  back,  and 
the  second  pulmonic  sound  is  loudly  accentuated,  from  which  points  a 
diagnosis  may  occasionally  be  made.  In  atresia  of  the  orifice  80  per 
cent,  of  the  subjects  die  in  the  first  year. 


IX.  Tricuspid  Insufficiency. 

Etiology. — (a)  The  congenital  form  is  most  rare,  isolated  tricuspid 
disease  occurring  in  0.8  per  cent,  of  cases  of  valvular  lesions.  The  ven- 
osity  of  the  blood  in  the  right  heart  tends  to  prevent  endocarditis,  ex- 
cept in  foetal  life  when  the  blood  is  arterial.  Myocarditis  or  ulcerative 
endocarditis  may  exceptionally  occur.  (6)  Of  acquired  forms,  the  rela- 
tive insufficiency  is  very  common,  resulting  from  (i)  valvular  lesions  of 
the  left  heart,  especially  mitral  stenosis;  (ii)  obstructive  lung  lesions, 
such  as  induration  or  emphysema;  (iii)  possibly  abdominal  lesions 
which  reflexly  contract  the  pulmonary  vessels,  and  (iv)  in  severe  anae- 
mias (Leube) ;  in  anaemic  regurgitation  cyanosis  and  dyspnoea  are  not 
observed. 

Mechanism. — Whatever  the  cause  of  the  high  pressure  in  the  lesser 
circulation,  it  leads  to  dilatation  and  hypertrophy  of  the  right  ventricle. 
Extreme  dilatation  stretches  the  tricuspid  orifice  so  that  the  valves  are 
incompetent  to  close  it,  and  relative  leakage  occurs.  The  leak  back- 
ward into  the  right  auricle  produces  its  dilatation  and  hypertrophy, 


TRICUSPID  INSUFFICIENCY 


415 


a  systolic  murmur  and  a  systolic  pulse  in  the  veins  of  the  neck  and 
liver. 

Physical  Signs. — 1.  Inspection,  (a)  A  positive  (systolic)  pulse  in 
the  jugular  veins  is  absolutely  pathognomonic  and  is  due  to  systolic 
entrance  of  blood  into  the  veins  from  the  right  ventricle  through  the 
insufficient  valves.    It  is  presystolic-systolic  and  is  known  as  positive  to 

Fig.  24. 


Negative  (diastolic-presystolic)  venous  pulse.    (After  Riegel  and  Sahli.) 

differentiate  it  from  the  negative  or  diastolic  venous  pulse  which  is 
observed  in  many  other  conditions^and  is  eitherphysiological,asondeep 
inspiration  caused  by  temporary  damming  back  of  the  blood  by  the 
auricular  systole,  or  pathological,  as  in  stasis.  It  is  seen  best  on  the  right 
side  because  of  the  more  direct  (vertical)  connection  with  the  right 
innominate  vein.  A  certain  degree  of  heart  force  is  necessary  for  its 
production,  and  it  may  cease  therefore  when  the  heart  grows  weak. 
Digitalis  may  cause  it  to  reappear  in  cases  of  relative  and  sometimes  of 
organic  leakage.  It  is  best  seen  when  the  patient  is  in  the  dorsal  decu- 
bitus. To  avoid  confusion  with  pulsation  transmitted  from  the  carotids, 
the  carotid  should  be  compressed  as  low  down  as  possible,  or  the  pul- 
sating jugular  vein  should  be  compressed  at  the  middle;  the  upper  part 
will  then  pulsate  if  the  carotids  beat  against  it  (transmitted  pulsation) 
and  the  lower  part  will  beat  if  the  pulsation  is  in  the  vein  itself.    Though 

Fig.  25. 


Positive  (presystolic-systol'c)  venous  pulse.    (After  Riegel.) 

it  is  seen  most  advantageously  in  the  internal  jugular  vein,  it  is  some- 
times seen  in  the  vena  cava  inferior  or  in  the  veins  of  the  chest  and 
extremities.  It  is  difficult  to  determine  when  the  heart  is  rapid  or  irreg- 
ular. (&)  A  liver  pulse,  systolic  in  time,  venous  regurgitant  in  origin, 
is  also  pathognomonic  of  this  disease,  (c)  The  right  heart  pulsates 
widely,  while  the  apex  beat  is  weak. 


416 


DISEASES  OF  THE  CIRCULATION 


2.  Palpation. — (a)  This  aids  in  determining  the  systoHc  phase  of 
the  venous  pulse,  and  (6)  it  estabhshes  the  systolic  venous  pulsation  of 
the  liver,  which  expands  in  the  bimanual  examination.  It  is  easier  to 
find,  and  often  earlier  to  appear  than  the  jugular  pulsation.  It  must 
not  be  confused  with  an  arterial  liver  pulse,  which  occurs  in  cases  of 
aortic  leakage,  exophthalmic  goitre,  and  of  liver  inflammation,  but  is 
less  expansile  than  throbbing,  (c)  A  systolic  thrill  over  the  tricuspid 
area;  (d)  tones  or  thrills  over  the  peripheral  veins;  and,  (e)  a  weak 
apex  and  radial  pulse  are  also  found. 

3.  Percussion. — This  shows  increased  dulness  to  the  right,  from 
distension  of  the  right  auricle  and  ventricle.  Changes  in  the  left  heart 
may  indicate  an  older  valvular  lesion  which  leads  up  to  the  tricuspid 
leakage.     (See  Plate  VIII,  Fig.  D.) 

4.  Auscultation. — (a)  A  systolic  murmur  is  heard  over  the  tricuspid 
region ;  it  may  have  a  different  quality  from  that  of  the  causal  mitral 
lesion.    Unlike  the  murmur  caused  by  mitral  lesions,  it  is  rarely  heard 

Fig.  26. 


Illustrating  the  influence  of  respiration  on  the  positive  (presystolic-systolic)  venous  pulse  of  the 

jugular  vein.    (After  Kovacs.) 

in  the  back.  The  murmur  is  absent  when  the  right  heart  is  weak,  be- 
cause it  then  fails  to  produce  the  necessary  vibration  or  eddy.  (6)  The 
second  pulmonic  sound  is  weak  because  the  pulmonary  circuit  is  poorly 
filled.  This  tone  often  varies  with  the  changing  activity  of  the  right 
ventricle.  It  may  remain  accentuated  even  with  tricuspid  leakage 
when  the  ventricle  is  fairly  strong,  (c)  Over  the  cervical  veins  may  be 
heard  a  systolic  tone  referable  to  closure  of  valves  in  the  veins;  or  the 
tone  may  be  double,  or  presystolic-systolic;  or  venous  murmurs  may 
take  the  place  of  the  single  or  double  tone. 

Diagnosis. — An  isolated  lesion  is  most  rare.  The  relative  insuffi- 
ciency is  diagnosticated  by  means  of  (a)  the  etiology,  (b)  the  large  right 
heart,  (c)  the  systolic  murmur,  (d)  the  positive  venous  pulse  in  the 
neck,  and  (e)  the  weak  second  pulmonic  tone.  Even  when  tricuspid 
incompetency  is  apparently  the  only  lesion,  it  should  be  remembered 
that  rest  or  digitalis  very  often  brings  out  a  causal  mitral  lesion.  Much 
is  said  regarding  the  "safety  valve"  action  of  the  tricuspid  valves, 
which  is  hard  to  understand.  Guarding  as  they  do  the  door  between 
the  venous,  and  arterial  circulation,  their  insufficiency  indicates  most 
serious  cardiac  failure. 


TRICUSPID  STEXOSIS  417 


X.  Tricuspid  Stenosis. 

Tricuspid  stenosis  is  rarer  than  tricuspid  insufficiency;  it  occurs 
alone  in  only  10  per  cent,  of  the  cases;  it  is  often  associated  with  in- 
sufficiency, or  with  mitral  or  aortic  stenosis.  Obstruction  of  this 
orifice  induces  hypertrophy  and  dilatation  of  the  right  auricle,  and 
this  produces  dulness  to  the  right  of  the  sternum.  In  the  single  lesion 
the  other  heart  chambers  and  the  large  vessels  are  small.  The  pulse  is 
weak.  The  second  pulmonic  sound  is  weak;  a  diastolic  or  presystolic 
murmur  and  thrill  to  the  right  of  the  sternum  are  detected  if  the  heart 
is  sufficiently  strong,  but  they  are  often  absent.  The  lesion  is  most 
serious,  because  it  taxes  the  weak  auricle  and  greatly  engorges  the 
venous  system.  The  diagnosis  is  most  difficult;  indeed  it  is  usually 
impossible.     (See  Plate  VIII,  Fig.  D.) 

XI.    Combined  Valvular  Lesions. 

These  occur  in  33  per  cent,  of  valvular  cases.  From  an  anatomical 
standpoint,  a  pure  lesion  is  rare,  and  double  lesions  are  found  oftener 
than  physical  signs  would  indicate.  Pure  lesions  occur  most  often 
on  the  arterial  valves.  One  lesion  may  follow  another;  for  instance, 
stenosis  may  gradually  result  from  insufficiency  sometimes  with  good 
results;   or  combined  lesions  may  develop  simultaneously. 

(a)  Combined  mitral  lesions  are  most  frequent,  though  one  lesion 
usually  predominates;  (b)  combined  mitral  and  aortic  lesions,  e.g., 
aortic  vegetations  reaching  the  nearest  mitral  cusp,  are  next  in  fre- 
quency and  include  71  per  cent,  of  the  cases  of  combined  lesions;  (c) 
double  aortic  lesions  are  less  common;  (d)  combined  aortic,  mitral  and 
tricuspid  lesions,  e.  g.,  stenosis  of  each  orifice  with  no  signs  other  than 
slowing  of  the  circulation,  occur  in  16  per  cent.,  and  (e)  combined  mitral 
and  tricuspid  lesions  (especially  relative  tricuspid  insufficiency)  occur 
still  less  often  (in  9  per  cent.). 

Diagnosis. — The  diagnosis  depends  upon  the  character  of  the  pulse, 
the  quality  and  direction  of  transmission  of  the  different  murmurs, 
and  the  hypertrophy  and  dilatation  of  the  right  or  left  heart.  Skoda's 
rule  was  that  a  murmur  is  usually  most  intense  at  its  point  of  origin 
except  in  cases  of  aortic  insufficiency;  and  Oppolzer  held  that  when 
listening  to  the  mitral  and  pulmonary  valves,  murmurs  transmitted  to 
them  disappear  as  examination  is  made  more  to  the  left,  though  mur- 
murs due  to  lesions  on  these  valves  remain;  on  listening  further  to  the 
right,  the  true  tricuspid  and  aortic  murmurs  remain  and  those  which 
are  transmitted  disappear.  In  diagnosis,  the  seeking  out  of  the  main 
lesions  and  the  avoidance  of  too  complicated  diagnoses  lead  to  the  most 
practical  results. 

In  cases  of  combined  aortic  and  mitral  disease:  (a)  Aortic  insuffi- 
ciency and  mitral  insufficiency  lead  to  dilatation  and  hypertrophy  of 


418  DISEASES  OF  THE  CIRCULATION 

both  ventricles;  the  combination  is  frequent  in  children;  the  aortic 
findings  as  to  pulse  are  frequently  modified:  the  mitral  insufficiency 
may  be  relative  (muscular)  or  organic  (valvular),  and  this  can  be 
determined  by  close  and  continued  observation  only.  (6)  Aortic 
stenosis  and  mitral  insufficiency  is  next  in  frequency  and  is  the  most 
common  combination  in  adults ;  less  blood  reaches  the  arteries  than  in 
simple  aortic  stenosis;  the  right  heart  suffers  disproportionately, 
whence  the  severity  of  this  complication.  The  systolic  murmurs 
usually  vary  from  each  other  in  location,  transmission,  and  quality, 
(c)  Aortic  insufficiency  and  mitral  stenosis  is  a  relatively  frequent  and 
favorable  combination,  because  the  left  ventricle  is  usually  less  dilated; 
both  may  produce  presystolic  apical  murmurs  and  therefore  the  state 
of  the  right  heart  and  the  second  pulmonic  tone  are  all-important 
diagnostically.  (d)  In  combined  aortic  and  mitral  stenosis,  the  greater 
the  aortic  stenosis,  the  more  is  the  hypertrophy  of  the  left  ventricle; 
the  more  dominant  the  mitral  stenosis,  the  less  is  the  hypertrophy  of 
the  left  ventricle,  and  the  greater  is  the  dilatation  and  hypertrophy  of 
the  right  ventricle.    Differentiation  is  often  difficult. 

General  Symptoms  of  Valvular  Disease.— The  heart  possesses  not 
only  a  certain  reserve  power  but  in  favorable  instances  its  musculature 
hypertrophies.  Symptoms  may  easily  be  lacking  in  the  early  stages, 
but  later  compensation  to  meet  the  lesion  may  fail,  either  tempor- 
arily ("disturbed  compensation"),  or  permanently  ("loss  or  rupture 
lof  compensation").  This  is  the  asystolie  of  French  writers.  Every 
hypertrophy  is  more  or  less  temporary  in  its  compensation,  and  ulti- 
mate cardiac  failure  is  inevitable.  All  lesions,  practically  speaking, 
.tend  to  reduce  arterial  tension,  increase  venous  pressure,  retard  the 
capillary  flow  and  promote  embolism.  Circulatory  disturbances  may 
he  spontaneous  or  induced  by  psychical  excitement,  physical  exertion, 
intercurrent  disease,  recurrent  endocarditis,  malnutrition,  excessive 
use  of  alcohol  or  tobacco,  or  changes  in  the  heart  muscle.  The  gen- 
eral symptoms  and  physical  findings  are  more  or  less  common  to  all 
lesions,  but  some  are  more  frequent  in  certain  forms  of  valvular 
disease. 

1.  Constitutional  Symptoms. — Anaemia  is  frequent  (aortic  insuffi- 
ciency); polymorphonuclear  leukocytosis  is  present  in  half  the  mitral 
cases;  Andral  spoke  of  a  "heart  cachexia";  the  body  temperature  is 
normal  or  subnormal  from  slow  circulation.  Fever  is  due  to  recurrent 
endocarditis,  embolism,  or  intercurrent  disease.  The  nails  are  often 
clubbed  in  congenital  lesions.  Skin  hemorrhages  are  due  to  "blood 
dissolution "  or  less  frequently  to  embolism. 

2.  Cardiac  Signs  and  Symptoms. — Apart  from  actual  change  in  the 
chambers,  such  as  dilatation  and  hypertrophy,  the  heart  itself  is  not 
well  nourished  in  "breaking  compensation,"  for  it  receives  less  arterial 
blood  and  is  engorged  with  venous  blood.  The  heart  muscle  is  in  some 
cases  fatty,  and  in  others  is  the  seat  of  myocarditis  about  the  arteries  or 
some  cyanotic  induration  about  the  veins.  These  changes  are  less  the 
cause  than  the  effect  of  lack  of  compensation;    the  autopsy  and  the 


GENERAL  SYMPTOMS  OF  VALVULAR  DISEASE 


419 


microscope  may  fail  to  demonstrate  the  cause  of  broken  compensation. 
Here  and  there  pressure  atrophy  occurs,  as  in  the  papillary  muscles 
(aortic  regul-gitation).  The  rhythm  is  frequently  disturbed,  especially 
in  mitral  lesions  (stenosis).  The  sphygmograph  sometimes  shows 
two  ventricular  contractions  occurring  very  close  together  (pulsus 
bigeminus);  when  the  pulse  intermits  to  the  finger,  the  tones  of  the 
abortive  contraction  may  be  heard  over  the  heart  with  the  stethoscope, 
the  weaker  wave  failing  to  reach  the  periphery.  In  general,  the  pulse 
beats  are  fewer  than  the  heart  beats.    Four  tones  corresponding  to  the 


Fig.  27. 


Pulsiis  bigeminus. 


two  heart  beats  are  sometimes  heard.  The  gallop-rhythm  (Bouillaud 
1847)  is  sometimes  heard.  There  may  be  such  irregularity  that  tones 
and  murmurs  are  indistinguishable  {delirium  cordis).  The  pulse  is 
slow  (the  bradycardia  of  aortic  stenosis)  or  faster  than  normal,  tachy- 
cardia (mitral  lesions). 

Among  the  complications  are  pericarditis  (aortic  lesions)  and  re- 
cnrrent  endocarditis.  Palpitation  is  frequent,  either  continuously  or 
intermittently,  and  is  sometimes  induced  by  lying  on  the  left  side.  It 
may  be  absent  with  the  greatest  heart  alteration  (as  in  aortic  insuffi- 
ciency). A  sense  of  tension  over  the  heart  is  not  infrequent,  and  pain 
like  that  of  angina  pectoris  occurs  in  aortic  oftener  than  in  mitral  disease 
(Nothnagel). 

3.  Nervous  Symptoms. — These  are  not  frequent.  Syncope  (aortic 
stenosis  especially)  occurs  from  arterial  anaemia  of  the  brain.  Venous 
congestion  is  evidenced  by  repeated  epistaxis,  or  vertigo,  tinnitus,  or 
muscce  volitantes.  Brain  hemorrhage  is  infrequent  (mostly  in  aortic 
insufficiency).  Chorea,  epileptiform  seizures,  and  embolism  of  the 
Sylvian  arteries  are  sometimes  observed  as  well  as  psychoses;  the 
latter  are  delirium,  mania,  melancholia,  and  suicidal  tendencies,  and 
are  usually  of  unfavorable  import;  stasis,  inanition,  carbon-dioxide 
narcosis  and  renal  inadequacy  are  their  cause.  Retinitis  hemor- 
rhagica and  simple  hemorrhages  result  from  stasis  and  anaemia. 

4.  Respiratory  Symptoms. — Lung  stasis  is  sometimes  confused  with 
independent  lung  disease  on  account  of  dyspnoea,  cough,  and  expectora- 
tion. Cyanosis  occurs  more  often  in  mitral  than  in  aortic  disease  and 
is  most  intense  in  lesions  of  the  pulmonary  orifice.  Bronchitis  and 
hcemoptysis  are  most  common  in  mitral  affections.  Bronchitis  results 
less  from  congestion  in  the  lesser  circuit  than  from  congestion  in  the 
cava  superior,  into  which  (and  the  azygos)  the  bronchial  veins  empty. 


420  DISEASES  OF  THE  CIRCULATIOX 

Though  usually  bilateral,  it  may  predominate  on  one  side,  from  such 
local  causes  as  pleural  adhesions.  Haemoptysis  results  from  lung 
stasis  with  vessel  rupture,  or  from  embolism  emanating  from  right- 
heart  clots  or  thrombosis  in  the  pulmonary  and  less  frequently  in  the 
peripheral  veins.  The  sputum  may  resemble  that  of  pneumonia, 
though  it  is  darker,  more  venous,  and  less  viscid.  It  contains  the  so- 
called  "heart  disease  cells"  (E.Wagner).  They  are  large  granular  deli- 
cate cells  ■v\-ith  oval  nuclei,  which  often  contain  hsemosiderin  or  more 
rarely  needles  or  plates  of  hsematoidin;  they  are  probably  alveolar 
epithelial  cells  (possibly  leukocytes)  and  also  occur  in  other  lesions 
than  brown  induration  (as  emphysema,  asthma,  pneumonia,  and 
phthisis).  See  Plate  IX.  Pulmonary  oedeiJia  is  either  (a)  due  to  weak- 
ening of  the  left  ventricle  while  the  right  heart  beats  more  strongly 
or  (b)  far  less  frequently  is  inflammatory.  Crepitant  rales  are  fre- 
quently heard.  In  mitral  disease  the  lungs  frequently  become  dis- 
tended and  rigid  from  engorgement  of  the  capillaries,  and  somewhat 
resemble  the  lung  in  emphysema  (von  Basch's  Lungenschwellung 
und  Lungenstarrheit).  Broum  induration  (cyanotic  induration)  of  the 
lungs  has  for  its  anatomical  basis,  (a)  capillary  engorgement  often  mth 
fatty  change  in  the  intima,  (6)  increased  inter-alveolar  and  peri- 
vascular connective  tissue,  (c)  hemorrhage  into  the  lung  from  vessel 
rupture,  id)  consequent  pigmentation  by  the  altered  blood-pigment  of 
the  lungs  and  sputum,  and  (e)  the  "heart-disease  cells."  Dyspnoea, 
the  "cry  of  distress  of  the  myocardium"  (Sansom),  constant,  inter- 
mittent, or  nocturnal,  is  caused  by  unbalanced  slow  circulation,  the 
bulging  of  the  turgid  capillaries  into  the  alveoli,  pressure  of  the  heart 
on  the  lower  left  lobe  or  left  bronchus,  ascites,  hydrothorax,  oedema, 
bronchitis,  or  infarcts.  It  may  come  on  even  without  effort  on  the  part 
of  the  patient  when  there  are  constipation  and  poor  digestion;  or  it 
may  occur  especially  at  night  when  the  voluntary  deep  and  diaphrag- 
matic respiration  of  the  waking  hours  is  not  in  play,  whence  the  respira- 
tory centre  becomes  anaemic.  The  dyspnoea  is  not  expiratory  as  in 
asthma  but  is  mixed  in  type  (see  Cardiac  Asthma  under  Cardiac 
Neuroses.  )  The  wheezing  which  is  heard  is  due  to  pulmonary  oedema. 
The  gallop-rhythm  is  rarely  absent,  and  this  threatens  relapse  of  the 
dvspnoea.  Arteriosclerosis  and  nephritis  are  important  elements  in  its 
production.  Exertion  not  only  increases  the  heart's  work  but  the 
carbon  dioxide  and  fatigue  substances  from  the  muscles  irritate  the 
respiratory  centre,  and  the  respiratory  muscles  ultimately  become 
tired.  The  breathing  is  more  rapid.  It  may  be  Cheyne-Stokes  in  type 
(aortic  stenosis);  cerebral  ansemia,  arteriosclerosis,  and  uraemia  are 
its  causes.  Hypostasis  and  lobular  pneumonia  may  develop.  Hydro- 
thorax  may  hasten  death  within  a  few  hours  (Andral). 

5.  Gastro-intestinal  Changes. — Gastralgia,  anorexia,  hemorrhagic 
infiltration  and  erosion,  vomiting  or  hiematemesis,  result  from  passive 
congestion  and  may  be  mistaken  for  independent  gastric  disease,  such 
as  cancer  or  ulcer.  Delayed  digestion  and  constipation  are  usual. 
The  secretion  of  hvdrochloric  acid  is  normal  except  in  cases  of  marked 


PLATE   IX. 


>*A* 


'^: 


Heart  Disease  Cells,  showing  Alveolar   Epithelial  Cells,  Loaded 
Do"wn  -with  Granules  of  Hsematin.     (Simon.) 


GENERAL  SYMPTOMS  OF  VALVULAR  DISEASE  421 

weakness  of  the  heart.  Intestinal  hemorrhage  may  result  from  capillary 
congestion,  rarely  from  embolism  of  the  mesenteric  artery,  and  most 
infrequently^  from  mesenteric  venous  thrombosis. 

6.  Changes  in  the  Liver. — The  liver  suffers  stasis  through  the  con- 
gested cava  and  hepatic  vein;  this  leads  to  cyanotic  distention  of  the 
central  veins  of  the  liver  lobules  (appearing  dark)  and  to  cloudy  and 
fatty  degeneration  of  their  periphery  (appearing  lighter),  the  "nutmeg 
liver."  This  occurs  particularly  in  mitral  disease.  The  liver  is  not 
uniformly  affected.  Pigmentation  occurs  and  connective  tissue 
develops  in  the  liver  and  its  capsule  (perihepatitis,  "iced  liver"). 
Small  granulations  develop  on  its  surface  and  in  some  instances  a  liver 
shrinkage  results  from  "cyanotic  induration"  (cardiac  cirrhosis, 
chronic  central  red  atrophy).  The  liver  is  symmetrically  large  before 
oedema  appears;  when  disturbed  compensation  is  being  restored,  it  is 
one  of  the  last  symptoms  to  disappear.  Occasionally,  from  local 
changes,  there  may  be  tumor-like  enlargement  of  the  liver,  which  may 
simulate  cancer.  There  is  a  feeling  of  tension  and  weight  in  the  right 
hypochondrium  and  the  organ  is  tender  and  variable  in  size;  it  may 
become  smaller  from  rest  or  from  administration  of  digitalis.  Its  edge 
is  rounded  and  not  hard  except  in  the  late  stages.  (See  Differential 
Table  of  Hepatic  Diseases).  The  icterus  viridis  develops  gradually 
and  is  a  combination  of  mild  icterus  and  cyanosis;  icterus  is  rarely 
intense  but  is  of  the  "urobilin"  type;  it  is  rarely  sudden  except  in  the 
infrequent  embolism,  which  may  cause  a  clinical  picture  resembling 
acute  yellow  atrophy.  Ascites  is  usually  late  and  secondary  to  the  liver 
congestion;  its  early  appearance  is  indicative  of  independent  liver 
disease  or  peritoneal  affections.     It  is  sometimes  chyliform. 

7.  Changes  in  the  Spleen. — The  spleen  is  sometimes  increased  from 
embolism  or  liver  disease,  but  is  often  harder  and  smaller  than  normal. 

8.  Changes  in  the  Kidneys. — The  kidneys  are  enlarged  from  hyper- 
semia,  the  capsule  strips  readily,  and  scattered  areas  of  blood  extrava- 
sation are  seen.  The  stellulce  Verheyniiare  prominent,  as  also  are  the 
glomeruli.  Some  epithelial  degeneration  from  malnutrition  is  seen  and, 
in  cases  of  long  standing,  "cyanotic  induration"  occurs.  Deformity 
from  the  stellate  scars  of  healed  embolism  and  fresh  infarcts  are  often 
encountered. 

Renal  symptoms  are  greater,  the  higher  the  venous  and  the  lower 
the  arterial  blood  pressure.  The  urine  is  decreased — its  daily  amount 
being  an  accurate  gauge  of  the  heart's  force;  it  is  of  higher  specific 
gravity  (1025  to  1030),  very  acid,  and  is  highly  colored  from  urates  and 
increased  uric  acid  (even  an  eight-fold  increase) ;  the  urea  is  decreased 
and  also  the  chlorides  when  oedema  exists;  albumin  is  frequent  (at 
the  most  2  per  l,000[Krehl]),and  there  may  possibly  be  a  few  red  disks 
though  these  are  more  usually  due  to  embolism  or  acute  nephritis. 
The  kidneys  are  slow  to  eliminate  methyl  blue  or  potassium  iodide. 
Krehl  has  found  granular  as  well  as  hyaline  casts,  contrary  to  the 
usual  experience.  (See  Differential  Table  of  Diffuse  Renal 
Diseases.)     Chronic    nephritis    may    coexist.      Rest    and     digitalis 


422  DISEASES  OF  THE  CIRCULATION 

increase  the  amount  of  urine  and  decrease  or  remove  the  albumin. 
In  women,  menstruation  is  frequently  increased  by  passive  congestion. 

9.  Embolism. — Embolism  occurs  as  it  does  in  acute  endocarditis  but 
its  significance  and  effects  are  wholly  mechanical.  Embolism  occurs  in 
about  one-third  of  the  cases.  Though  it  is  most  common  in  the  kidney 
(77  per  cent.)  and  spleen  (54.7  per  cent),  it  also  occurs  in  the  arteries 
of  the  brain  (22.7  per  cent.)  (left  Sylvian  artery),  in  the  extremities 
especially,  in  the  branches  of  the  left  iliac  artery,  in  the  retina, liver,  aorta 
(with  paraplegia),  and  mesenteric  vessels  (in  1  per  cent.).  In  the  lungs 
it  results  from  right-heart  clots  or  thrombosis  in  the  large  peripheral  or 
pulmonary  veins.  The  special  visceral  features  of  embolism  will  be 
discussed  under  Diseases  of  the  Brain,  Lung,  Kidney,  etc. 

10.  (Edema. — This  is  a  result  of  venous  stasis,  transmitted  to  the 
lymph-vessels  and  interspaces,  and  is  also  an  evidence  of  changes  in 
the  vessel  walls  from  actual  blood  alteration,  for  in  some  cases  at  least 
the  blood  is  thinned  (hydrsemia).  It  appears  first  in  the  connective 
tissue  of  the  lower  extremities  (right  leg);  it  disappears  over  night; 
and  it  extends  upward  to  the  vulva  or  scrotum,  abdomen,  chest  and 
serous  sacs  (ascites,  hydrothorax  and  hydropericardium)  and  brain  ven- 
tricles. The  loss  of  fluid  to  the  system  is  unfavorable;  the  anasarca  also 
impedes  the  arterial  circulation,  threatens  life  from  involvement  of  the 
glottis  or  lungs,  increases  the  tendency  to  secondary  infections  (erysipe- 
las, cellulitis,  ulceration,  or  gangrene)  and  may  lead  to  hypertrophy  of 
the  connective  tissue  about  the  genitalia  (cardiac  elephantiasis).  It  is 
most  common  in  mitral  disease.  The  prognosis  is  less  favorable  if  the 
liver  becomes  very  large  before  oedema  appears. 

11.  Changes  in  the  Joints. — Swollen  joints  and  tabes  dorsalis  (aortic 
insufficiency),  are  occasionally  associated  with  valvular  disease. 

Course  and  Prognosis  of  Valvular  Disease. — Patients  may  live  for 
years  with  compensated  valvular  affections;  a  case  of  aortic  leakage 
lived  for  twenty-five  years  and  a  case  of  mitral  leakage  lived  for  sixty- 
six  years.  As  a  rule  the  course  is  chronic  and  unfavorable,  and  is 
influenced  by  the  following  conditions: — 

1.  State  of  the  Heart  Muscle. — This  muscle  is  the  basis  of  hyper- 
trophy and  compensation.  Myocarditis  is  most  unfavorable  whether 
associated  or  not  with  coronary  disease,  for  digitalis  has  then  no  effect 
on  the  heart  muscle.  In  cases  where  digitalis  has  immediate  effect,  the 
prognosis  is  favorable.  The  size  of  the  heart  is  more  important  than 
valvular  murmurs.  Great  dilatation  or  dilatation  without  hypertrophy 
is  most  unfavorable. 

2.  Sex. — The  prognosis  is  .generally  better  in  women,  because  they 
are  less  exposed  and  less  subject  to  physical  strain  and  coronary 
disease.  Pregnancy  as  a  rule  is  a  rather  unfavorable  complication. 
Peter  advises,  "In  girls,  (with  valvular  lesions)  no  marriage,  in  wives, 
no  pregnancy;   in  mothers,  no  nursing." 

3.  Age. — In  the  flrst  decade  of  life  the  prognosis  is  poor,  even  though 
the  heart  and  coronary  vessels  are  young,  because  hypertrophy  and 
dilatation  are  extreme,  exercise  is  difficult  to  regulate,  the  valvular 


GENERAL  TREATMENT  OF  VALVULAR  DISEASE  423 

lesion  tends  to  recur  and  the  endocarditis  tends  to  develop  into  peri- 
carditis or  pancarditis.  After  puberty  the  outlook  is  better,  except,  of 
course,  in  congenital  types. 

4.  Valve  Involved.- — Opinions  vary  widely;  for  instance,  aortic  in- 
sufficiency is  rated  as  the  most  favorable  form  by  some,  and  as  the  most 
unfavorable  by  others.  This  may  depend  on  the  type,  the  outlook 
being  fair  in  the  endocarditic  and  most  ominous  in  the  atheromatous 
type.  The  best  clinicians  disagree  as  to  the  relative  outlook  in  mitral 
and  aortic  lesions,  although  subjects  of  mitral  insufficiency  seem  to 
have  the  more  favorable  prognosis.  Broken  compensation  is  more 
likely  to  be  restored  in  mitral  insufficiency  than  in  mitral  stenosis  or  in 
aortic  lesions.  Mitral  stenosis  is  less  favorable,  although  it  is  often 
found  in  women  at  an  advanced  age.  Aortic  stenosis  is  also  found  at 
an  advanced  age.  Combined  or  multiple  lesions,  with  some  few 
exceptions,  are  unfavorable.  The  writer  observed,  in  a  young  physi- 
cian, a  complete  recovery  from  a  double  mitral  lesion;  in  eight  years 
after  his  causal  rheumatism  the  outlines  and  tones  became  perfectly 
normal.    Pulmonary  lesions  give  a  tendency  to  early  tuberculosis. 

5.  Mode  of  Life.— The  social  scale,  hygiene,  necessity  of  hard  work, 
psychical  excitement,  alcoholism,  exposure,  and  the  individual  consti- 
tution, are  most  important  factors. 

6.  Unfavorable  Symptoms. — Cardialgia,  angina  pectoris,  embolism, 
persistent  palpitation,  dyspnoea,  and  irregular  or  intermittent  pulse  are 
unfavorable  symptoms.  The  "reserve  heart  power"  of  Martins  is 
not  present  in  all  cases;  this  is  due  to  failure  of  the  coronary  vessels 
to  increase  their  calibre  (Verney). 

7.  Favorable  Conditions.— As  described  by  Sir  Andrew  Clark,  these 
are  good  general  health,  just  habits  of  living,  and  absence  of  special 
rheumatic  or  catarrhal  tendencies,  endocarditic  (not  atheromatous) 
origin,  no  changes  in  the  heart  after  three  years'  observation,  sound 
ventricles  and  arteries,  and  freedom  from  stasis  in  the  lungs,  liver,  and 
kidneys. 

8.  Sudden  Death. — In  most  cases,  sudden  death  occurs  in  aortic 
affections  from  coronary  disease,  but  it  may  also  result  from  cerebral 
or  pulmonary  embolism,  from  thrombosis  cordis  occluding  an  orifice, 
from  heart  rupture,  from  sudden  ventricular  dilatation,  and  from 
glottis  oedema. 

9.  Intercurrent  or  Associated  Disease. — Tabes  and  chorea  have 
been  mentioned.  Valvular  disease  does  not  exclude  cancer  nor  typhoid, 
as  was  once  claimed.  The  acute  fevers  greatly  tax  the  myocardium. 
Tuberculosis,  which  is  said  to  be  rare  except  in  pulmonary  valve  lesions 
(since  the  lungs  are  hypersemic),  is  found  in  8  per  cent,  of  autopsies  on 
valvular  subjects. 

Treatment  of  Valvular  Disease. — (A)  In  Compensated  Lesions. — 
In  compensated  lesions  medicinal  treatment  is  usually  unnecessary 
With  some  exceptions,  the  patient  is  informed  of  the  nature  of  his 
trouble  that  his  cooperation  may  be  enlisted.  The  mode  of  life  is 
important,  i.  e.,  regular  orderly  living,  as  free  as  possible  from  psychi- 


424  DISEASES  OF  THE  CIRCULATION 

cal  or  sexual  excitement,  worry,  or  hurry.  Especial  care  should  be 
enforced  in  aortic  cases  because  of  danger  of  sudden  death.  Much 
depends  on  the  social  status  of  the  patient.  Plenty  of  sleep  is  advisable, 
although  heavy  sleep  after  meals  is  said  to  promote  fatty  degeneration. 
The  diet  should  be  simple  but  not  too  schematic.  Tobacco  should  be 
interdicted,  but  like  alcohol  can  sometimes  be  given  with  care  and 
moderation;  beer  and  champagne  are  but  poorly  tolerated,  though 
some  red  wine  and  brandy  or  cognac  are  permissible,  especially  in 
adults  and  in  the  aged.  Coffee  may  be  given  in  the  morning  but  should 
not  be  strong,  for  cardiac  irregularity  frequently  results.  A  breakfast 
of  milk,  with  a  Httle  liquor,  may  be  taken  before  rising,  and  the  noon 
meal  should  be  the  heartiest  of  the  day.  Nitrogenous  food  is  best, 
with  such  light  carbohydrates  as  toast;  foods  which  ferment,  such  as 
cabbage,  beans,  or  brown  bread,  should  be  avoided  and  the  amount  of 
fluid  ingested  should  be  moderately  restricted.  Those  things  which 
load  the  stomach  heavily,  are  prone  to  elevate  the  diaphragm,  and 
every  meal  somewhat  taxes  the  heart.  A  light  meal  at  night  is  the  best 
precaution  against  gastric  and  cardiac  oppression  during  the  sleeping 
hours.  A  milk  diet  is  recommended  in  cases  of  stasis,  especially  when 
there  is  much  hepatic  congestion,  but  it  necessitates  the  ingestion  of  too 
large  quantities  of  milk. 

Exercise.— Exercise  must  be  rational,  and  in  moderate  cases  is  advis- 
able, for  the  muscles  can  not  only  accommodate  all  the  blood  of  the 
body,  but  also  by  their  activity  reflexly  stimulate  the  heart  muscle. 
Palpitation,  recurrent  endocarditis  and  intercurrent  fever  necessitate 
keeping  the  patient  in  bed.  Moderate  massage  is  beneficial,  but  care 
must  be  taken  lest  it  produce  dilatation  of  the  abdominal  vessels. 
Deep  breathing  and  singing  are  also  beneficial.  Plethoric  patients 
should  be  given  an  enema  of  salines,  which  should  be  allowed  to  re- 
main in  the  bowels  over  night.  Tepid  baths  are  more  beneficial  than 
those  which  are  cold  or  hot. 

Climate. — High  altitudes  are  to  be  avoided,  although  moderate 
elevation  is  tonic.  The  seashore  often  disagrees  with  rheumatic  or 
catarrhal  subjects.    A  warm  climate  should  be  chosen  for  the  winter. 

(5).  Broken  Compensation. — Broken  compensation  may  be  acute, 
gradual  or  terminal,  as  by  coronary  occlusion,  and  is  evidenced  by 
dyspnoea  which  develops  on  exertion  or  spontaneously  during  the 
night,  by  ansemia,  by  irregular  pulse  (of  special  significance  in  aortic 
cases),  and  by  dilatation.    The  indications  are  as  follows: 

1.  Absolute  Rest  in  Bed. — This  is  frequently  curative,  especially 
in  chlorosis  or  in  pregnancy.  Some  patients  are  obliged  to  sit  up 
because  of  dyspnoea.  Liebermeister's  case  of  severe  cardiac  disease 
which  recovered  while  in  bed  with  a  broken  leg,  is  an  example  of  com- 
pensation restored  without  digitalis  or  other  drugs.  Rest  is  imperative 
in  intercurrent  fevers,  bronchitis,  recurrent  endocarditis,  and  acute 
cardiac  insufficiency.  Bed  sores  can  be  prevented  by  the  use  of  water- 
cushions,  and  by  cleanliness.  The  head  may  be  propped  up  by  back- 
rests, but  they  should  have  side  supporters  so  that  falling  to  sleep  will 


GENERAL  TREATMENT  OF  VALVULAR  DISEASE  425 

not  waken  the  patient.    Rest  should  be  combined  with  purgation  (see 
below).  ' 

2.  Saliiste  Purgation. — Epsom  or  Glauber  salts  §ss-j  in  con- 
centrated form  should  be  given  in  the  morning  or  compound  jalap 
powder  3ss-j  at  night.  These  and  kindred  remedies  deplete  or 
bleed,  as  it  were,  the  portal  circulation  and  relieve  the  heart.  Consti- 
pation per  se  often  increases  the  size  of  the  left  heart. 

3.  Venesection. — This  is  necessitated  by  extreme  venous  engorge- 
ment evidenced  by  cyanosis,  orthopnoea,  dilatation,  or  tricuspid  leak- 
age. Six  ounces  to  nearly  a  quart  may  be  drawn.  The  effects  are 
too  often  considered  transient  although  the  symptoms  return  sooner 
or  later.  In  two  cases  apparently  dying  of  valvular  disease,  where 
no  blood  could  be  obtained  from  the  arms,  the  external  jugular  veins 
were  opened,  and  the  patients  lived  more  than  a  year  afterward. 
Venesection  is  not  to  be  left  until  the  patient  is  in  extremis.  It  may 
be  necessary  to  have  the  patient  "actively  move  the  arm  so  as  to 
bring  the  blood  from  the  capillaries  into  the  veins"  (Liebermeister). 

4.  The  Oertel  and  Schott  Methods. — (See  Treatment  of 
Disease  of  the  Heart  Muscle.) 

5.  Digitalis. — Digitalis  was  first  recommended  by  Withering,  and 
its  physiological  action  demonstrated  by  Traube.  Its  general  indi- 
cations are  (a)  dilatation:  digitalis  gives  or  restores  tone  to  the  heart- 
muscle  and  its  ganglia,  and  upon  these  the  drug  exercises  its  main 
influence;  (6)  junctional  dissociation:  it  is  claimed  that  the  ventricles 
have  different  innervation  and  that  the  drug  is  used  most  efficaciously 
when  the  pulmonary  and  venous  circulations  are  engorged  from  too 
weak  systole  of  the  right  and  too  strong  systole  of  the  left  ventricle. 
When  the  fulse  is  irregular,  digitalis  coordinates  the  cardiac  energy 
by  action  on  the  heart  muscle  and  its  ganglia  or  upon  the  terminal 
branches  of  the  vagus,  (c)  Rapid,  weak,  heart  action:  digitalis  slows 
the  heart  by  action  on  the  vagus  and  by  increasing  arterial  pressure. 
It  tends  to  abolish  abortive  cardiac  contractions  (y.  s.  pulsus  bige- 
minus),  and  synergizes  the  systole  of  the  chambers,  as  is  shown  by 
the  strong  systolic  spasm  of  the  heart  in  cases  of  digitalis  poisoning. 
The  slower  and  stronger  systole  empties  more  completely  all  the  heart- 
chambers,  forces  the  venous  and  arterial  blood  into  the  main  arteries, 
and  squeezes  the  venous  blood  out  of  the  heart  muscle  itself,  thereby 
improving  the  intrinsic  heart  circulation.  The  slower  and  more 
complete  diastole  allows  of  better  filling  of  the  heart  and  drainage 
of  the  engorged  veins.  Digitalis  raises  the  arterial  tension  by  increas- 
ing the  working  power  of  the  heart  and  by  its  centric  and  local  action 
on  the  vasomotors. 

In  the  individual  lesions:  (a)  in  mitral  stenosis,  the  longer  diastole 
drains  the  left  auricle  and  lung  vessels  and  the  stronger  systole  forces 
the  retarded  blood  through  the  stenotic  orifice;  (b)  in  mitral  insufli- 
ciency,  the  best  results  are  obtained;  the  leaking  cusps  are  better 
coapted  and  the  stronger  systole  fills  the  aorta  and  pulmonary  artery; 
(c)  in  aortic  stenosis,  when  dilatation  occurs  or  the  hypertrophy  is 


426  DISEASES  OF  THE  CIRCULATION 

inadequate,  digitalis  is  valuable;    (d)  in  aortic  regurgitation,  it  is  theo- 
•retically  contraindicated  since  it  increases  the  diastole  and  hence  the 
leakage;  it  is  however  practically  valuable. 

Digitalis  is  contra-indicated  (a)  in  balanced  compensation;  (b)  in 
adequate  hypertrophy;  (c)  unless  rest  and  purgation  have  first  been 
tried ;  (d)  when  the  vessels  are  fragile,  as  in  aneurysm  and  advanced 
atheroma  (on  account  of  danger,  e.g.,  of  brain  hemorrhage);  (e)  in 
fatty  degeneration  of  the  heart,  except  when  resulting  from  stasis  and 
malnutrition;  (/)  in  vascular  contraction.  It  is  in  this  case  combined 
with  nitroglycerine,  strophanthus  or  potassium  iodide,  for  the  purpose 
of  "unlocking  the  arteries"  (Balfour).  The  drug  is  not  absolutely 
contra-indicated  in  the  high  tension  of  arteriosclerosis  and  nephritis, 
for  it  may  relieve  the  condition,  paradoxical  as  this  may  seem,  by 
lessening  dyspnoea  and  carbon-dioxide  narcosis,  (g)  In  idiosyncrasy 
to  the  drug,  e.^.,  when  there  are  gastrointestinal  symptoms  which,  how- 
ever, are  more  often  due  to  stasis.  Digitalis  also  causes  contraction  of  all 
unstriped  muscular  tissue  (gastric,  muscular).  It  may  cause  insomnia, 
delirium,  headache,  diplopia,  blindness  to  green  colors,  etc.  Digitalis 
is  said  to  dilate  the  left  and  contract  the  right  coronary  artery;  there- 
fore when  the  right  coronary  vessel  is  diseased,  it  may  dilate,  and 
cause  excessive  contraction  of  the  right  ventricle  and  thus  dissociate 
the  heart's  action. 
.  Cumulative  action  is  averted  (a)  by  intermittent  administration,  al- 
though some  patients  tolerate  digitalis  continuously  for  months  or 
years,  as  Thomeyer's  case  who  used  digitalis  eight  and  a  half  years, 
taking  in  all  over  15  ounces  of  the  solid  digitalis;  (b)  by  great  care  in 
ambulatory  cases;  (c)  by  care  in  cardiac  dropsy,  on  relief  of  which 
toxic  quantities  may  be  resorbed  from  the  tissues;  (d)  by  care  in  in- 
tercurrent febrile  affections,  for  toxic  effects  often  follow  the  fall  of 
temperature;  (e)  by  withdrawal  on  the  appearance  of  vomiting, 
syncope,  reduced  urine  or  irregular  pulse  (with  twice  as  many  heart 
as  pulse  beats) .  Twenty-seven  cases  of  pulsus  bigeminus  from  the 
use  of  digitalis  are  reported. 

Digitalis  may  fail  to  operate  unless  free  purgation,  venesection,  and 
mechanical  removal  of  the  anasarca  have  been  first  employed. 

Preparations. — Some  physicians  prefer  the  powder,  gr.  j,  others  the 
tincture,  ttj^xv  to  xx,  or  the  infusion  §ss-j.  The  infusion  is  considered 
more  diuretic  (containing  digital ein  and  digitonin). 

Infusi  digitalis 5iij. 

Spts.  setheris  nitrosi 3j. 

Potas.  bicarbonatis 3ss. 

Aquae oij. 

S. — ^To  be  taken  after  meals. 

Larger  doses  may  be  given  though  with  risk.  It  is  excellent  for  rectal 
use  when  the  stomach  is  irritable.  The  tincture  is  thought  to  be  the 
best  cardiant  because  it  contains  digitalin  and  digitoxin.  The  writer 
has  found  digitalin  almost  inert.     Digitoxin  has  seemed  of  doubtful 


GENERAL  TREAT  MET  OF  VALVULAR  DISEASE  427 

value,  but  in  the  author's  hands  it  has  often  slowed  and  strengthened 
the  weak  and  irregular  heart  (gr.  4io  t.  i.  d.),  when  digitalis  has  failed; 
it  easily  disorders  the  stomach,  and  often  cannot  be  given  for  more 
than  six  or  eight  doses.  Digitoxin  is  often  advantageously  combined 
with  champagne.  For  hypodermic  use,  the  fluid  extract,  TTjjij  to  iv,  is 
a  non-irritant.  Cloetta's  digalen  is  a  soluble  non-irritant  digitoxin, 
and  may  be  given  intravenously,  1  c.c.  equalling  0.3  mg.,  or  ilo 
grain.  The  writer  believes  the  preparation  acts  promptly,  though  it 
is  somewhat  irritating  when  given  hypodermatically. 

6.  Other  Cardiants. — (a)  Strophanthus ,  -njiv  to  x  of  the  tinc- 
ture every  eight  hours,  may  be  given.  Advantages:  it  is  more  rapid 
in  action  than  is  digitalis,  has  no  cumulative  effects,  perpetuates  the 
effects  of  digitalis  after  the  first  five  or  seven  days,  and  is  indicated 
especially  in  the  irregular  heart  of  mitral  disease,  in  children  under 
twelve  years,  in  cases  where  we  are  waiting  for  the  digitalis  to  act,  and 
in  dilatation  where  the  blood  pressure  is  high.  Disadvantages:  it  is 
less  certain  and  less  energetic;  it  is  inferior  in  oedema  and  does  not 
give  tone  to  the  vessels  (which  may  be  an  advantage  in  atheroma). 
(6)  Strychnine  stimulates  the  vagus  and  heart  muscle,  besides  being 
a  splendid  vascular  tonic  (see  Pneumonia,  Treatment)  and  tonic 
to  the  nervous,  gastric,  and  blood-making  tissues.  Given  carelessly, 
it  may  irritate  the  heart,  decrease  the  urine  by  spasm  of  the  renal 
vessels,  or  even  induce  rupture  of  the  vessels,  (c)  Spartein  sulphate 
(gr.  i  to  ^  every  six  or  eight  hours)  is  given  in  capsule  because  of  its 
bitterness;  larger  doses  may  be  given,  gr.  j  to  gr.  iss;  it  seems  to  quiet 
the  nervous  system  and  regulate  the  heart  better  than  other  remedies 
(See)  but  is  very  inferior  to  digitalis.  It  does  not  contract  the  ves- 
sels.   Convallaria  and  adonis  are  very  unsatisfactory. 

7.  Symptomatic  Treatment. — (a)  Dropsy. — Saline  or  hydragogue 
catharsis  often  relieves  moderate  oedema.      Digitalis,  alone  or  com- 
bined with  calomel  or  blue  mass,  and  pulv.  scillse  (Guy's  pill)  is  often 
efficacious- 
ly 

Pulv.  digitalis gr.  x._ 

Massse  hydrargyri gr.  vj. 

Pulv.  scillse      gr.  X, 

M.  et  ft.  capsulse  x. 
S. — One  after  meals  for  one  or  two  days. 

Mercurials,  which  were  recommended  by  Jendrassik,  must  be  used 
with  the  greatest  care.  The  author  saw,  in  consultation,  a  case  com- 
plicated by  nephritis  in  which  the  tongue  sloughed  off  after  five  grains 
of  calomel  had  been  given.  Desperate  stomatitis  may  result  in  alco- 
holic, myocarditic,  or  nephritic  subjects.  Excess  of  digitalis,  it  must 
be  recalled,  is  held  to  suppress  the  urine  by  inducing  renal  spasm. 
It  is  better  to  use  potassium  salts,  as  potassium  acetate  gr.  xxx,  t.  i.  d., 
which  are  less  abundant  in  the  tissues  than  the  sodium  salts;  the 
potassium  acetate,  e.  g.,  passes  through  the  tissues  and  kidneys,  taking 
fluid  with  it  (Bunge).     Huchard  proved  that  the  diuresis   following 


428  DISEASES  OF  THE  CIRCULATION 

digitalis  was  associated  with  increase  of  sodium  chloride  elimination. 
Caffeine  with  digitalis  is  beneficial  in  dropsy  when  the  pulse  is  slow, 
the  mind  dull,  and  the  digestion  sluggish;  it  may  cause  nervousness 
or  insomnia  (therefore  should  be  given  early  in  the  day),  irregular 
pulse  (therefore  should  be  combined  with  rum  or  brandy),  or  bilious- 
ness; gr.  V  should  be  given,  but  not  for  more  than  three  days — 

Caffeinee  citratse oss. 

Sodii  benzoatis 3ss. 

Aquse 3iij. 

M.  et  S. — One  hypodermieful  (3ss),  as  indicated. 

Diuretin  (daily  dosage  of  60  to  90  grains)  may  have  marvellous  effects 
or  may  absolutely  fail;  chemically  it  is  sodio-salicylate  of  theobrom- 
ine; it  contains  50  per  cent,  theobromin,  and  operates  on  the  renal 
cells  directly,  and  possibly  also  on  the  heart  and  vessels.  Canadian 
hemp  (fluidextr,  apocyni  v^  xv)  is  hard  to  obtain  pure  but  some- 
times justifies  Benjamin  Rush's  term,  "a,  vegetable  trochar."  Sweats 
and  the  use  of  pilocarpine  are  both  dangerous  and  injurious.  Mechan- 
ical drainage  is  recommended,  by  scarification,  by  multiple  knife  or 
pinpricks,  or  by  Southey's  capillary  tubes;  but  the  best  method  is 
by  a  single  long  deep  incision  down  to  the  bone.  Sodium  chloride 
should  be  excluded  from  the  diet  (see  Dropsy,  Treatment  of 
Chronic  Nephritis).  Ascites,  from  heart  disease  alone,  rarely 
necessitates  puncture :  it  is  indicated  chiefly  in  coincident  liver  cirrho- 
sis or  in  chronic  peritonitis.  Hydrothorax  is  far  more  important,  and 
thoracic  paracentesis  should  not  be  delayed  when  dyspnoea  is  urgent. 

(b)  Anosmia. — The  administration  of  digitalis  with  iron,  arsenic, 
and  zinc  phosphide  often  produces  remarkable  improvement;  iron 
and  arsenic  may  be  useful  without  employing  digitalis  at  all. 

Pulv.  digitalis gr.  xx. 

Ferri  redacti 5ss_. 

Ac.  arsenosi gr-  J- 

Zinci  phosphidis gr.  j . 

M.  et  ft.  pilulse,  xx. 
S. — ^One  pill  after  meals. 

Cod-liver  oil  is  excellent  in  children. 

(c)  Insomnia. — It  is  often  difficult  to  relieve  insomnia  or  unrestful 
sleep,  broken  by  nightmare  or  sudden  "heart  starts."  Spts.  chloro- 
formi,  spts.  camphorse,  and  spts.  setheris  compos,  aa  3ss  are  often 
helpful.  Sulphonal  (gr.  xx  in  hot  milk  at  bed-time)  may  be  tried  but 
is  somewhat  dangerous  in  stasis;  not  more  than  three  doses  should  be 
given.     Chloralamide  may  be  tried,  but  morphia  is  most  efficacious. 

(d)  Dyspnoea. — The  ice-bag,  quinine  and  nitroglycerine  gr.  ^U 
(though  it  gives  better  results  in  5  per  cent,  alcoholic  solution),  are 
of  value  for  high  tension.  Morphine  may  be  given  in  the  early  stages, 
and  without  hesitation,  and  especially  at  night,  for  restlessness  and 
dyspnoea;  it  is  excellent  while  waiting  for  digitalis  to  act.   It  is  almost 


GENERAL  TREATMENT  OF  VALVULAR  DISEASE  429 

specific  and  lessens  the  irritability  of  the  respiratory  centre.  It  is 
dangerous  when  the  heart  weakens,  the  lungs  become  oedematous,  or 
Cheyne-Stt>kes  breathing  is  present.  Dyspnoea  is  often  renal  or  due 
to  (right-sided)  hydrothorax,  chronic  bronchitis,  or  excessive  dilata- 
tion, and  appropriate  treatment  is  indicated  by  catharsis,  paracentesis, 
potassium  iodide,  or  digitalis,  respectively. 

(e)  Cardiac  Symptoms. — Cough,  cyanosis,  pulmonary  oedema,  and 
haemoptysis  are  usually  true  cardiac  symptoms,  and  have  for  their 
anatomical  basis  pulmonary  engorgement  or  brown  induration;  they 
are  relieved  by  the  cardiants.  Balfour  recommends  the  following 
combination  for  associated  bronchial  catarrh: 

^  ..  . 

Ammonii  carbonatis 3j. 

Tr.  hyoscyami 3iv. 

Potassii  iodidi 3j- 

Tr.  digitalis 3j. 

Infusi  calumbse    , q.s.  ad   5vj. 

M.  et  S. — One  teaspoonful  every  four  hours. 

Expectorants  usually  nauseate.  Haemoptysis  is  often  beneficial;  it 
may  be  regarded  as  a  species  of  lung  venesection  and  is  seldom  urgent 
or  fatal.  For  cyanosis,  alcohol  and  camphor  are  indicated.  Pulmon- 
ary oedema  necessitates  phlebotomy;  and  a  30-grain  dose  of  lead 
acetate,  gr.  xk  of  nitroglycerine,  and  gr.  I  of  morphine  should  be 
given. 

(/)  Palpitation  and  Pain. — For  palpitation  and  throbbing,  the  ice- 
bag  may  be  used;  a  precordial  blister,  or  tapping  several  times  on 
the  back,  or  a  few  minims  of  tr.  belladonnse  and  tr.  aconiti  are 
often  helpful. 

Fluidextracti   belladonnse gtt.  xv. 

Tr.  digitalis 3j. 

Aq.  laurocerasi q.s.  ad   §j. 

M.  et  S. — One  teaspoonful  two  or  three  times  daily. 

Care  regarding  the  evening  meal  (see  Diet)  and  the  condition  of  the 
colon  is  important.  Ten  grains  of  iodide  of  potash  with  nitroglycerine 
(or  gr.  ss  of  erythrol  tetranitrate  which  produces  a  more  lasting  effect), 
are  valuable  for  the  pain  of  aortic  lesions,  especially  when  these  are 
accompanied  by  weakness,  pallor,  neuralgia,  vertigo,  or  headache. 

(g)  Gastric  Symptoms. — These  are  troublesome  and  ominous.  They 
are  largely  due  to  portal  stasis,  for  the  liver  is  enlarged  and  there  is 
usually  not  much  oedema.  They  are  more  often  caused  by  stasis 
than  by  a  cumulative  effect  of  digitalis,  which  should  then  be  given 
by  rectum.  Small  doses  of  carbolic  acid,  gr.  ^  every  half  hour  for  five 
to  ten  doses,  and  rectal  nourishment  are  indicated. 


430  DISEASES  OF  THE  CIRCULATION 


(III).      CONGENITAL  HEART-DISEASE. 

These  cases  are  infrequent  and  are  usually  most  complicated.  They 
occur  largely  in  the  right  heart,  upon  which  more  work  is  devolved 
in  foetal  life.  The  causes  are  (a)  developmental  errors  or  deficits,  and 
these  are  by  far  most  frequent;  (b)  foetal  endocarditis  which  is  nearly 
always  sclerotic  and  very  rarely  verrucose;  (c)  foetal  myocarditis  or 
(d)  adult  endocarditis  developing  upon  developmental  anomalies.  They 
are  most  often  seen  in  male  children,  and  heredity  seems  occasionally 
a  factor. 

1.  Pulmonary  Stenosis. — This  is  by  far  the  most  frequent  con- 
genital lesion  and  occurs  in  various  forms;  (a)  stenosis  or  actual 
atresia  of  the  orifice  itself  from  endocarditis  (the  orifice  closed  by  a 
diaphragm  or  ring)  or  myocarditis.  In  this  form  the  second  pulmonic 
tone  is  weak  or  absent,  (b)  Changes  in  the  conus  arteriosus  which 
obstruct  the  onward  flow  of  blood.  The  second  pulmonic  sound  is 
clearly  heard,  if  the  valves  are  normal.  The  constriction  may  cause 
the  development  of  a  second  ventricle,  (c)  The  pulmonary  vessel 
beyond  the  valves  is  narrowed  or  even  converted  into  an  impervious 
cord;  this  is  a  grave  type  of  pulmonary  stenosis.  The  second  pul- 
monic sound  is  usually  heard. 

The  physical  signs  are  hypertrophy  and  dilatation  of  the  right  ven- 
tricle, a  thrill  over  the  pulmonic  area,  and  a  systolic  murmur  prop- 
agated into  the  neck  when  there  is  a  defect  in  the  interventricular 
septum.  These  cases  are  more  favorable  than  those  in  which  such 
defect  does  not  obtain,  because  in  them  the  right  ventricle  is  atrophic 
and  the  subjects  rarely  live  over  a  year.  In  pulmonary  stenosis  other 
congenital  abnormalties  are  most  common.  If  the  closure  or  stenosis 
exist  before  the  end  of  the  second  month  of  foetal  life,  the  interven- 
tricular septum  fails  (in  75  per  cent,  of  cases)  to  close,  and  is  pushed 
to  the  left,  so  that  the  aorta  may  partly  or  entirely  originate  in  the 
right  ventricle.  If  the  closure  develops  after  the  second  month,  the 
foramen  ovale  remains  patent  (66  per  cent.).  Upon  these  openings 
acute  endocarditis  is  likely  to  develop.  The  ductus  Botalli  usually 
remains  open  and  thereby  conducts  blood  from  the  aorta  to  the  pul- 
monary artery  and  lungs.  Should  the  ductus  Botalli  and  the  pulmon- 
ary orifice  be  closed,  collateral  circulation  is  possible  through  the 
oesophageal,  pericardial,  and  bronchial  arteries.  The  right  ventricle 
usually  hypertrophies,  especially  at  the  conus,  but  hypertrophic  changes 
in  this  chamber  are  not  constant;  the  left  heart  is  atrophic. 

2.  Defects  of  the  Interauricular  Septum. — The  foramen  ovale  is 
open  to  some  extent  in  44  per  cent,  of  all  autopsies,  and  the  membrane 
is  deficient,  cribiform,  or  wholly  absent.  The  foramen  ovale  usually 
closes  in  the  first  week  of  life,  but  fails  to  adhere  when  low  pressure 
in  the  left  auricle  exists.  Entire  absence  of  the  septum  is  the  most 
extreme  defect  possible;  this  is  called  the  ''reptilian  heart,"  or  cor 
hiloculare   when   the   interventricular  septum  is  also  absent,  or  the 


CONGENITAL  HEART-DISEASE  431 

cor  triloculare  when  the  ventricular  septum  is  present.  Its  patency 
aids  compensation  in  this  condition  or  when  the  valvular  orifices  are 
narrowed  or  closed  or  when  the  great  vessels  are  transposed.  Symp- 
toms are  absent  or  are  those  of  the  more  important  associated  trouble, 
for  its  patency  is  almost  a  necessity  in  some  congenital  lesions.  Rare 
occurrences  are  presystolic  murmur  at  the  level  of  the  third  or  fourth 
ribs;  "crossed  or  paradoxical  embolism,"  which  may  occur,  for  in- 
stance, in  the  brain  from  venous  thrombosis  in  the  leg  or  even  from 
particles  of  the  liver  or  of  neoplasms  (the  clots  or  tissue  which  pass 
directly  from  the  right  to  the  left  auricle) ;  and  positive  venous  pulse 
in  mitral  regurgitation.  Several  cases  have  been  found  in  living 
subjects  over  seventy  years  of  age. 

3.  Defects  of  the  Interventricular  Septum  {Maladie  de  Roger). — 
These  have  been  spoken  of  under  pulmonary  stenosis.  They  may  be 
single,  associated  with  other  anomalies,  or  may  result  from  myocarditis. 
Sometimes  a  canal-like  opening  connects  the  aorta  with  the  right 
ventricle.  The  deficit  occurs  oftenest  in  the  upper  "undefended" 
part  of  the  septum.  When  it  is  wholly  absent  the  heart  has  but  three 
chambers,  the  "trilocular  heart"  (cor  triloculare  hiatriatum).  Symp- 
toms are  absent,  complicated,  or  ambiguous.  At  times  the  signs  are 
those  of  mitral  leakage  without  the  lung  symptoms  of  stasis.  A  loud 
systolic  murmur  is  heard  over  the  upper  third  of  the  precordium  but 
does  not  reach  the  large  vessels. 

4.  Patency  of  the  Ductus  Botalli. — The  duct  is  usually  closed  by 
proliferation  of  its  coats  within  the  first  month  of  life,  because  the 
pulmonary  blood-pressure  is  lowered  after  birth.  Thus  premature 
closure  follows  pulmonary  stenosis,  which  necessitates  poor  filling  of 
the  lungs  with  blood.  Permanent  patency  of  the  duct  is  promoted 
by  other  congenitar lesions  or  by  atelectasis  or  pneumonia  in  the  new- 
born. It  leads  to  increased  blood  tension  in  the  lung.  The  second 
pulmonic  sound  is  accentuated,  and  the  artery  is  frequently  dilated, 
whence  the  dulness  in  the  second  left  interspace,  with  thrill,  pulsation, 
and  loud  vibratory  systolic  murmur  which  may  reach  the  cervical 
vessels  or  the  fourth  dorsal  vertebra  behind.  Sometimes  the  vessel 
is  so  dilated  as  to  compress  the  recurrent  laryngeal  nerve  and  thus 
cause  hoarseness.  The  right  ventricle  is  hypertrophied  and  dilated; 
it  is  distinguished  in  clear  cases  from  pulmonary  stenosis  by  the 
greater  cyanosis  of  the  latter  lesion,  the  less  frequent  propagation  to 
the  neck,  and  the  absence  of  the  second  pulmonic  sound. 

5.  Persistent  Isthmus  Aortse. — The  foetal,  developmental,  throm- 
botic or  inflammatory  narrowing  at  a  point  between  the  left  subclavian 
artery  and  the  ductus  Botalli  (46  per  cent,  below  the  duct,  37  per  cent, 
at  the  duct,  and  17  per  cent,  over  it),  is  characterized  (a)  by  hyper- 
trophy of  the  left  ventricle  (50  per  cent.)  to  overcome  the  stenosis, 
and  sometimes  by  a  systolic  murmur  in  the  interscapular  region;  (6) 
by  largeness  and  fulness  of  the  aorta  above  the  isthmus,  of  arteries 
of  the  head  (brain  hemorrhage),  neck  and  arms  (full  radials);  (c) 
by  a  small,  retarded,  abdominal  and  femoral  pulse,  corresponding 


432  DISEASES  OF  THE  CIRCULATION 

to  the  anatomical  smallness  of  the  vessels  below  the  isthmus;  (d)  by 
a  pronounced  collateral  circulation  between  the  branches  of  the  aortic 
arch  and  those  of  the  thoracic  and  abdominal  aorta,  especially  the 
internal  mammary,  inferior  thyroid,  and  transversalis  colli  arteries. 
Other  anomalies,  such  as  open  foramen  ovale,  are  present  in  37  per 
cent,  of  cases. 

The  observant  pathologist  makes  the  diagnosis  at  once;  he  cuts 
through  the  large  vessels  in  the  skin  of  the  chest  and  abdomen,  and 
the  clinician  when  he  feels  the  large  vessels  (present  in  25  per  cent, 
of  the  cases)  and  the  thrill  in  them  or  hears  their  tones  and  systolic 
(or  less  often,  diastolic)  murmur,  suspects  the  lesion.  Valvular  lesions, 
especially  aortic  insufficiency,  may  coexist.  Broken  compensation  may 
intervene,  though  all  cardiac  signs  may  be  lacking.  Aneurysm  and 
mediastinal  tumor  are  frequently  confused  with  it.  The  aorta  some- 
times ruptures.  The  lesion  is  nearly  twice  as  common  in  the  new-born 
as  it  is  in  adults.  Vierordt  (1898)  collected  only  135  cases  from  the 
literature. 

6.  Aortic  Atresia  or  Stenosis. — The  lesion  is  uncommon.  The 
conus  arteriosus  may  be  greatly  constricted.  If  the  lesion  is  develop- 
mental, the  interventricular  and  -auricular  septa  are  open;  if  endo- 
carditic  or  myocarditic,  they  are  closed,  provided  the  lesion  develops 
after  the  third  month  of  foetal  life.  The  left  ventricle  hypertrophies 
in  stenosis  or  atrophies  in  atresia,  while  the  right  ventricle  hyper- 
trophies in  order  to  force  the  blood  from  the  pulmonary  artery  through 
the  ductus  Botalli  into  the  aorta.  The  lesion  may  be  associated  with 
other  cardiac  anomalies,  with  myo-  or  endocarditis,  or  with  chlorosis, 
tuberculosis,  or  haemophilia. 

7.  Mitral  Changes. — These  are  very  rare. 

8.  Tricuspid  Stenosis  or  Atresia. — This  is  developmental  or  inflam- 
matory. In  atresia  the  interventricular  and  -auricular  septa  are  open 
and  the  right  heart  is  atrophic.    Tricuspid  insufficiency  is  most  rare. 

9.  Transposition  of  the  Arteries  and  Veins. — In  this  lesion  the 
foramen  ovale  remains  open;  the  aorta  originates  in  the  right  heart. 

10.  Valvular  Anomalies. — These  are  largely  of  anatomical  interest. 
The  semilunar  valves,  especially  the  pulmonary,  may  be  increased 
in  number  from  three  to  five;  or  they  may  be  decreased  to  two,  which 
occ\irs  especially  in  the  aortic  valves.  Whether  developmental  or 
inflammatory  in  origin,  accessory  or  abnormal  valves  are  particularly 
prone  to  acute  or  chronic  endocarditis. 

11.  Anomalies  in  Location  and  Development. — These  are  absence 
of  the  heart,  acardia,  double  heart,  or  ectopia  cordis,  where  the  heart 
lies  in  the  abdomen,  or  in  the  pectoral  (with  fissured  sternum)  or 
cervical  regions. 

Dextrocardia  (dexiocardia)  occurs  with  situs  viscerum  inversus;  the 
mitral  valve  has  three  cusps,  the  tricuspid  has  but  two;  the  pulmonary 
veins  empty  into  the  right  auricle;  the  pulmonary  artery  arises  from 
the  left,  and  the  aorta  from  the  right,  ventricle;  the  aorta  runs  to  the 
right  of  the  spine,  to  the  right  of  the  oesophagus,  and  to  the  left  of  the 


CONGENITAL  HEART-DISEASE  433 

cava;  the  vena  azygos  is  on  the  left  and  hemiazygos  is  on  the  right; 
the  innominate  artery  is  left-sided;  the  right  lung  has  two  lobes,  the 
left  three;  the  bronchial  fremitus  is  greater  on  the  left  side,  the  left 
bronchus  being  larger;  the  spleen,  liver,  stomach,  and  colon,  are 
transposed;  the  right  kidney  and  testicle  are  higher  than  the  left. 
The  heart  alone  is  rarely  transposed.  In  one  case  complete  trans- 
position of  all  the  viscera  except  the  csecum  occurred. 

General  Syjnptoms  of  Congenital  Heart  Disease.— C?/ano5i5  is 
present  in  90  per  cent,  of  cases  whence  the  name  "morbus  cseruleus"; 
it  is  more  intense  than  in  acquired  lesions.  It  usually  appears  early, 
and  is  either  general  or  limited  to  the  nose,  fingers,  etc. ;  the  skin 
may  be  actually  purple,  and  this  is  due  to  mixing  of  the  arterial  and 
venous  currents,  to  a  sluggish  circulation  in  the  small  veins,  or  to 
impaired  function  of  the  red  cells.  Some  subjects  are  anaemic,  but  a 
most  striking  increase  of  the  red  cells  up  to  eight  or  nine  millions 
(polycythsemia  rubra)  is  seen  in  some  cases,  probably  as  a  compen- 
satory effort.  The  haemoglobin  may  register  130  and  the  specific 
gravity  1,077.  Dyspnoea,  cough,  convulsions,  and  marked  clubbing 
of  the  fingers  and  toes,  are  frequent.  The  pulse  is  variable  and  the 
temperature  often  subnormal.  Mental  and  physical  development  is 
incomplete,  and  exophthalmos,  swelling  of  the  face,  lips  and  nose, 
and  of  the  optic  disk  are  frequent.  CEdema  and  stasis  are  not  frequent. 
There  is  a  tendency  to  hemorrhage  and  pulmonary  tuberculosis. 
Coincident  mal development  occurs  (in  10  per  cent,  of  cases)  in  other 
organs,  such  as  the  stomach,  colon,  kidney,  and  spleen;  imperforate 
anus,  hypospadias,  cryptorchismus,  polydactylia,  hare-lip,  spina  bifida, 
acrania,  anencephalus,  and  uterus  bicornis  also  occur.  The  murmurs 
are  usually  systolic  and  rough,  although  very  complicated  lesions  may 
exist  with  normal  heart  tones.  In  a  few  instances  the  foetal  murmur 
was  heard  before  birth  (Peter).  The  dulness  concerns  the  right 
ventricle  chiefly. 

Prognosis. — The  prognosis  is  poor,  for  the  lesion  is  incurable  and 
compensation  is  incomplete.  The  patient  usually  succumbs  to  cardiac 
failure  or  to  pulmonary  tuberculosis  (25  to  40  per  cent,  of  cases) 
in  the  second  decade  (81  per  cent.),  hence  Rokitansky's  rule,  that 
cyanosis  protects  the  lungs  from  tuberculosis,  is  not  absolute. 

Treatment. — The  treatment  is  wholly  symptomatic.  The  body 
should  be  kept  warm;  baths  should  be  employed  to  guard  against 
colds;  mental  and  bodily  strain  should  be  avoided;  and  in  general 
the  therapy  of  adult  valvular  disease  should  be  followed,  except  that 
the  heart  stimulants  must  be  used  with  considerable  caution  only. 


28 


434  DISEASES  OF  THE  CIRCULATION 

DISEASES  OF  THE  HEAET  MUSCLE. 

DILATATION  OF  THE  HEART. 

Definition. — Dilatation  means  distention  of  the  chambers  of  the 
heart;  it  may  be  partial  or  complete.  Hypertrophy  is  thickening  of  the 
walls  of  one  or  more  chambers.  The  two  conditions  are  quite  separate 
in  themselves,  though  they  are  frequently  combined. 

Pathology. — Dilatation  occurs  (a)  with  thinning  of  the  walls,  simple 
dilatation,  or  (6)  with  eccentric  hypertrophy  (q.  v.).  It  is  most  common 
in  the  thin-walled  auricles  and  less  resistant  rio^ht  yentricle.  The  mus- 
cle  is  lax  and  the  heart,  when  held  inverted  by  the  basal  vessels,  may 
in  extreme  instances  fall  flabbily  like  a  cap  over  the  hand.  The  dilata- 
tion may  be  so  extreme  that  the  endo-  and  pericardium  almost  touch. 

There  is  much  blood  in  the  heart's  chambers,  in  the  cavse  and  other 
veins.  Long-standing  dilatation  is  not  to  be  confused  with  dilatation 
occurring  during  the  death  agony  from  acute  lung  disease,  suffocation, 
etc.,  in  which  the  right  heart  is  chiefly  affected  and  in  which  on  removal 
of  the  post-mortem  clots  the  chambers  seem  more  nearly  of  normal  size. 
The  papillary  muscles  and  the  trabecule  are  flattened  as  in  aortic  in- 
competency (pressure  atrophy),  and  are  not  infrequently  thickened 
(pressure  sclerosis).  Microscopically  the  heart  muscle  may  be  normal, 
or  may  show  e\ddences  of  fatty  or  cloudy  (or  amyloid)  degeneration,  or 
acute  or  chronic  myocarditis.  The  precise  role  of  degeneration  in  the 
ganglia  of  the  heart  has  not  been  determined. 

Etiology. — 1.  Mechanical  Causes. — The  normal  heart  may  yield  to 
increased  blood-pressure  or  a  weak  heart  may  yield  to  normal  pressure. 

The  mechanical  causes  are:  (a)  Valvular  disease,  e.  g.,  dilatation  of 
the  left  ventricle  in  aortic  insufficiency,  or  of  the  left  auricle  and  right 
ventricle  in  mitral  stenosis.  Hypertrophy  is  usually  inversely  pro- 
portional to  the  dilatation.  In  combined  valvular  lesions,  as  aortic  and 
mitral  insufiiciency,  the  heart  is  enormous — the  ox  heart,  cor  bovinum, 
bucardia.  (b)  Causes  raising  arterial  blood  pressure,  as  stenosis  of  the 
aorta,  arteriosclerosis,  and  nephritis.  These  causes  produce  hyper- 
trophy and  dilatation  of  the  left  ventricle.  Workers  in  caissons  may 
suffer  from  dilatation,  (c)  Causes  raising  blood  tension  in  the  lesser 
circulation,  as  spinal  deformity,  chronic  disease  of  the  lungs  and  pleura, 
which  produce  hypertrophy  of  the  right  ventricle;  of  these  emphysema 
is  the  most  important.  Abdominal  lesions  are  thought  by  French 
writers  to  reflexly  raise  the  pulmonary  blood  pressure  and  induce 
hypertrophy  and  dilatation.  Lichtheim's  classic  on  the  lesser  circula- 
tion proved  that  the  lung  vascular  area  must  be  reduced  more  than  25 
per  cent,  in  order  to  affect  the  right  heart.  The  size  of  the  heart  varies 
much  physiologically;  rapid  heart  action  allows  less  complete  physio- 
logical dilatation  than  does  slow  action.  When  there  is  pulmonary 
obstruction  with  its  consequent  heart  changes,   the  patient   stands 


DILATATION  OF  THE  HEART  435 

pneumonia,  bronchitis,  and  other  infections  very  poorly.  When  severe 
exercise  is  indulged  in,  the  systole  is  incomplete  and  right-heart  dilata- 
tion— even  tricuspid  regurgitation  and  marked  venous  stasis — may 
follow.  Air  embolism  also  produces  dilatation.  Physical  training 
increases  the  power  and  reserve  strength  of  the  right  heart;  i.e.,  it 
increases  the  "wind"  and  endurance.  An  equal  effort  in  an  individual 
out  of  training,  or  in  a  man  with  poor  nutrition,  "breaks  his  wind"  and 
produces  transient  or  permanent  cardiac  exhaustion. 

2.  Nutritive  Disturbances. — Dilatation  may  be  induced  (a)  by  acute 
infections,  leading  to  cardiac  degeneration  or  acute  myocarditis;  (6) 
by  anaemia,  hemorrhages  or  loss  of  fluids;  (c)  by  chronic  myocarditis, 
fatty  heart,  or  coronary  atheroma,  possibly  following  sudden  heart 
strain  as  in  athletics;  by  endo-  or  pericarditis  invading  the  heart  muscle 
by  contiguity,  pericardial  adhesions,  etc.;  {d)  by  poisons,  alcohol, 
tobacco,  chloroform  or  anaesthesia;  (e)  it  very  frequently  follows  hyper- 
trophy or  is  associated  with  it. 

Symptoms. — The  symptoms  are  those  of  cardiac  insufficiency 
{v.  Uncompensated  Valvular  Disease),  as  dyspnoea — which  is  es- 
pecially greatin  pericardial  adhesions — cardiac  asthma,  cough,  syncopal 
attacks,  and  precordial  anxiety.  Cardiac  failure  begins  when  the  sys- 
tole is  unable  to  expel  all  the  blood  from  the  dilated  chambers. 

Physical  Signs. — It  is  not  easy  to  separate  the  signs  of  hypertrophy 
and  those  of  dilatation. 

1.  Dilatation  of  the  Left  Ventricle. — (a)  On  inspection,  the  apex  beat 
is  dislocated  downward  and  to  the  left  and  is  diffuse,  undulating  and 
weak,  if  indeed  it  is  not  absent.  (6)  On  palpation,  the  apex  may  not 
be  felt  even  though  visible  (Walshe).  In  other  cases  the  apex  and  heart 
shock  are  snappy  and  may  feel  strong  to  the  inexperienced  hand;  the 
sharp,  snappy  action  contrasts  sharply  with  the  weak,  rapid,  and 
often  irregular  radial  pulse,  (c)  On  auscultation,  the  heart  tones  are 
weak,  though  sometimes  snappy.  The  first  apex  tone  is  more  valvular. 
The  second  aortic  sound  is  weak  because  of  poor  arterial  tension.  In 
insufficient  hearts,  the  heart  tones  sound  alike,  a  condition  termed 
embryocardia  from  its  resemblance  to  the  foetal  heart  tones.  An  apical 
systolic  murmur  is  frequent,  especially  in  arteriosclerotic  dilatation. 
It  is  sometimes  due  to  relative  insufficiency  of  the  mitral  valve  whose 
normal  circumference  of  three  and  one-half  inches  may  be  increased  by 
one  or  two  inches.  Von  Jiirgensen  holds  that  it  is  often  due  to  irregular 
muscular  contraction.  Rest  and  the  administration  of  digitalis  fre- 
quently cause  it  to  disappear.  Gallop-rhythm,  in  which  three  tones  are 
heard,  like  the  rhythm  of  a  galloping  horse,  consists  of  either  doubling 
of  the  first  (Potain)  or  second  tone  (Fraentzel),  or  of  the  addition  of  a 
presystolic  tone  (Rosenbach)  caused  by  the  auricular  contraction.  It 
is  heard  in  the  failing  hypertrophied  hearts  of  nephritics  more  than  in 
all  other  conditions  combined.  It  is  also  found  in  valvular  lesions, 
atheroma,  emphysema,  and  in  acute  diseases  such  as  pneumonia, 
typhoid,  and  diphtheria.  The  auricle  (causing  the  extra  sound) 
cannot  long  compensate.    Whatever  its  cause,  it  is  a  sign  of  great  danger 


436  DISEASES  OF    THE  CIRCULATION 

although  the  heart's  tone  may  temporarily  improve  with  rest  and  with 
the  use  of  heart  tonics,  (d)  On  jpercussion,  the  heart  extends  to  the  left 
and  downward,  giving  a  more  oval  area  of  dulness. 

2.  Dilatation  of  the  Right  Ventricle. — This  is  more  common,  (a) 
On  inspection,  a  diffuse  beat  is  seen  to  the  right  of  the  sternum  or 
indeed  in  the  epigastrium;  and  (b)  it  may  be  palpated,  (c)  Ausculta- 
tion shows  weakness  of  the  heart  tones,  and  (d)  percussion  outlines 
dulness  to  the  right  of  the  sternum.  Extreme  dilatation  increases  the 
tricuspid  orifice  from  four  and  one-half  to  five  or  six  and  one-half 
inches,  and  the  physical  findings  of  (relative)  tricuspid  insuflSciency 
obtain. 

3.  Dilatation  of  the  Auricles. — The  deep  location  of  the  left  auricle 
renders  it  almost  impossible  to  obtain  physical  signs  of  dilatation. 
The  changes  usually  ascribed  to  the  left  auricle  are  due  to  enlargement 
of  the  conus  of  the  right  ventricle,  though  a  presystolic  wave  may  be 
seen  in  the  second  left  interspace.  The  right  auricle  is  frequently 
distended  and  this  is  recognized  by  undulation  to  the  right  of  the  ster- 
num above  the  right  ventricle,  by  dulness,  and  sometimes  by  a  presys- 
tolic wave. 

Dilatation  of  all  the  chambers,  both  right  and  left,  combines  the 
physical  findings  of  each  type,  thus  giving  the  heart  a  triangular  or  a 
trapezoid  conformation.  The  cardiac  symptoms  and  physical  findings 
of  dilatation  may  develop  gradually,  or  abruptly  after  violent  exercise, 
especially  when  the  heart  is  congenitally  weak  or  when  its  nutrition  is 
altered. 

Diagnosis. — The  diagnosis  depends  on  the  etiological  factors,  the 
weak  tones,  the  increased  dulness,  and  cardiac  and  somatic  evidences 
of  cardiac  failure.  The  greater  the  dilatation,  the  less  marked  is  the 
difference  between  the  systole  and  diastole.  The  absolute  heart  dulness 
in  middle  life  is  bounded  by  the  left  border  of  the  sternum,  the  fourth 
or  fifth  rib,  and  the  left  parasternal  line,  or  it  may  extend  even  a 
little  more  to  the  left.  The  relative  duhiess  reaches  from  the  third  or 
fourth  rib  above  to  the  apex  beat  on  the  left  and  to  a  line  drawn  ob- 
liquely from  the  third  left  costal  cartilage  across  the  sternum  to  the  fifth 
right  costal  articulation.  Percussion  is  difficult  in  distorted,  fatty  or 
oedematous  chests.  Differentiation  concerns  the  same  group  of  con- 
ditions discussed  under  the  diagnosis  of  effusive  pericarditis  {q.  v.). 
The  Schott  method  of  treatment  {v.  i.)  frequently  is  of  value  in  diag- 
nosis; it  helps  dilatation  but  is  without  effect  on  pericardial  exudate. 
Rest  and  the  use  of  digitalis  greatly  benefit  dilatation  and  hydroperi- 
cardium,  sometimes  within  a  very  short  time,  while  pericardial 
effusion  is  unaffected  by  this  treatment.  Consolidation  of  the  adjacent 
lung  margin  can  usually  be  recognized  by  the  altered  breathing  and 
rales.  Mediastinal  tumor  and  aneurysm  are  suggested  by  pressure 
symptoms.  If  the  margins  of  the  lung  are  adherent  from  pleural  adhe- 
sions, especial  care  in  percussion  is  imperative,  and  dilatation  is  diag- 
nosticated by  the  relative,  more  than  by  the  absolute,  heart  dulness. 
Palpatory  percussion,  very  lightly  made,  is  most  valuable  and  the  feel 


DILATATION  OF  THE  HEART  437 

of  the  increased  diilness  has  greater  diagnostic  value  than  the  sound 
elicited.  Emphysema  may  greatly  obscure  the  outlines  of  the  heart, 
but  the  heart's  outlines  are  usually  disclosed  by  careful  palpatory  per- 
cussion for  the  relative  dulness.  Encapsulated  pleurisy  is  differentiated 
by  careful  puncture,  if  other  signs  fail.  The  fluoroscope  is  frequently 
of  aid.  In  short  chests,  the  apex  is  seen  normally  at  or  even  beyond  the 
nipple.  This  occurs  in  12  per  cent,  of  women.  Though  spinal  curva- 
ture frequently  overtaxes  the  right  heart  and  thus  induces  dilatation, 
the  diagnosis  must  be  made  with  care,  for  the  topographical  relations 
are  much  disturbed  by  visceral  luxation,  and  the  irregularity  of  the 
sternum  and  ribs  makes  percussion  uncertain.  In  fat  individuals, 
dulness  may  result  from  adipose  deposit  in  the  mediastinum,  but  dif- 
ferentiation is  often  easy  by  means  of  the  normal,  though  perhaps 
distant,  heart  tones  and  by  the  character  of  the  pulse.  Dilatation  must 
not  be  mistaken  for  dislocation  due  to  gaseous,  tumor,  or  fluid  disten- 
tion of  the  abdomen. 

Prognosis. — The  prognosis  depends  on  the  individual  and  on  the 
etiology. 

Treatment. — The  therapy  is  as  follows:  (a)  The  cause  must  be 
treated.  (6)  The  dietetic,  special  and  general  indications  of  valvular 
disease  (q.  v.)  must  be  carried  out.  (c)  OerteVs  treatment  consists  of  (i) 
limitation  of  the  amount  of  water  ingested,  and  stimulation  of  its  excre- 
tion by  sweats  and  deep  inspirations.  Beer  must  be  interdicted,  but 
many  nervous  subjects  tolerate  limitation  of  water  very  poorly.  Water 
should  be  given  in  small  quantities  at  frequent  intervals,  (ii)  Re- 
duction of  the  body-weight  (see  Obesity),  (iii)  Stimulation  of  the 
circulation  by  exercise.  Mountain  climbing  is  said  to  stimulate  the 
heart,  develop  the  respiratory  muscles,  increase  the  lung  capacity,  and 
widen  the  vessels.  The  objections  to  active  exercise  are  that  rest  in 
bed  gives  better  results,  and  that  exercise  causes  harm  when  the  heart 
muscle  or  coronaries  are  diseased,  or  when  endocarditis,  pericardial 
adhesions,  or  Bright's  disease  exist,  (d)  The  so-called  Schott  method 
was  originated  by  Beneke  and  Saetherburg,  and  was  elaborated  by  the 
Nauheim  physicians.  It  consists  of  (i)  baths  in  springs  containing 
sodium  and  calcium  chloride,  iron  carbonate,  and  carbon  dioxide. 
The  temperature  should  be  a  few  degrees  below  body-heat,  and  a  little 
carbon  dioxide  should  be  used  in  the  baths  at  first.  They  should  be 
given  once  daily  for  two  or  three  days,  and  then  intermitted;  they 
should  last  from  five  to  twenty  minutes.  They  may  be  given  artificially 
with  almost  equally  good  results,  using  40  gallons  of  water,  with  3 
to  10  pints  of  salt,  10  ounces  of  pure  calcium  chloride  and  carbon 
dioxide  generated  in  a  vessel  from  sodium  bicarbonate  and  hydrochloric 
acid.  The  temperature  should  be  later  reduced  to  90°  or  less,  and  the 
amount  of  carbon  dioxide  should  be  increased.  The  bloodvessels  are 
first  contracted  and  later  dilated.  The  pulse  becomes  slower  and  fuller, 
dilatation  decreases,  stasis  is  lessened,  diuresis  is  increased,  and  the 
metabolism  of  the  muscles  and  heart  is  improved,  (ii)  Resisted  move- 
ments should  be  carefully  and  gradually  employed.     Though  active 


438  DISEASES  OF  THE  CIRCULATION 

exercise  constricts  the  vessels,  gentle  movements  by  the  patient,  resisted 
by  the  operator,  dilate  the  vessels. 

Yeo  {Manual  of  Medical  Treatment)  summarizes  the  resistance 
movements  as  follows: 

Each  exercise  is  made  against  slight  resistance  applied  by  the  physician  or  a  trained 
assistant. 

1.  The  arms  are  extended  in  front  of  the  body  at  the  level  of  the  shoulder,  with  the 
palms  of  the  hands  touching.  The  two  arms  are  then  moved  slowly  outward  till  they 
are  in  a  line  with  each  other;  they  are  then  brought  back  to  their  original  position. 

2.  The  arm  and  hand  hanging  down  with  the  palm  turned  forward,  the  forearm  is 
flexed  upon  the  arm  (which  is  kept  still)  until  the  fingers  touch  the  shoulder.  The 
forearm  is  then  extended  to  its  original  position.  This  is  first  done  with  one  arm  and 
then  with  the  other. 

3.  The  arms,  hanging  do-wn  as  in  No.  2,  are  raised  outward  until  the  thmnbs  meet 
over  the  head;  they  are  then  retm-ned  to  their  original  position. 

4.  With  arms  dependent,  the  fingers,  at  the  first  phalangeal  joints,  are  pressed 
together,  and  the  arms  are  then  raised  until  the  hands  are  above  the  head,  after 
which  they  are  brought  back  to  their  original  position. 

5.  The  arms,  hanging  in  the  position  of  "attention,"  are  advanced  forward  parallel 
to  each  other  until  they  are  elevated  to  a  vertical  position;  they  are  then  brought 
back  to  where  they  were  before. 

6.  Same  as  No.  1,  but  with  fists  clenched. 

7.  Same  as  No.  2,  but  with  fists  firmly  clenched. 

8.  The  arms,  starting  from  the  position  of  "attention,"  describe  a  circle  by  moving 
forward  and  upward  until  they  are  raised  vertically;  then  each  palm  is  tm-ned  out- 
ward, and  the  arms  descend  backward  to  their  former  position. 

9.  The  body  is  bent  forward,  and  then  brought  back  to  the  erect  position,  the 
knees  not  being  moved. 

10.  The  body  is  rotated,  without  any  movement  of  the  feet,  first  to  the  right  and 
then  to  the  left,  and  then  back  to  its  original  position. 

11.  The  body  is  flexed  laterally,  as  far  as  possible,  first  to  the  one  side  and  then  to 
the  other,  and  afterward  restored  to  its  original  erect  position. 

12.  The  patient,  standing  with  the  feet  side  by  side  and  supporting  himself  by 
leaning  with  one  hand  upon  any  object,  flexes  the  opposite  thigh  as  far  as  it  is  possible, 
and  afterward  extends  it  until  the  feet  are  again  side  by  side;  then,  leaning  on  the 
other  hand,  he  carries  out  a  similar  movement  with  the  other  thigh. 

13.  The  patient,  supporting  himself  by  one  hand,  as  in  12,  and  the  knee  being  kept 
straight,  each  leg  in  turn  is  raised  as  high  as  possible  in  front  of  the  body,  and  then  in 
the  same  way  behind. 

14.  Supporting  himself  by  placing  both  hands  in  front  on  the  back  of  a  chair,  the 
patient  first  flexes  one  leg  and  then  the  other  upon  the  thigh  as  far  as  he  can. 

15.  Each  leg  in  turn  is  abducted  as  far  as  possible,  the  knees  being  kept  straight, 
the  patient  resting  on  one  or  other  hand  the  while. 

16.  The  arms,  held  horizontally  outward,  are  rotated  forward  and  backward  at 
the  shoulder  joint. 

17  and  18.  Flexion  and  extension,  first  of  the  wTists,  and  second  of  the  ankles. 

In  resisting  these  movements  the  operator  places  the  palm  of  his  hand  on  that  side 
of  the  patient's  limb  or  body  toward  which  the  movement  is  to  be  made.  In  the 
movements  of  the  wrist  the  operator  closes  his  thumb  and  forefinger  round  that  joint. 

(iii)  Passive  movements  and  massage.  Contraindications  to  Schott's 
method  are  aneurysm,  angina  pectoris,  acute  cardiac  insufficiency, 
tendency  to  hemorrhage  and  embolism,  and  possibly  nervousness. 


HYPERTROPHY  OF  THE  HEART. 

Pathology. — The  muscle  fibers  increase  even  tenfold  in  size  (hyper- 
trophy) and  increase  in  number  (hyperplasia).  Hypertrophy  may  exist 
alone — simple  hypertrophy.    It  more  frequently  occurs  with  dilatation 


HYPERTROPHY  OF  THE  HEART  439 

— eccentric  hypertrophy.  Concentric  hypertrophy,  i.  e.,  with  decrease  in 
the  size  of  the  ventricle,  is  rarer  and  some  regard  it  as  merely  a  post- 
mortem condition;  the  ventricle  may  be  firmly  contracted  in  death 
from  violence  or  from  cholera,  or  hemorrhage,  but  it  can  be  distended 
by  the  finger.  The  size  of  the  normal  heart  is  that  of  the  fist  (Laennec), 
and  the  normal  weight  is  about  9^  ounces  (300  gm.).  The  heart  is 
sometimes  increased  four  times  in  weight,  even  to  59  ounces  (1,980 
gm.)  (Stokes) — the  corbovinum.  Its  consistence  is  increased,  and  its 
color  is  normal  or  darker.  In  total  hypertrophy  the  heart  is  round; 
in  partial,  the  right  or  left  ventricle  is  larger.  The  left  ventricle 
normally  measures  nine  to  ten  millimeters,  but  this  may  be  more  than 
doubled  in  hypertrophy;  the  right  ventricle  measures  three  or  four 
millimeters;  the  left  auricle  measures  three,  and  the  right  two,  milli- 
meters. In  the  foetus  the  ventricles  are  equally  thick.  Up  to  the 
eighth  year,  the  left  ventricle  is  relatively  thicker  than  in  the  adult, 
because  of  narrowing  of  the  aorta  at  its  isthmus. 

Etiology. — The  causes  of  hypertrophy  of  the  left  ventricle  are  usually 
mechanical  resulting  from  (a)  valvular  lesions  (aortic  stenosis  and 
insuflSciency,  mitral  insufficiency) ;  (b)  renal  disease;  usually  from  a 
chronic  interstitial  nephritis  but  occasionally  from  other  forms,  from 
hypoplasia  of  one  kidney,  from  hydronephrosis,  etc.  It  is  caused  by 
mechanical  obstruction  to  the  flow  of  blood  or  by  retention  within  the 
blood  of  waste  substances  which  excite  arterial  spasm;  (c)  arterio- 
sclerosis iq.v.),  developed  by  Traube;  (d)  congenital  narrowness 
(hypoplasia)  of  the  arterial  system,  or  of  the  aorta  at  the  isthmus;  (e) 
dilatation  of  the  aorta,  diffuse  or  aneurysmatic,  or  occurring  rarely  from 
general  arterial  dilatation  (Nothnagel  and  Fraentzel);  (/)  pericardial 
adhesions;  (g)  myocarditis  iq.v.);  ih)  pregnancy;  it  is  claimed  that 
the  placental  circulation  or  increased  intraabdominal  pressure  in- 
creases the  heart's  work.  The  high  diaphragm  apposes  the  heart  to  the 
chest  wall  and  tips  the  apex  outward  so  as  to  simulate  hypertrophy; 
(i)  over-exertion;  the  " irritable  heart  of  soldiers"  (Da  Costa,  Myers, 
Fraentzel)  is  caused  by  forced  marches,  cold,  and  mental  excitement; 
the  so-called  idiopathic  hypertrophy  occurs  in  hard  workers,  and 
especially  in  Munich  from  excessive  use  of  beer  and  from  the  resulting 
plethora;  hypertrophy  results  from  continued  hard  work  while 
dilatation  follows  sudden  cardiac  strain;  {j)  nervous  causes;  these 
are  exophthalmic  goitre,  and  the  use  of  tobacco,  especially  strong 
Havana  cigars,  which  causes  rapid  irregular  heart  action.  Pujatin,  Ott 
and  others  have  found  degenerative  and  sclerotic  changes  in  the 
cardiac  ganglia. 

Hypertrophy  of  the  right  ventricle  depends  on  (a)  hypertrophy  con- 
secutive to  left  heart  disease;  the  entire  heart  usually  hypertrophies 
from  the  intimate  connection  between  the  muscular  fibres  of  both  sides ; 
(6)  right-heart  valvular  lesions  and  congenital  heart  disease;  (c)  in- 
creased pulmonary  pressure  from  disease  of  the  pulmonary  artery,  or 
pressure  upon  it;  {d)  emphysema,  chronic  bronchitis,  spinal  deformity, 
pulmonary  induration,  bronchiectasis,  and  extensive  pleural  adhesions. 


440  DISEASES  OF  THE  CIRCULATION 

Hypertrophy  of  the  auricles  always  coexists  with  dilatation  (stenosis 
of  the  auriculo ventricular  orifices). 

S3nnptoms. — Hypertrophy  of  the  left  heart  may  exist  without  any 
subjective  sensations,  or  there  may  be  palpitation,  inability  to  lie  on  the 
left  side,  cough,  cardiac  oppression  or  pain  or  cerebral  congestion 
(tinnitus,  flashes  before  the  eyes,  headache,  or  vertigo).  There  is 
frequently  a  tendency  to  hemorrhage  (epistaxis,  cerebral  hemorrhage, 
excessive  menstruation).  Polyuria  results  from  high  arterial  tension. 
The  causal  disease  (nephritis,  valvular  disease,  arteriosclerosis, 
emphysema)  presents  its  own  symptoms.  Right-heart  hypertrophy  is 
attended  by  brow^n  induration  of  the  lungs,  haemoptysis,  cyanosis,  or 
bronchial  catarrh. 

Physical  Signs. — Much  confusion  in  the  clinical  description  prevails 
because  the  signs  of  hypertrophy  are  very  often  confounded  with  those 
of  dilatation,  although  both  conditions  very  frequently  coexist. 

Hypertrophy  of  the  Left  Ventricle. — 1.  Inspection. — This  discloses 
(a)  a  strong,  sometimes  heaving,  diffuse  apex;  essential  dislocation 
to  the  left  or  downward  indicates  coincident  dilatation,  because 
thickening  of  the  heart  muscle  alone  scarcely  gives  any  increase  in 
the  size  of  the  heart.  Rotatory  retraction  of  the  apex  beat  is  sometimes 
seen.      (6)  Precordial  prominence;    (c)  forcible  pulsation  of  the  vessels. 

2.  Palpation. — Palpation  confirms  (a)  the  strong  apex  heat,  detects 
(&)  the  palpable  second  aortic  tone  due  to  high  tension  (or  atheroma), 
and  sometimes  (c)  a  systolic  apical  thrill  (transmission  of  the  strong  first 
tone).  (fZ)  The  pidse  is  regular,  full  and  hard  in  simple  hypertrophy, 
but  in  the  eccentric  form  it  is  softer  and  more  rapid.  It  is  sometimes 
weak  or  almost  absent  in  the  arms;  this  is  due  to  loss  of  vessel  tonus. 
(e)  Thrills  over  the  peripheral  vessels  from  high  tension  vibration  may 
be  felt. 

3.  Percussion. — It  is  usually  stated  that  the  left  heart  is  dislocated 
downward  to  the  left  but  this  is  infrequent,  as  enlargement  means 
dilatation  (or  an  atheromatous  relaxed  aorta  which  allows  sinking  of  the 
heart). 

4.  Auscultation. — This  brings  out  (a)  usually  the  loud  first  tone,  over 
the  apex  (but  not  always,  as  for  example  in  aortic  leakage) ;  it  discloses 
(6)  the  accentuated  and  frequently  metallic  second  aortic  tone;  (c)  systolic 
arterial  bruits  from  tension  and  vibration  of  the  walls;  (d)  the  gallop- 
rhythm  in  cases  of  failing  hypertrophy,  especially  in  nephritics;  (e)  a 
peculiar  clink,  which  is  sometimes  heard  to  the  right  of  the  apex;  (/) 
an  apical  systolic  murmur  is  sometimes  heard,  and  is  frequently 
of  the  cardiopulmonary  type.  Seitz,  Gendrin  and  others  have  re- 
corded murmurs  resembling  the  pericardial  rub,  due  to  the  violent 
beating  of  the  heart  or  to  muscular  contraction  (Jiirgensen). 

Hypertrophy  of  the  Right  Ventricle. — (1)  Inspection  shows  a  strong, 
systolic  impulse  under  the  sternum  which  is  (2)  palpable,  as  is  the  strong 
second  pidmonic  tone.  (3)  Av^cidtation  brings  out  the  accentuated 
second  pulmonic;  and  (4)  percussion  is  negative,  unless  there  is  coinci- 
dent dilatation. 


ATROPHY  OF  THE  HEART  441 

Diagnosis. — In  lejt-sided  hypertrophy,  the  cardinal  signs  are  (a)  the 
tense  pulse,  (b)  the  strong,  hard  apex  beat,  and  (c)  the  accentuated 
second  aortic  tone;  in  right-sided  hypertrophy  they  are  (1)  the  strong 
second  pulmonic  tone,  and  (2)  the  substernal  pulsation.  Percussion  is 
useless,  for  it  discloses  dilatation  only. 

Hypertrophy  of  the  left  heart  must  not  be  confused  with  nervous 
overaction  of  the  heart  in  which  the  apex  is  not  heaving.  Retraction  of 
the  left  lung  merely  exposes  more  of  the  left  ventricle,  but  the  heart  in 
this  case  seems  enlarged  upward  and  to  the  left.  In  narrow  chests  with 
poor  lungs,  the  heart's  dulness  is  wide,  but  the  cardinal  symptoms  of 
hypertrophy  are  lacking.  The  same  caution  in  the  diagnosis  of 
hypertrophy  at  puberty  is  necessary  because  at  this  period  the  heart  is 
nervously  unstable,  the  chest  is  thin,  and  the  heart  is  normally  wider 
than  in  the  adult.  Perplexity  may  be  caused  when  abundant  casts  and 
blood  are  found  in  the  urine;  these  are  usually  indicative  of  nephritis, 
but,  if  there  are  other  evidences  of  stasis,  such  as  congested  liver,  they 
are  compatible,  in  the  minds  of  some  writers,  with  stasis  alone.  Ne- 
phritis may  cause  hypertrophy;  nephritis  and  hypertrophy  may  be 
due  to  a  common  cause;  or  a  failing  heart  may  produce  renal  stasis 
(see  Nephritis,  Differential  Table). 

Prognosis. — The  immediate  outlook  is  good  because  hypertrophy  is 
usually  a  compensatory  process;  the  ultimate  outlook  is  bad,  because 
cardiac  insufficiency  is  the  ultimate  issue.  Symptoms  usually  appear 
first  either  gradually  or  suddenly  in  the  stage  of  broken  compensation 
from  intercurrent  fevers,  malnutrition,  or  mental  and  physical  strain. 
The  best  outlook  is  in  hypertrophy  caused  by  tobacco  or  athletics,  for 
this  may  regress.  Gallop-rhythm  is  ominous  as  is  the  occurrence  of  the 
first  and  second  apical  tones  close  together.  Hypertrophy  leads  to 
fatty  and  other  change  in  the  heart,  to  sclerosis  of  the  vessels,  and  in  the 
pulmonary  circuit  to  pulmonary  atheroma,  acute  congestion,  and 
oedema. 

Treatment. — The  therapy  is  eminently  causal  and  dietetic;  alcohol, 
tea  and  coffee,  tobacco,  and  cold  baths,  are  to  be  avoided,  and  con- 
stipation must  be  prevented.  The  symptomatic  treatment  and  the  use 
of  cardiants  in  the  uncompensated  stage  are  identical  with  the  indica- 
tions in  valvular  disease. 


(C).  ATROPHY  OF  THE  HEART, 

Atrophy  of  the  heart  presents  more  pathological  than  clinical  interest. 

Etiology.— The  heart  is  at  times  congenitally  weak  and  small.  It 
may  then  be  associated  with  small  vessels,  chlorosis  (Virchow),  or  with 
hypoplasia  of  the  genitalia  (Rokitansky).  Pressure  atrophy,  coronary 
sclerosis,  pericarditic  adhesions,  the  senile  involution,  and  cachectic 
diseases,  are  the  most  frequent  causes.  Anatomically,  the  heart  is 
reduced  in  size  and  weight  (even  to  1^  ounces)  the  subpericardial  fat 
disappears,  the  pericardium  wrinkles,  the  coronary  arteries  are  tortuous, 


442  DISEASES  OF  THE  CIRCULATION 

and  the  heart  muscle  is  pigmented.  The  valves,  especially  the  aortic, 
may  waste.  The  atrophy  may  be  partial,  as  that  of  the  left  ventricle  in 
some  cases  of  mitral  stenosis.  Simple,  concentric,  and  eccentric  atrophy 
are  described. 

The  symptoms  are  indeterminate,  and  the  diagnosis  impossible. 


FATTY  HEART. 

Etiology  and  Pathology. — Fatty  heart  is  no  distinct  pathological  nor 
clinical  entity.  Two  forms  are  recognized,  (1)  fatty  infiltration,  and 
(2)  fatty  degeneration. 

1.  Fatty  Infiltration  (Lipoma  cordis  capsulars,  Virchow). — This 
form  consists  of  invasion  of  the  heart  muscle  by  the  subpericardial 
fat,  which  is  normally  found  about  the  heart,  in  its  furrows,  at  the  tips 
of  the  ventricles,  and  around  the  basal  vessels.  The  fat  extends  in  paral- 
lel lines  between  the  muscle  fibers,  which  it  may  wholly  replace.  The 
fatty  infiltration  was  considered  primary  by  von  Leyden;  Struempell 
believes  muscle  atrophy  is  primary  and  the  fatty  infiltration  secondary; 
Rosenbach  holds  that  fatty  infiltration  and  muscular  atrophy  are 
secondary  to  a  common  nutritive  disturbance.  The  fat,  which  is 
usually  most  developed  in  the  outer  layers  of  the  myocardium,  may 
reach  to  the  endocardium.  Fatty  infiltration  is  most  common  in  obese 
males  over  forty  years  of  age,  but  has  been  seen  in  young  subjects. 
It  may  occur  after  the  menopause  or  in  sterile  women.  Plethora, 
high  living,  excessive  use  of  alcohol,  and  heredity,  are  factors.  The 
heart  is  reduced  25  per  cent,  in  weight  compared  with  the  body-weight 
(Hirsch). 

2.  Fatty  Degeneration. — This  form  is  caused  by  deficient  oxygena- 
tion which  is  either  (a)  general,  resulting  from  acute  infections,  old 
age,  cachexia,  marasmus,  anaemia,  from  such  poisons  as  phosphorus, 
chloroform,  or  mercury,  and  from  loss  of  fluids  from  diarrhoea;  or 
(h)  local  or  cardiac,  from  pericarditis;  from  coronary  disease,  which 
more  frequently  produces  myofibrosis ;  and  from  cardiac  failure  follow- 
ing hvpertrophy.  Most  degeneration  occurs  in  the  left  heart.  The 
fatty  heart  is  large  and  flabby;  it  is  yellow-brown— the  "faded  leaf" 
color  of  Laennec;  the  splashes  and  streaks  of  fatty  degeneration  con- 
trast with  the  normal  areas,  giving  the  variegated  "tiger"  or  "tabby- 
cat"  appearance;  oil  globules  are  found  in  rows  in  the  muscle  fibers 
and  may  replace  them  in  part  or  in  whole.  Frequently  the  muscle 
fibers  appear  dry  and  granular  ("albuminoid"  degeneration)  and  this 
is  probably  the  first  step  in  fatty  degeneration.  The  striations  of  the 
muscle  disappear  later.  Its  consistence  is  decreased  and  its  muscula- 
ture is  friable. 

The  extent  of  the  process  is  in  direct  ratio  to  the  intensity  of  nutri- 
tive alteration;  parenchymatous  and  fatty  degeneration  are  observed 
in  those  segments  of  the  heart  where  the  greatest  work  and  the  most 
nutrition  are  demanded,  as  in  the  papillary  muscles  of  the  mitral 


FATTY  HEART  443 

valves,  and  where  pressure  is  greatest,  viz.,  the  interventricular 
septum  and  the  left  conus  arteriosus.  In  embryonal  life,  these  condi- 
tions obtain  in  the  right  heart.  The  early  investigations  of  von  Ley- 
den  and  those  of  more  recent  date  by  Goebel  have  determined  that 
these  changes  are  first  focal  and  later  diffuse. 

Symptoms  and  Signs. — No  symptoms  are  characteristic.  Extensive 
fatty  changes  may  occur  without  clinical  symptoms  (latency),  as  in 
pernicious  ansemia.  Leube  details  a  case  without  symptoms  in  which 
the  apex  was  completely  fatty.  In  some  obese  subjects,  cardiac 
embarrassment  develops  with  dyspnoea,  palpitation,  a  somewhat 
characteristic  wheezing,  etc.  The  autopsy  may  reveal  fatty  heart, 
but  far  more  frequently  myocarditis,  idiopathic  hypertrophy,  or  cor- 
onary disease  is  found;  i.  e.,  there  is  no  uniformity  in  the  pathological 
findings,  nor  parallelism  between  them  and  the  clinical  signs.  Though 
percussion  of  obese  individuals  is  unsatisfactory,  the  heart  is  found 
dilated.  In  fatty  heart,  the  tones  are  weak  and  distant,  though  pure, 
the  apex  beat  is  weak,  diffuse,  or  absent,  and  sometimes  an  apical 
systolic  murmur  is  heard,  which  is  probably  due  to  irregular  systolic 
vibration.  Gallop-rhythm  is  heard  when  the  heart  is  fatigued.  The 
pulse  may  be  rapid  from  brain  anaemia;  it  may  be  somewhat  dicrotic, 
small,  and  arrhythmic.  Low  temperature,  sweating,  and  bronchitis  are 
common. 

Much  stress  was  formerly  laid  on  the  Adams-Stokes  syndrome,  a 
triad  of  symptoms  including  (a)  a  slow  pulse,  even  14  to  the  minute, 
due  to  anaemic  stimulation  of  the  vasomotor  centre,  or  to  heart  changes, 
and  followed  by  (6)  pseudo-apoplectic  seizures,  unconsciousness,  tem- 
porary paralysis,  or  convulsions  (pseudo-epilepsy),  which  are  clearly 
dependent  on  cerebral  anaemia,  for  one  of  Stokes's  cases  warded  off 
these  attacks  by  assuming  the  genupectoral  position;  and  (c)  Cheyne- 
Stokes'  respiration,  in  which  respiration  becomes  slower,  and  is 
followed  by  a  period  of  apnoea  lasting  a  half  minute  or  more,  with  res- 
piration gradually  returning  to  the  normal.  Narcotics  increase  or 
induce  the  condition.  The  pupils  narrow  during  the  apnoeic  period 
and  muscular  twitching  is  common.  This  triad  is  observed  in  uraemia, 
cholaemia,  and  diseases  of  the  vagus  and  medulla  as  well  as  in  heart 
disease.  It  seems  likely  that  in  Stokes'  case  the  brain  was  also  dis- 
eased. The  syndrome  is  based  on  the  bradycardia  which  appears  to 
,  be  most  frequent  in  disease  of  the  bundle  of  His  (see  Brady-cardia, 
Cardiac  Neuroses). 

Diagnosis.^The  diagnosis  is  at  best  uncertain.  As  stated,  fatty 
heart  may  cause  no  clinical  symptoms,  or  the  symptoms  observed  in 
the  obese  may  be  due  to  other  lesions.  Apparently  increased  dulness 
is  often  due  to  mediastinal  obesity.  The  main  point  is  to  exclude 
valvular  lesion  and  confine  the  diagnosis  to  a  myocardial  affection 
(v.  Myocarditis). 

Prognosis. — The  prognosis  depends  upon  the  cause.  It  is  grave 
in  diabetic  or  arteriosclerotic  subjects,  or  when  coronary  disease, 
angina,  lung  oedema,  or  an  irregular  or  very  slow  pulse  intervene. 


444  DISEASES  OF  THE  CIRCULATION 

Sudden  death  is  not  uncommon  from  acute  dilatation,  pulmonary  em- 
bolism, brain  anaemia  or  hemorrhage,  "heart  block"  (described  under 
bradycardia),  or  rarely  from  heart  rupture. 

Treatment. — The  treatment  is  that  of  obesity  in  fatty  infiltration, 
but  distinction  must  be  made  between  (a)  obesity  with  anoemia,  in 
which  the  subject  is  obese  and  pale,  with  cold  extremities,  much 
sweating,  scanty  urine,  weak  and  easily  fatigued  muscles,  and  dyspnoea; 
and  (6)  obesity  with  plethora,  in  which  the  color  is  red,  the  urine  in- 
creased and  uratic,  the  heart  stronger,  the  muscles  fairly  developed, 
and  exercise  possible  with  little  dyspnoea.  Schott's  treatment  is  bene- 
fi,cial  in  the  first  type,  and  Oertel's  method  in  the  latter  (see  Dilatation 
OF  Heart).  Saline  cathartics,  total  abstinence  from  alcohol,  and  the 
use  of  potassium  iodide  for  general  or  coronary  sclerosis  are  indicated. 
The  brain  symptoms  of  anaemia  and  the  sudden  syncope  are  met  by 
the  setherial  alcoholics.  Cardiac  insufficiency  is  treated  as  in  uncom- 
pensated valvular  lesions  and  dilatation.  Morphine  should  be  avoided 
entirely  or  used  only  with  great  circumspection. 


ACUTE  MYOCARDITIS. 

Etiology  and  Pathology. — Acute  myocarditis  is  of  the  greatest 
clinical  and  prognostic  importance. 

Acute  diffuse  parenchymatous  myocarditis  corresponds  to  granular 
and  fatty  degeneration  (v.  i.);  to  the  "mushroom"  heart  of  Stokes 
(described  under  Typhus)  which,  when  held  inverted  by  the  base, 
would  fall  like  a  cap  over  the  hand;  and  also  corresponds  to  the  "  soft- 
ened heart"  of  Laennec  and  Louis. 

Acute  diffuse  interstitial  myocarditis  has  been  most  studied  of  late 
years,  while  formerly  the  degenerations  attracted  most  attention. 
Round  cells  are  found  in  the  interstitial  tissue,  with  or  without  muscular 
alteration.  Vacuohzation,  nuclear  multiplication,  pigmentary  deposit, 
blood  extravasations,  waxy  and  other  changes  are  also  found.  Though 
it  was  first  discovered  by  Leyden  in  scarlatina,  it  is  found  in  a  very 
large  percentage  of  cases  of  diphtheria  and  typhoid  by  Rhomberg; 
it  also  occurs  in  acute  endocarditis  and  rheumatism  (10  to  20  per 
cent.),  less  frequently  in  variola,  influenza,  gonorrhoea,  quinsy,  and 
other  infections.  Though  the  typhoid  bacillus,  the  gonococcus,  and 
Bacillus  pyocyaneus  have  been  found  in  the  myocardium,  they  are 
chiefly  important  as  causing  toxaemia.  In  some  instances  acute  myo- 
carditis is  seemingly  primary. 

H.  Martin  has  found  inflammatory  thickening  of  the  intima  in  the 
coronary  radicles,  also  minute  thrombi,  lamellar  splitting  of  the  elastic 
tunic,  and  proliferation  of  the  media.  Rhomberg  found  a  perineuritis 
in  one-half  of  typhoid  and  diphtheria  autopsies.  Virchow,  Hayem, 
and  Renault,  hold  that  inflammation  is  primary  and  degeneration 
secondary;  Weber,  Blind,  and  others  regard  the  process  as  degenera- 
tion rather  than  inflammation. 


ACUTE  MYOCARDITIS  445 

Symptoms  and  Signs. — During  the  progress  of  an  acute  infection, 
the  heart's  strength  decreases;  its  tones,  especially  the  first  mitral, 
become  fainter;  the  apex  is  less  distinct  and  is  dislocated  somewhat 
to  the  left  by  dilatation ;  and  the  pulse  grows  weaker  and  more  irreg- 
ular. Vasomotor  relaxation  is  probably  a  very  important  element  in 
the  heart  failure.  Gallop-rhythm  and  embryocardia  develop,  and  there 
is  usually  a  relative  (muscular)  mitral  leakage.  Cardiac  pain  may  be 
severe.  These  changes  may  develop  during  the  infection  as  is  the 
case  in  typhoid,  scarlatina,  and  rheumatism;  or  they  may  occur  sev- 
eral (two  to  ten)  weeks  after  the  infection,  as  in  10  to  20  per  cent,  of 
the  cases  of  diphtheria.  Sudden  death  without  symptoms  may  occur 
during  convalescence.  Rheumatic  myocarditis  often  leads  to  chronic 
fibrous  myocarditis. 

Diagnosis. — The  diagnosis  is  made  from  the  etiology;  acute  myo- 
carditis is  distinguished  with  great  difficulty  from  acute  endocarditis 

Treatment. — 1.  Prophylaxis. — Hydrotherapy  is  indicated  in  typhoid 
and  antitoxin  in  diphtheria;  the  patient  should  have  absolute  rest 
well  into  convalescence,  because  sudden  heart  insufficiency,  or  unex- 
pected death  may  follow  effort,  difficult  defecation,  or  other  exertions; 
sexual  intercourse  should  be  forbidden.  The  heart  must  be  carefully 
watched  in  every  convalescence. 

2.  Cardiants. — These  are  indicated  as  in  valvular  incompetency, 
although  digitalis  and  strychnine  are  apparently  of  little  use. 


Acute  Circumscript  Myocarditis. 

Acute  circumscript  myocarditis  (the  disease  of  gladiators,  Galen) 
is  usually  septic  and  embolic.  It  is  one  form  of  sepsis,  and  its  heart 
foci  are  usually  multiple.  It  is  usually  caused  by  the  pyogenic  organ- 
isms. The  issues  are  (a)  resorption  with  fibrosis,  (6)  caseation  or 
calcification,  and  (c)  rupture  into  the  pericardium  or  into  the  heart 
cavity,  thus  producing  ''heart  ulcers"  and  pulmonary  or  arterial 
embolism,  heart  aneurysm,  abnormal  communications  between  the 
chambers,  or  sudden  valvular  insufficiency.  The  latter  is  sometimes 
suggestive,  though  it  is  usually  impossible  to  make  a  diagnosis.  The 
treatment  is  that  of  the  fundamental  septicopysemia  and  the  resulting 
cardiac  insufficiency. 


Fragmentation  of  the  Heart  Muscle. 

Fragmentation  of  the  heart  muscle  (Zenker,  Virchow,  Rindfleisch, 
Coats,  Renault,  and  Landouzy)  occurs  in  two  forms  (a)  segmentation, 
or  separation  from  each  other  of  the  heart  fibers,  and  (6)  fragmenta- 
tion, or  rupture  across  the  normal  or  degenerated  muscle  fibers.  It 
has  also  been  called  segmentary  myocarditis,  and  though  it  most 


446  DISEASES  OF  THE  CIRCULATION 

frequently  occurs  in  death  from  violence,  it  may  have  some  clinical 
significance  in  cases  of  sudden  or  gradual  heart  weakness  (see 
Myolysis  under  Diphtheria). 


CHRONIC  MYOCARDITIS  (CHRONIC  FIBROUS  OR  INTERSTITIAL 
MYOCARDITIS,  MYOFIBROSIS  CORDIS). 

Etiology  and  Pathology. — Chronic  myocarditis  is  rarely  a  disease 
sui  generis,  and  the  term  is  somewhat  ill-chosen.  It  is  a  sequel  of 
some  previous  retrogressive  lesion — a  secondary  process.  It  compen- 
sates for  destruction  of  heart  tissue,  and  is  in  itself  a  measure  of 
that  loss.  It  is  more  often  a  fibroid  degeneration  than  an  inflammation. 
The  longitudinal  incision  of  the  heart  muscle  discloses  the  scar-like 
tissue  which  is  often  unseen  in  the  ordinary  transverse  sections  (Koester 
and  Riihle).  This  tissue  is  seen  most  frequently  in  the  left  ventricle 
(lower  two-thirds  of  its  anterior  wall  near  the  apex  and  the  upper 
two-thirds  of  its  posterior  wall  near  the  auricle)  as  glistening  sunken 
areas  under  the  pericardium  or  endocardium.  It  also  occurs  in 
the  papillary  muscles  or  interventricular  septum.  The  scars  appear 
as  streaks,  flecks,  stellate  plaques,  sometimes  measuring  three  or  four 
centimeters,  or  even  larger.  The  foci  may  be  macro-  or  microscopic, 
circumscribed  or  general.  Large  areas  may  form  from  fusion  of  small 
foci.     Grross  changes  in  the  heart  include  the  following: 

1.  Hypertrophy. — This  is  vicarious  and  occurs  when  the  flbrosis  is 
not  great.  The  relation  is  twofold;  (a)  hypertrophy  often  compen- 
sates for  muscular  destruction  and  maintains  the  heart;  or  (b)  fibrosis 
develops  in  tired  hypertrophied  hearts.  Hypertrophy  is  inversely 
proportional  to  the  number  of  scars. 

2.  Dilatation. — This  follows  extensive  fibrosis  and  decreased  power 
to  resist  pressure.  Fibrosis  of  the  tissue  can  neutralize  dilatation  to 
some  extent,  and  is  therefore  a  conservative  agent. 

3.  Atrophy  of  the  Myocardium. 

4.  Valvular  Disease. — This  has  no  necessary  afliliation  with  myo- 
carditis, though  they  are  indirectly  associated.  A  relative  mitral 
insufficiency  may  follow  myocarditis  in  the  mitral  papillary  muscles 
(Hamernjk).  Dittrich  first  described  the  genuine  heart-stenosis,  a 
cicatricial  contraction  of  the  left  conus  arteriosus  in  the  adult,  or  of 
the  right  conus  in  the  foetus,  following  myocarditis  at  those  sites. 
Relative  aortic  insufficiency  may  follow  enormous  dilatation  and  myo- 
carditis of  the  left  ventricle  (personal  observation). 

5.  Partial  Heart  Aneurysm  and  Heart  Rupture. — Partial  heart 
aneurysm,  a  localized  bulging  of  the  heart  wall,  is  seen  largely  near 
the  apex  (left  ventricle,  68  per  cent,  of  cases.  Pel  vet),  where  acute 
myomalacia  cordis  or  chronic  fibrosis  occurs  most  frequently;  it  is 
seen  more  rarely  at  the  base,  or  in  the  interventricular  septum  which 
may  bulge  into  the  right  heart;  and  it  occurs  most  infrequently  in 
the  right  ventricle  or  auricle.    The  heart  aneurysm  is  usually  small,  but 


CHRONIC  MYOCARDITIS  447 

may  equal  the  size  of  the  heart ;    it  is  usually  single  (though  four  were 
found  by  Thurnam),  and  may  communicate  with  the  heart  cavity 
by  a  necl^-like  constriction;    its'  walls  consist    of  connective  tissue 
which  is  rarely  ossified  as  in  Corvisart's  case;  it  often  contains  thrombi 
and  is  adherent  to  the  pericardium.     In  unfavorable  cases  it  ruptures 
or  tears  loose  a  valvular  attachment.    During  twenty  years  ending  in 
1903,  D.  G.  Hall  found  112  cases  recorded  (26  had  aneurysm  in  the 
valves,  and  25  in  the  coronary  vessels) ;  Voelker  alone  made  a  diagnosis. 
Rupture  of  the  heart  occurs  through  the  left  ventricle  (80  per  cent.). 
Pathogenesis. — The  most  frequent  cau^e  is  disease  of  the  coronary 
arteries,  which  are  incessantly  active  and  are  end-arteries,  anastomos- 
ing with  each  other  only  through  their  capillaries.     The  vessels  of 
Thebesius,  entering  the  muscle  from  the  auricles  and  ventricles  as 
well  as  some  supernumerary  vessels,  may  carry  on  a  collateral  circula- 
tion when  the  coronary  arteries  are  occluded.     Coronary  narrowing 
may  be  gradual,  by  slow  obliterative  endarteritis  in  the  trunk  or  by 
the  occlusion  of  the  vessel  from  an  atheromatous  plaque  in  the  aorta; 
or  it  may  be  sudden  and  fatal  by  embolism  or  thrombosis  in  an  already 
narrowed  vessel.    The  most  common  location  for  coronary  obstruction 
is  in  the  left  ventricle  (anterior  coronary  artery  which  is  most  active, 
and  relatively  small)  and  in  the  interventricular  septum.     In  fairly 
acute  coronary  obstruction,  the  heart  muscle  becomes  ischsemic,  pale 
yellow  or  white,  and  opaque;   and  the  necrotic  area  becomes  swollen 
and  prominent  (coagulation  necrosis).     A  wedge-shaped  anaemic  (or 
hemorrhagic)   infarct  is  less  common  than   an   irregularly  outlined 
necrosis.     The  muscle  fibers  become  fragmented,  lose  their  nuclei, 
and  disappear;  this  process  may  lead  to  rupture  of  the  heart.    Ziegler 
named  it  myomalacia  cordis.    White  cells  surround  the  focus.    Sudden 
death  is  very  common.     If  the  subject  lives,  scar-tissue  develops  to 
replace  the  deficit,  and  is  known  as  dystrophic  sclerosis.    Such  "myo- 
carditis" is  not  inflammatory;   it  is  often  an  uncomplicated  coagula- 
tion necrosis  with  substitution  by  scar-tissue.    Huchard  employs  the 
terms,  arteriosclerosis  of  heart  and  arterial  cardiopathy,  to  emphasize 
the  causal  role  of  arterial  disease.     Coronary  arteritis  most  frequently 
runs  a  subacute  or  chronic  course.     Its  causes  are  those  of  arterio- 
sclerosis (q.v.).     A  less  frequent  cause  is  actual  chronic  myocarditis 
following  acute  myocarditis  due  to   acute   infections,  such   as   rheu- 
matism, typhoid,  or  diphtheria.     Koester,  Ruehle,  and  others  have 
found  myocarditis  in  cases  of  cardiac  insufficiency,  resulting  from 
valvular  disease,  and  also  in  idiopathic  cardiac  hypertrophy.    French 
writers  describe  an  acute  endarteritis  following  acute  infections  and 
leading  to  myofibrosis.    Dehio  holds  that  myocarditis,  or  myofibrosis, 
is  a  result  of  dilatation,  that  it  occurs  where  the  muscle  is  destroyed, 
and  is  therefore  a  necessary  and  protective  process.     This  view  con- 
forms with  Thoma's  conception  of  arteriosclerosis    (q.v.).      Dehio 
considered  that  myofibrosis  has  no  affiliation  with  acute  myocarditis, 
that  it  occurs  in  all  cavities  of  the  heart,  and  often  in  the  weaker 
and  more  dilated  auricles,  that  dilatation  is  the  determining  factor. 


448  DISEASES  OF  THE  CIRCULATION 

and  that  it  is  always  a  process  secondary  to  the  degeneration  of  hyper- 
plastic muscle,  to  pressure,  and  to  venous  stasis. 

Symptoms. — (a)  In  the  latent  type  there  are  no  symptoms,  and 
sudden  apoplectiform  death  occurs,  while  the  subject  is  apparently 
in  perfect  health.  (6)  Most  cases  present  chronic  symptoms  of  cardiac 
insufficiency.  The  cervical  veins  are  enlarged  and  there  is  general 
venous  congestion.  The  pulmonary  circulation  suffers  especially,  as 
is  shown  by  cyanosis,  by  duskiness  of  the  skin,  by  infarcts  which 
are  often  large  (Riihle),  by  hydrothorax,  oedema  of  the  lungs,  bron- 
chitis, and  by  dyspnoea  which  is  often  nocturnal  and  develops  on 
exertion.  The  heart  symptoms  are  precordial  oppression  or  dull  pain, 
palpitation,  cardiac  asthma,  or  genuine  angina  pectoris.  Examination 
of  the  heart  sometimes  gives  negative  results,  but  dilatation  and 
hypertrophy  are  usually  present  (cardiomegalia).  The  heart  tones 
at  first  are  often  clear,  but  later  become  faint  and  irregular,  so  that 
in  the  resulting  dehrium  cordis,  the  tones  are  disorderly,  and  the  phase 
of  the  murmur,  due  to  relative  muscular  insufficiency  or  to  arterio- 
sclerotic dilatation,  cannot  be  distinguished.  The  second  pulmonic 
sound  is  accentuated  or  split,  and  the  second  aortic  tone  is  weak, 
because  the  arterial  tension  is  low.  The  pulse  is  usually  irregular 
(Riihle,  Riegel,  Bard,  Phillippe),  and  may  be  so  either  from  the  begin- 
ning or  may  become  so  later,  with  paroxysms_  of  arrhythmia  which 
some  consider  an  extension  of  the  degeneration  and  sclerosis.  Irreg- 
ularity usually  precedes  the  cardiac  insufficiency  and  persists  during 
restoration  of  compensation.  A  regular  pulse  may  be  present  through- 
out (Ebstein  and  Renoy),  or  a  number  of  regular  strong  beats  is  fol- 
lowed by  a  wave  of  rapid  tumbling  heart  action.  Simple  intermission 
and  the  pulsus  bigeminus  are  also  seen.  The  pulse  rate  is  often  slow 
at  first,  and  gradually  increases  to  90  or  100,  with  ominous  crises  of 
tachycardia.  In  some  instances  the  pulse  is  persistently  slow  and  this 
is  associated  with  syncope  from  brain  anaemia  (v.  i.  Bradycardia). 
It  is  seen,  then,  that  the  rate  and  rhythm  of  the  pulse  vary,  and  though 
irregularity  is  of  important  diagnostic  value  there  is  no  constancy  in 
the  pulse  findings. 

Oedema  is  present,  but  as  a  rule  is  less  common  and  intense  than 
it  is  in  valvular  disease.  Embolism  may  occur.  Digestive  disturbances 
are  almost  constant  (Riihle),  and  Huchard  maintains  that  they  have 
an  important  bearing  on  the  heart's  action;  alimentary  autotoxaemia 
from  carelessness  in  regard  to  diet,  may  cause  paroxysmal  cardiac 
symptoms.  Potain  and  Barie  hold  that  digestive  disorders  induce  a 
reflex  contraction  of  the  lung  vessels  and  thus  lead  to  dyspnoea.  The 
urine  is  that  of  stasis  in  the  later  stages,  but  early  in  the  disease  poly- 
uria may  prevail  from  hypertrophy  and  high  blood  pressure.  Renal 
insufficiency  may  lead  to  renal  toxaemia  (Houchard). 

Diagnosis. — There  Are  Five  Cardinal  Points. — (a)  In  the  majority  of 
cases  arteriosclerosis  is  most  important.  Its  causes  should  be  sought 
in  the.  anamnesis,  and  the  peripheral  arteries  and  aorta  should  be 
examined  for  its  usual  signs  (q.  v.).    Arteriosclerosis  is  usually  general, 


CHRONIC  MYOCARDITIS  449 

but  may  exist  in  the  heart  or  brain  without  being  seen  in  the  radial 
arteries,  and  the  converse  is  also  true.  (6)  The  heart  is  usually  dilated 
and  hypertrophied ;  {.  e.,  its  transverse  measurement  is  increased,  (c) 
No  valvular  murmur  exists  (in  uncomplicated  cases).  The  systolic 
apical  murmur  of  arteriosclerotic  dilatation  may  be  heard  or  the  soft 
variable  bruit  of  relative  mitral  leakage,  which  often  disappears  with 
rest  and  catharsis,  (d)  The  'pulse  is  fast  and  irregular.  A  regular 
pulse  does  not  absolutely  exclude  myocarditis.  Arrhythmia,  whether 
congenital,  neurasthenic,  or  caused  by  tobacco,  must  be  excluded,  (e) 
Dyspncea  and  pulmonary  stasis  are  suggestive. 

Differentiation  is  often  so  difficult  that  many  able  clinicians  limit 
the  diagnosis  to  Tnuscular  insufficiency;  for  fatty  heart,  idiopathic 
hypertrophy  and  dilatation,  or  pericardial  adhesions,  may  be  found  at 
autopsy  instead  of  the  anticipated  myocarditis.  Sometimes  when  myo- 
carditis is  suspected,  the  heart  shows  nothing  microscopically  or 
macroscopically,  thus  demonstrating  that  the  causes  of  heart  failure 
are  often  beyond  the  detection  of  the  microscope.  A  diagnosis  is 
made  by  exclusion,  and  then  is  often  only  a  "probability  diagnosis." 
In  distinguishing  myocarditis  from  the  "heart  of  renal  disease"  long 
observation,  the  gallop-rhythm  (more  common  in  the  cor  renale),  and 
uraemic  manifestations  are  helpful.  Myocarditis  and  renal  disease  are 
rather  frequently  associated.  From  mitral  stenosis:  both  lesions  cause 
irregularity  and  a  weak,  radial  pulse  and  apex  beat;  when  the  pre- 
systolic stenotic  murmur  is  absent,  the  loud  second  pulmonic  sound, 
the  loud,  snapping,  apical  tone  and  the  wide,  right  heart  are  most 
suggestive  of  mitral  stenosis.  Digitalis  very  frequently  fails  to  act  in 
myocarditis.  From  cerebral  apoplexy:  the  sudden  "stroke"  or  "car- 
diac apoplexy"  of  coronary  disease  may  be  the  first  sign  of  myocardial 
disease  and  may  be  mistaken  for  hemorrhage  of  the  pancreas,  cerebral 
apoplexy,  or  embolic  processes.  The  autopsy,  in  cases  of  sudden 
death  or  death  after  a  few  hours,  often  discloses  coronary  closure  with 
myomalacia  cordis  or  fibrous  myocarditis. 

Prognosis. — The  prognosis  is  that  of  uncompensated  valvular  lesions 
with  the  extra  consideration  that  the  muscle  itself  and  most  often  its 
nutrient  arteries  are  involved.  Because  of  the  facts  that  digitalis  is 
often  inefficient  in  these  cases,  and  that  angina  pectoris,  cerebral 
anaemia,  heart  rupture,  or  coronary  closure  may  occur,  the  outlook 
is  most  unpromising.  Some  patients,  especially  elderly  subjects,  may 
live  a  decade  or  more,  until  intercurrent  pneumonia  or  another  secon- 
dary affection  causes  their  death.  Early  digestive  symptoms  are  less 
favorable  than  early  oedema  or  congested  liver. 

Treatment.— The  therapy  is  (a)  that  of  the  causal  factor,  arterio- 
sclerosis {q.  V.)  being  the  most  common  cause.  Potassium  iodide 
relieves  pain,  and  lessens  the  atheroma;  it  should  be  given  in  doses 
of  5  to  10  grains  after  meals,  freely  diluted  in  milk  or  water — 

Potassii  iodidi onss. 

Syr.  sarsaparillse  co oiv. 

M.  et  S. — One  teaspoonful  in  a  glass  of  water  after  meals. 
29 


450  DISEASES  OF  THE    CIRCULATION 

(b)  Dietetic;  stimulants  should  be  used  carefully,  and  overexertion 
and  excitement  should  be  avoided,  (c)  The  Schott  treatment  (v.  s.). 
(d)  Cardiants.  Digitalis  is  beneficial  in  the  less  developed,  but  not 
in  the  advanced  cases.  It  is  to  be  avoided  when  the  pulse  is  slow. 
Strychnine  is  frequently  valuable.  When  there  are  anginal  seizures 
or  hard  vessels,  nitroglycerine  should  be  given  (see  Therapy  of  Val- 
vular Disease).  Nitrite  of  amyl  is  usually  ineffectual.  Caffeine, 
camphor,  morphine,  and  alcoholics  should  be  administered  for  cardiac 
asthma;  morphine  is  considered  somewhat  dangerous  in  angina  pec- 
toris (q.  v.). 

RUPTURE  OF  THE  HEART. 

Etiology. — -(a)  Spontaneous  rupture  is  practically  unknown.  (6) 
Rupture  through  the  altered  heart  muscle  occurs  in  myocarditis,  heart 
aneurysm  (in  which  case  it  may  even  perforate  the  chest  wall),  myoma- 
lacia cordis  (from  coronary  atheroma  and  embolic  occlusion),  coronary 
aneurysm;  fatty  heart,  abscess,  gumma  or  neoplasm  of  the  heart, 
ulcerative  endocarditis  or  obstructive  valvular  disease,  and  stenosis 
of  the  isthmus  of  the  aorta.  It  occurs  largely  in  men  over  sixty  years 
of  age.  It  may  occur  during  sleep  or  may  be  caused  by  trauma,  vomit- 
ing, great  effort,  excitement,  delivery,  coitus,  or  by  the  use  of  digitalis. 
Kroll  collected  332  cases  of  rupture  of  the  heart. 

Pathology  and  Symptoms. — (a)  Partial  rupture  of  the  valves  in- 
duces sudden  valvular  insufficiency.  (6)  Total  rupture  of  the  heart  is 
usually  single  (though  a  case  having  five  rents  is  recorded),  and  takes 
place  in  the  left  ventricle  (80  per  cent.)  where  the  pathological  factors 
(v.  s.)  come  most  into  play;  it  occurs  less  frequently  in  the  interven- 
tricular septum,  right  ventricle  and  auricles.  Sudden  death  may  occur 
without  prodromes,  or  death  may  result  after  a  few  hours  to  eleven 
or  seventeen  days.  The  symptoms  are  a  sense  of  something  giving 
way  in  the  chest,  great  precordial  pain,  incoercible  vomiting  or  diar- 
rhoea, cerebral  anaemia  or  irritation  of  the  vagus  from  hsemopericar- 
dium,  collapse,  and  death  from  pressure  of  the  blood  on  the  venae 
cavse  (Cohnheim)  or  on  the  heart.  Hsemopericardium  (q.  v.)  may  be  sus- 
pected because  of  greatly  increased  triangular  dulness,  faint  heart  tones, 
and  absent  or  weak  apex  beat  within  the  left  border  of  the  dulness. 

Diagnosis  and  Treatment. — The  diagnosis  is  rarely  made.  It 
depends  on  (a)  the  etiology,  (6)  increased  dulness,  (c)  cardiac  insuffi- 
ciency, and  (d)  symptoms  of  internal  hemorrhage.  The  outlook  is  bad, 
and  the  treatment  wholly  symptomatic;  the  most  absolute  rest  should 
be  enforced. 

Heart  injury  was  first  operated  on  by  Farina  (1896).  The  first 
cardiorrhaphy  for  rupture  was  by  Rehn  (1897).  Frazier  (1906) 
collated  102  operations  for  injury,  of  which  42  per  cent,  recovered. 

Disease  of  the  Coronary  Arteries. — This  has  been  sufficiently  consid- 
ered under  myocarditis  (heart  aneurysm)  and  rupture  of  the  heart. 
It  will  be  considered  again  under  angina  pectoris,  which  anatomically 


TUMORS  OF  THE  HEART  451 

belongs  to  disease  of  the  heart  muscle  though  it  is  usually  described 
under  cardiac  neuroses. 


TUMORS  OF  THE  HEART. 

These  are  most  rare  because  the  heart  is  rather  insusceptible  even 
to  neoplasms  in  its  immediate  vicinity.  They  cannot  be  diagnosticated. 
Carcinoma  and  sarcoma  are  the  most  frequent,  and  lipoma,  myxoma, 
fibroma,  and  myoma,  are  infrequent.  They  are  usually  secondary. 
Cardiac  insufficiency,  valvular  compression  or  other  disorder  and  em- 
bolism sometimes  develop. 

Parasites  are  most  often  accidental  post  mortem  findings.  In 
Hosier's  monograph  echinococcus  is  the  most  frequent  and  occurs 
twice  as  often  in  the  right  ventricle  as  in  the  left.  Grulee  (1905) 
collected  55  cases  of  echinococcus  of  the  heart.  Cardiac  rupture, 
sudden  death  from  occlusion  of  the  pulmonary  trunks,  relative  pul- 
monary insufficiency,  or  cardiac  incompetence  may  occur.  The  cysti- 
cercus,  the  pentastomum  and  trichina  are  of  purely  anatomical  interest. 


SYPHILIS  OP  THE  HEART  (See  Syphilis). 
CARDIAC  THROMBOSIS— THROMBOSIS  CORDIS. 

This  usually  occurs  at  the  time  of  or  after  death,  and  is  of  little 
clinical  interest. 

Symptoms. — (a)  Entire  latency.  (6)  Thrombosis  sometimes  de- 
velops during  life  and  leads  to  pulmonary  or  arterial  embolism,  (c) 
Sudden  cardiac  weakness,  (d)  Sudden  valvular  stenosis,  a  ball  throm- 
bus (kugelthrombus)  forming  in  the  auricle,  and  occluding,  for  instance, 
the  mitral  orifice;  it  is  beyond  clinical  recognition,  although  ac- 
cording to  von  Ziemssen,  it  is  frequently  associated  with  gangrene 
of  the  lower  extremities;  in  Curschmann's  case  an  ascites  resem- 
bling chronic  peritonitis  was  the  sole  finding. 


NEUROSES  OF  THE  HEART. 

PALPITATION  OF  THE  HEART. 

Palpitation  is  also  known  as  cardiopalmus,  cardiogmus,  or  hyper- 
kinesis  cordis,  and  is  purely  a  symptom.  In  health  and  in  many  cases 
of  severe  heart  disease  the  patient  is  not  conscious  of  his  heart-action. 


452  DISEASES  OF  THE  CIRCULATION 

The  most  extreme  irregularity  (delirium  cordis),  or  the  pounding  heart 
caused  by  aortic  insufficiency,  may  escape  the  patient's  notice,  though 
the  normal  heart's  action  may  cause  palpitation  after  overwork,  from 
abuse  of  coffee  and  other  causes. 

Etiology. — 1.  Nervous  Causes  (Hypersesthesia  of  the  Centripetal 
Fibers  from  the  Heart  to  the  Brain). — Nervous  excitability  is  common, 
especially  in  medical  students,  whose  hearts  must  therefore  be  examined 
repeatedly  when  they  first  study  physiology  or  physical  diagnosis. 
Even  physicians  are  not  wholly  free  from  heart  egotism.  Peter  Frank 
had  violent  palpitation  while  writing  his  "Diseases  of  the  Heart," 
so  that  he  thought  he  had  aneurysm.  It  is  common  in  school  chil- 
dren, and  results  from  nervous  tension,  fear  of  examinations  and 
public  exercises.  It  is  more  frequent  in  women  and  may  be  connected 
with  puberty,  the  climacteric,  or  menstruation.  It  occurs  almost  con- 
stantly in  exophthalmic  goitre  and  very  commonly  (50  per  cent.)  in 
neurasthenics,  so  that  a  special  neurasthenia  cordis  has  been  recog- 
nized, which  is  attended  by  turgid  face,  red  eyes,  contracted  temporal 
arteries,  and  angioneurotic  oedema,  which  symptoms  disappear  when 
the  seizure  is  over.  Hysteria  is  a  less  important  cause.  Nervous 
exhaustion,  chlorosis,  pernicious  anaemia,  acute  infections,  lactation, 
poor  hygiene,  the  beginning  of  tuberculosis,  and  sexual  excess  or  per- 
version, may  produce  palpitation.  The  "irritable"  heart  of  soldiers, 
observed  by  Da  Costa  in  our  Civil  War,  which  is  associated  with 
arrhythmia,  diarrhoea,  emotional  causes,  and  physical  strain,  is  often 
placed  under  this  head,  but  is  better  classified  as  muscular  insufficiency. 

2.  Reflex  Causes. — This  type  might  be  included  under  nervous 
palpitation.  It  follows  dyspepsia,  especially  after  a  heavy  meal,  and 
peptones  or  other  products  of  digestion  have  been  thought  causal. 
Dyspepsia  may  cause  it  by  mechanical  gastric  distention  or  by  toxaemia. 
It  may  also  result  from  constipation,  intestinal  parasites,  gall-stones 
(Kehr),  renal  calculi  (Potain  and  Houchard),  puncture  of  ascites, 
prostatic,  uterine,  or  ovarian  disease,  floating  kidney,  and  diseases  of 
the  teeth  and  nose. 

3.  Toxic  Causes. — Palpitation  may  result  from  the  use  of  coffee, 
tea,  alcohol,  tobacco,  narcotics,  and  from  gout. 

4.  Cardiac  Causes. — Palpitation  may  occur  in  organic  heart  disease, 
viz.:  valvular  disease,  acute  myocarditis,  hypertrophy,  dilatation, 
coronary  atheroma,  and  in  obesity.  It  may  be  symptomatic  of  heart 
failure,  as  in  the  heart  of  nephritics. 

Symptoms. — The  patient  complains  of  "feeling  the  heart  beat," 
"goneness,"  "fluttering,"  forcible,  irregular,  or  intermittent  action  of 
the  heart,  dyspnoea,  anxiety,  vertigo,  tinnitus,  and  spots  before  the 
eyes.  In  some  instances,  the  symptoms  recur  periodically.  Inter- 
mittent epigastric  throbbing  is  not  infrequently  present.  Vasomotor 
symptoms,  as  flushing  of  the  face,  spastic  urine,  etc.,  are  not  uncommon. 

Physical  Examination. — Sometimes  the  heart  is  absolutely  normal. 
Conceptions  of  palpitation  differ  widely,  and  some  authors  describe 
it  under  tachycardia.     The  heart's  rate  is  often  increased,  going  up 


PALPITATION  OF  THE  HEART  453 

suddenly  after  exertion  or  fright  to  100  or  150,  with  violent  arterial 
throbbing.  The  increased  rate  may  be  due  to  stimulation  of  the 
accelerator  nerves  or  of  the  vagus.  The  heart  is  rarely  slowed,  as  in 
Binswanger's  case.  The  rhythm  may  be  normal  or  disturbed.  A 
series  of  rather  rapid  beats  followed  by  a  series  of  slower  beats  is 
possibly  somewhat  characteristic  of  nervous  palpitation.  If  the  pulse 
is  irregular  when  the  patient  is  quiet  it  sometimes  becomes  regular 
after  exertion.  The  first  apex  tone  is  often  accentuated,  is  even  metal- 
lic, or  may  be  heard  by  the  patient,  or  by  the  physician  at  some  dis- 
stance  from  the  patient's  chest.  In  some  nervous  subjects  the  systole 
sounds  short  (Miiller).  The  second  tone  at  the  base  is  more  often 
strong  than  weak.  A  murmur  over  the  pulmonary  region  is  usually 
functional. 

Diagnosis. — (a)  The  etiology  is  of  the  greatest  importance.  It  is 
confirmed  by  (6)  negative  results  of  examination  of  the  heart  during 
the  attacks,  but  particularly  in  the  intervals.  Coronary  disease,  arterio- 
sclerosis, myocarditis,  etc.,  are  usually  excluded  with  ease,  but  it 
should  always  be  remembered  that  nervous  palpitation  may  co-exist 
with  organic  difficulties.  Palpitation  is  held  by  some  to  lead  to  dila- 
tation or  hypertrophy,  but  this  is  probably  confusion  of  cause  and 
effect,  (c)  If  pain  be  present  in  nervous  palpitation,  it  is  more  often 
lower  (an  "epigastric  cramp")  than  that  of  organic  lesions,  the  pain 
of  which  radiates  to  the  shoulder  or  arms. 

Prognosis. — Though  palpitation  is  sometimes  lifelong,  the  outlook 
is  generally  favorable,  but  this  depends  on  the  etiology.  The  old 
belief  that  fright  could  cause  death  is  as  unfounded  as  most  popular 
conceptions,  and  few  such  instances  are  recorded  (Bollinger,  Laache). 

Treatment. — Treatment  must  be  based  on  the  cause,  (a)  If  the 
cause  is  nervous,  suggestion  is  valuable  and  repeated  examinations  of 
the  heart  and  body  are  essential,  in  order  to  assure  the  patient  and  to 
avoid  error.  Regulated  exercise,  tepid  baths  with  active  friction,  light 
meals,  regular  habits,  and  possibly  the  rest  cure  of  Mitchell,  are  indi- 
cated. It  seems  from  personal  experience  that  isolation  often  in- 
creases introspection.  In  anaemic  cases  full  doses  of  iron,  arsenic,  and 
strychnine  should  be  given.  Goddell's  combination  of  the  three  vale- 
rianates is  valuable: 

Ferri  valerianatis. 

Quinina?  valerianatis. 

Ammon.  valerianatis aa  gr.  xx. 

M.  et  ft.  in  pil.  xx. 
S. — One  pill  after  meals. 

In  cases  of  violent  throbbing,  a  few  doses  of  veratrum  often  quiet  the 
general  and  cardiac  nervousness.  A  belladonna  plaster  or  a  few  drops 
of  the  fluidextract  helps  the  patient  greatly  by  anaesthetizing  the 
peripheral  fibers  of  the  vagus.  Sexual  hygiene  must  be  strictly 
observed. 


454  DISEASES  OF  THE  CIRCULATION 

Fluidextr.  veratri ■    •  gtt.  x. 

Fluidextr.  belladonnse gtt.  xv. 

Aquffi q-s-  ad   oj- 

M.  et  S. — One  teaspoonful  every  half  hour  for  two  or  three  doses. 

(&)  When  the  case  is  reflex,  flatulency  and  constipation  must  be  treated 
and  the  nose  sometimes  should  be  cauterized.  Bromides  are  of  value 
but  must  be  given  well  diluted  or  in  pepsin  elixir,  in  order  to  avoid 
added  gastro-intestinal  disorder. 

Sodii  bromidi 5]. 

Spts.  ammon.  aromat oss. 

Syr.  zingiberis oiij. 

Aqua; Q-s-  ad   oi]- 

M.  et  S. — One  teaspoonful  in  hot  water  every  half-hour  for  four  doses. 

A  light  evening  meal  of  non-nitrogenous  food  is  beneficial  in  children 
afflicted  with  night  terrors  or  palpitation,  (c)  The  toxic  type  is  easily 
treated  when  the  noxa  is  recognized,  (d)  In  cardiac  disease,  the  car- 
diants,  morphia,  belladonna,  aconite  and  the  ice-bag  are  indicated 
{v.  Valvular  Disease).  DigitaUs  is  of  little  use  in  the  truly  nervous 
type. 

TACHYCARDIA. 

Definition. — Tachycardia  is  the  usual  term  for  rapid  heart  action, 
ahhough  polycardia  and  pyknocardia  are  better  etymologically,  for 
tachycardia  imphes  quick  (not  rapid)  heart  action  Hke  the  pidsusceler. 
Tachycardia,  Hke  palpitation,  is  only  a  symptom.  Some  hearts  nor- 
mally beat  90  to  100  (120  in  the  case  of  Congreve). 

Etiology. — Larcenia's  division,  somewhat  modified,  is  as  follows: 
(a)  Heart  and  vascular  disease,  coronary  or  valvular  affections,  and 
acute  or  chronic  myocarditis,  (b)  Nervous  affections,  (i)  brain  and 
cord  disease,  as  of  the  medulla  (vagus  centre),  tumors,  softening, 
hemorrhage,  multiple  sclerosis,  acute  ascending  paralysis,  bulbar 
paralysis,  injury  especially  to  the  cervical  spine,  myelitis  and  tabes; 
(ii)  neuritis,  compression  of  the  trunk  of  the  vagus  by  tumors,  irri- 
tation of  the  accelerator  nerve,  neuroses  as  exophthalmic  goitre, 
emotional  tachycardia,  and  reflex  tachycardia  from  uterine  or  ovarian 
disease  or  from  the  menopause,  (c)  General  diseases  such  as  fevers, 
chronic  troubles  (tuberculosis,  cancer) ;  and  convalescence,  exhaustion 
or  excesses,  (d)  Toxic  causes,  resulting  from  tea,  coffee,  alcohol,  lead, 
digitaHs,  atropine,  amyl  nitrite,  etc.  Cases  are  recorded  (Tarchanoff) 
in  which  individuals  by  voluntarily  moving  the  ear  or  skin  muscles  of 
the  neck  can  raise  the"^  heart's  rate,  through  the  spinal  accessory  nerve 
and  the  vagus. 

A  special  variety  is  the  tachycardia  paroxysmalis,  described  first  by 
Proebsting  (1881)  and  later  by  Nothnagel,  Bouveret,  and  Martins. 
Paroxyms  of  rapid  heart  action  occur  abruptly,  last  from  a  few  seconds 
or  minutes  to  days  or  even  weeks,  and  usually  end  abruptly.     This 


TACHYCARDIA  455 

type  is  seen  mostly  in  strong,  hard-working  men,  who  indulge  in  ex- 
cesses in  alcohol,  tobacco,  etc.    Broadbent  saw  a  case  at  ten  years  of  age. 

The  pulse'  becomes  small,  is  usually  weaker  and  soft,  and  its  rate 
reaches  150,  250  (Bowles),  or  even  280  (Bristowe).  It  is  at  times  strong 
(Brieger,  Nothnagel)  and  is  usually  regular,  though  arrhythmia  may 
develop  at  the  beginning  and  end  of  the  seizure.  The  sphygmogram 
reveals  more  beats  than  does  palpation.  The  heart  often  dilates 
(Martins),  for  the  tachycardia  and  dilatation  are  coordinate  to  the 
causal  factor.  The  pause  of  the  heart  (the  time  between  systoles)  is 
lessened  (Fran9ois  Frank)  and  the  systole  is  incomplete.  The  systolic 
tone  is  often  clicking.  The  apex  is  apparently  strong,  but  throbbing  is 
an  index  of  weakness  and  dilatation.  Embryocardia  (Stokes,  Huchard) 
is  sometimes  present  while  heart  murmurs  are  rare.  The  vessels, 
especially  the  carotids,  pulsate  violently,  and  the  patient  is  anxious, 
depressed,  and  frequently  shows  signs  of  venous  stasis  or  cyanosis, 
although  the  face  is  at  times  flushed.  The  urine  is  of  low  specific 
gravity.  The  lungs  are  usually  normal  but  Riegel,  Tuczek,  Edinger 
and  Kredel,  describe  an  acute  distention  of  the  lungs  like  that  observed 
in  valvular  disease,  which  may  be  caused  by  vagus  or  phrenic  irritation 
or  tonic  contraction  of  the  diaphragm. 

Diagnosis. — Permanent  tachycardia  suggests  organic  disease  of  the 
centres  in  the  medulla  or  nerve  trunks.  The  physiology  of  the  vagus 
and  accelerator  nerves  from  the  clinical  standpoint  is  still  obscure.  It 
has  been  held  that  (a)  increase  in  the  pulse  up  to  120  indicates  sympa- 
thetic irritation  (accelerator  stimulation),  which  is  relieved  by  mor- 
phine; (b)  increase  from  120  to  180  indicates  paralysis  of  the  vagus,  and 
this  is  relieved  by  pressure  on  the  vagus  trunk;  (c)  increase  over  180  is 
indicative  of  sympathetic  irritation  in  addition  to  paralysis  of  the  vagus. 
Sympathetic  symptoms  may  prevail,  as  protrusion  of  the  eyeball,  wide 
pupils,  and  increase  in  the  interpalpebral  fissure;  other  evidences  of 
vagus  involvement  may  exist,  such  as  respiratory,  laryngeal,  or  gastric 
symptoms.  The  diagnosis  of  vagus  neurosis  rests  upon  (a)  the  exclu- 
sion of  organic  heart  and  brain  disease,  (b)  a  high  pulse  rate,  e.  g.,  150; 
(c)  occurrence  in  paroxysms  with  intervals  of  normal  pulse  rate;  {d) 
inhibitive  action  upon  the  paroxysm  of  manual  compression  or  of 
electrical  stimulation  of  the  vagus. 

Prognosis. — The  prognosis  varies  with  the  cause  and  type;  the 
permanent  variety  is  less  favorable  than  the  paroxysmal  and  temporary 
forms.  The  outlook  is  generally  good.  Bouveret  holds  that  permanent 
cure  is  rare  and  has  reported  four  cases  of  sudden  death.  The  infre- 
quent autopsies  (only  14  in  135  cases  collected  by  Hoffmann  in  1900) 
show  degenerations,  etc.,  in  the  heart  muscle.  It  is  well  to  regard  with 
doubt  and  caution  all  cases  of  tachycardia  other  than  those  resulting 
from  emotional  causes. 

Treatment. — Stimulation  of  the  vagus  is  effected  by  faradization  of 
the  neck,  holding  of  the  breath,  by  Valsalva's  experiment,  by  pressure  on 
the  right  vagus,  the  use  of  the  ice-bag,  lying  down,  swallowing  ice,  or  by 
induction  of  vomiting  by  apomorphine.    Morphine, asafoetida,  valerian, 


456  DISEASES  OF  THE  CIRCULATION 

and  the  bromides,  are  frequently  of  value.     The  causal  factors  must 
receive  consideration. 

BRADYCARDIA. 

Definition. — Bradycardia,  spanocardia  or  brachycardia  is  the  usual 
term  for  slow  heart  but  oligocardia  is  a  better  designation.  A  pulsus 
tardus  is  normal  to  some  individuals  and  in  certain  families  may  be 
seen  in  successive  generations.  It  is  often  an  accommodative  effort  as 
in  aortic  stenosis.  The  apparent  pulse  rate  must  be  verified  by  cardiac 
auscultation  because  the  pulse  record  is  often  but  half  as  frequent  as  the 
actual  heart  rate.  The  pulse  rate  may  fall  to  20  or  even  to  6  beats  a 
minute.  Paroxysmal  bradycardia  may  occur  with  weak  heart,  palpi- 
tation, difficulty  in  breathing,  or  gastric  distress. 

Following  Riegel's  classification,  two  types  are  distinguished:  (1) 
Physiological  bradycardia,  which  is  rather  infrequent  in  occurrence; 
it  is  observed  in  starvation,  and  during  the  puerperium;  the  rate  is 
from  34  to  60.  (2)  Pathological  bradycardia  may  show  6  to  9  beats  a 
minute   (Norfleet),  and  the  pulse  and  breathing  may  run  parallel. 

Etiology. — The  etiological  factors  of  the  pathological  type  are:  (a) 
Acute  infections;  bradycardia  is  very  common  during  or  after  typhoid, 
pneumonia,  diphtheria,  and  rheumatism.  Traube  explained  the  slow 
pulse  as  due  to  exhaustion,  but  it  is  probably  caused  by  acute  myo- 
carditis, which  induces  lessened  conductivity,  or  "heart-block."  (b) 
Digestive  disorders,  which  caused  the  majority  of  Riegel's  collection; 
jaundice,  especially  hght  forms,  constipation,  gastric  cancer  or  ulcer, 
vomiting  (which  causes  bradycardia  and  arrhythmia  in  children),  and 
gall  stones  are  the  most  frequent  causes,  (c)  Respiratory  disease  is  a 
less  frequent  cause;  emphysema  occurs  frequently  with  a  slow  strong 
pulse,  which  is  sometimes  an  unfavorable  symptom,  (d)  Circulatory 
disease,  such  as  aortic  stenosis,  fatty  heart,  coronary  atheroma  or  chronic 
myocarditis,  is  an  etiological  factor  and  lessens  the  conduction  and 
contractibility  of  the  heart  muscle.  Dehio  uses  atropine  to  distinguish 
between  (i)  disease  of  the  heart  muscle,  upon  which  the  drug  has  but 
little  effect,  and  (ii)  slow  heart  due  to  inhibition  of  the  vagus  (trunk  or 
centre)  in  which  it  brings  the  heart  to  or  above  the  normal  rate,  (e) 
Toxic  conditions  such  as  poisoning  from  lead,  alcohol,  tobacco  (coronary 
spasm),  canned  meats,  cojffee,  muscarine,  digitahs  and  other  drugs  may 
cause  bradycardia ;  it  also  occurs  in  cholsemia  and  early  in  uraemia,  in 
which  cases  it  is  unfavorable.  (/)  General  troubles  are  also  causative, 
such  as  diabetes,  cachexia,  anaemia  or  exhaustion,  all  of  which  lessen 
the  irritability  of  the  heart  muscle,  (g)  Nervous  conditions,  fright, 
apoplexy,  epilepsy,  meningitis,  brain  tumor,  disease  or  injury  of  the 
medulla  or  cervical  cord,  general  paralysis,  melancholia,  hysteria,  vagus 
stimulation  by  tumors,  and  compression  of  the  vagus  trunk,  are  also 
factors  in  its  development.  Jacob  describes  an  angiospastic  form 
(bradycardia  with  chills,  wide  pupils,  cold  skin,  loud  second  aortic 
tone,  etc). 


BRADYCARDIA  457 

The  Adams-Stokes  syndrome  (described  under  fatty  heart)  results 
chiefly  from  arteriosclerotic  changes  in  the  medulla  and  heart,  but 
rarely  fronl  toxins  or  neuroses.  The  causal  condition  is  "  heart  block, " 
in  which  the  transmission  of  the  peristaltic  contraction  wave  from  the 
auricle  to  the  ventricle  is  "  blocked  " ;  the  ventricles  contract  two  to  four 
or  more  times  less  frequently  than  the  auricles,  whose  movements  may 
be  seen  in  the  pulsating  cervical  veins  or  by  the  fluoroscope.  The 
syndrome  consists  of  (i)  bradycardia  (with  arrhythmia  and  hemi- 
systole);  (ii)  cerebral  disturbance  (syncope,  apoplectiform  or  epilep- 
tiform seizures);  and  (iii)  accessory  symptoms  (Cheyne-Stokes 
respiration,  angina  pectoris,  etc.). 

In  1903  His,  junior,  found  a  band-like  muscular  bundle  connecting 
the  auricles  and  ventricles,  which  is  known  as  the  "  bundle  of  His. "  It 
measures  18  millimeters  in  length,  2.5  millimeters  in  width,  and  1.5 
millimeters  in  thickness,  and  courses  posteriorly  in  the  septum  ventric- 
ulorum,  whence  it  reaches  the  right  auricle  and  its  valves.  According  to 
Erlanger  (1906),  slight  compression  of  His's  bundle  increases  the  inter- 
ventricular pause;  marked  compression  causes  intermittency  in  the 
ventricular  contractions;  complete  compression  results  in  independent 
contraction  of  the  auricles  and  ventricles.  In  "heart-block"  the  vagus 
loses  control  of  the  ventricle  but  the  accelerator  does  not.  The  epilepti- 
form attacks  of  the  syndrome  are  due  to  cerebral  ansemia  and  the 
apoplectiform  attacks  result  from  cerebral  venous  congestion.  In  a 
case  of  the  writer,  myofibrosis  was  found;  in  the  case  of  Stengel,  an 
endocarditic  patch ;  and  in  the  case  of  Jellick,  Cooper  and  Ophuls,  a 
focus  of  acute  anaemic  necrosis  (myomalacia  cordis.). 

Prognosis. — The  constant  is  less  favorable  than  the  paroxysmal  type. 

Treatment. — The  causal  therapy  alone  is  of  value.  Morphine  and 
atropine  have  been  recommended,  but  must  be  given  with  care  where 
there  is  disease  of  the  central  nervous  system.  Strong  cardiants,  such 
as  digitalis,  are  usually  contra-indicated  and  in  the  Adams-Stokes 
syndrome  are  actually  dangerous.  Alcohol  is  injurious.  In  the  Adams- 
Stokes  syndrome,  nitroglycerine  is  indicated,  while  bromides  are 
deleterious. 

ARRHYTHMIA. 

In  an  irregular  heart  the  individual  beats  are  irregular  in  rhythm,  in 
strength,  or  in  both. 

Etiology. — The  cases  are  (a)  nervous,  (i)  resulting  from  brain 
disease,  as  meningitis,  concussion,  or  pressure  from  hemorrhage  or 
tumor,  (ii)  psychical,  (iii)  reflex,  usually  from  the  digestive  tract,  lungs 
and  kidney;  or  (6)  cardiac,  (i)  toxic,  from  tobacco,  alcohol,  tea,  coffee 
or  digitalis,  or  (ii)  organic,  from  changes  in  the  peri-,  myo-  or  endocar- 
dium. Changes  in  the  heart  ganglia,  which  have  been  considered 
causes,  are  probably  in  most  cases  the  result  rather  than  the  cause. 
The  recent  studies  of  Gaskell,  Englemann,  Mackenzie,  and  Wencke- 
bach, have  shown  that  the  heart's  function  resides  in  the  heart  itself 


458  DISEASES  OF   THE  CIRCULATIOX 

(myogenic  contractility,  conducti^-ity,  excitability,  tonicity,  and  rhyth- 
micity ). 

Varieties. — Varieties  are  distinguished  as  follows:  (a)  Iniermittence. 
The  dropping  of  a  beat  may  be  complete  or  rudimentary  (a  slight  in- 
dication of  the  deficient  systole  is  recognized  in  a  faint  first  tone).  Some 
persons  can  voluntarily  drop  a  beat  by  contracting  the  neck  muscles, 
probably  through  reflex  action  upon  the  vagus  by  the  spinal  accessory 
nerve  which  supplies  the  muscles  (Bonders).  (6)  Deliriwn  cordis,  in 
which  the  greatest  irregularity  prevails — "folie  cardiaque."  (c)  Einbryo- 
cardia,  the  foetal  heart  rhythm  of  Stokes,  and  (d)  the  gallop-rhyihm  of 
the  heart  in  cases  of  renal  disease,  hypertrophy,  etc.,  which  has  been 
described  under  Dilatatiox.  {e)  The  alternate  heart  heat,  in  which  a 
strong  heart  beat  is  followed  by  a  weak  one,  with  corresponding  findings 
in  the  pulse  (pulsus  alternans) .  "When  the  irregularity  recurs  at  even 
intervals  the  term  allorrhythmia  is  employed.  (/)  The  higeminal  heart 
heat  consists  of  a  strong  beat  quickly  followed  by  a  weaker  one,  T\-ith  a 
pause  before  the  next  similar  group ;  the  second  beat  is  often  weak,  and 
may  not  reach  the  radial  vessels;  this  variety  occurs  frequently  in 
mitral  disease  and  in  the  cumulative  effects  of  digitalis.  The  trigeminal 
heart  beat  and  pulse  are  similar,  except  that  each  group  comprises  three 
beats.  They  usually  indicate  heart  weakness,  (g)  The  puhus  para- 
doxus, intermitting  with  inspiration,  has  been  considered  under  con- 
cretio  cordis  (v.  Pericarditis).  It  may  be  marked  in  young  persons, 
in  convalescence,  neurasthenia  and  brain  disease. 


ANGINA  PECTORIS. 

Angina  pectoris  (stenocardia,  breast-pang)  was  first  described  by 
Heberden  and  then  by  Hunter.  Ed\\ard  Jenner  first  recognized  the 
connection  between  angina  pectoris  and  coronary  disease.  By  far  the 
best  treatises  are  Osier's  classic  on  Angina  Pectoris  and  Allied  States, 
and  Neusser's  Heft  2,  Ausgeivdhlte  Kapitel  der  Jclinischen  Symptom- 
atologie. 

Definition. — An  arteriosclerotic  cardiopathy,  characterized  (a)  by 
paroxysms  of  excruciating  pain  over  the  heart,  which  radiates  to  the 
neck  and  arms,  (b)  by  mental  anguish,  a  sense  of  dying,  and  (c)  fre- 
quently by  sudden  death. 

Etiology  and  Pathology. — The  chief  and  practically  constant  patho- 
logical finding  is  arteriosclerosis  involving  the  heart  muscle  directly  by 
coronary  atheroma,  or  indirectly  by  plaques  in  the  aorta  at  the  coronary 
orifices.  The  aorta  is  often  atheromatous  without  coronary  involve- 
ment and  coronary  sclerosis  is  frequent  without  much  change  in  the 
aorta. 

Though  it  is  usually  described  under  cardiac  neuroses,  its  proper 
place  is  under  arteriosclerosis.  It  is  notable  that  atheroma  is  frequent 
and  angina  pectoris  is  rare.  The  etiology  is  that  of  arteriosclerosis 
{q.  v.),  syphilis,  gout,  alcohol,  contracted  kidneys,  sometimes  infections 


ANGINA  PECTORIS  459 

such  as  rheumatism  or  influenza.  A  history  of  its  occurrence  through 
several  generations  of  a  family  is  sometimes  elicited.  It  occurs  chiefly 
in  men  (80  4o  90  per  cent,  of  cases  or  more),  usually  after  the  fortieth 
year  (although  cases  in  the  second  decennium  have  been  reported)  and 
in  the  well-to-do  classes,  professional  men,  hard  workers,  and  luxurious 
livers.    Angina  is  far  more  common  in  private  than  in  hospital  practice. 

S3niiptoms. — Mode  of  Onset. — (a)  In  some  cases  the  onset  is 
gradual,  and  is  preceded  by  dyspnoea  (especially  when  dressing  or  un- 
dressing, lacing  the  shoes,  emptying  the  bowels,  sitting  up,  or  beginning 
to  exercise),  by  short  deep  respiration,  precordial  oppression,  pul- 
monary oedema,  bronchial  catarrh,  strong  beating  in  the  second  or 
third  left  interspaces,  and  diflficulty  in  moving  the  left  arm.  This 
cardiac  weakness  ("cardiac  asthma"),  is  follow^ed  by  genuine  angina. 
Heart  weakness  and  angina  are  coordinate  phenomena,  secondary  to 
coronary  disease,  (b)  In  other  cases  angina  is  the  first  important  symp- 
tom of  cardiac  disease.  It  is  excited  by  (i)  muscular  effort,  as  walking 
up  hill;  (ii)  mental  excitement, as  anger  or  coitus;  (iii)  chilling  or  bath- 
ing; (iv)  flatulent  dyspepsia  or  overloading  the  stomach,  which  may 
induce  the  attack  when  the  patient  is  quiet  or  just  going  to  sleep,  (c) 
Death  may  be  the  first  symptom. 

Paroxysm. — The  attack  itself  consists  of  (1)  sudden  agonizing  pain, 
which  is  lancinating  and  feels  like  an  iron  hand  squeezing  the  heart. 
Its  explanation  is  disputed  and  nearly  one  hundred  theories  have  been 
elaborated.  The  pain  emanates  from  the  cardiac  plexus  lying  behind 
the  aorta,  and  in  the  nerve  branches  from  it  to  the  coronary  arteries, 
whence  its  reflection  to  other  parts,  which  will  be  mentioned  later.  The 
best  explanation,  pathologically,  is  that  during  the  seizure  the  heart 
muscle  is  ischcemic  from  coronary  obstruction  or  possibly  from  super- 
induced spasm  of  the  vessel  (Allan  Burns,  Potain).  In  man  and  in  the 
horse,  atheroma  or  thrombosis  of  the  abdominal  aorta  or  its  branches 
to  the  legs,  shuts  off  the  blood  necessary  during  exertion ;  with  moderate 
exercise  the  collateral  circulation  is  sufficient,  but  prolonged  exertion 
produces  tingling,  cramps,  and  transient  paraplegia  ("intermittent 
claudication").  The  heart-pang  is  caused  by  an  analogous  coronary 
ischeemia  when  unusual  stress  is  thrown  on  the  diseased  coronaries. 
In  the  case  of  the  author's  father,  two  seizures  of  angina  were  followed 
by  "claudication,"  albuminuric  retinitis  and  the  Adams-Stokes  syn- 
drome; the  abdominal  aorta  was  clearly  to  be  seen  and  felt  as  a  hard 
uneven  rigid  tube.  The  "unutterable"  pain  is  usiiaWy  substernal  and 
radiates  to  the  left  shoulder,  neck  and  arm.  Irradiation  may  be 
observed  to  the  chin,  ear,  jaw,  occiput,  larynx,  and  even  to  the  gall- 
bladder and  renal  region,  spine,  stomach,  left  leg  and  testis  (which  may 
swell).  In  aortic  disease,  pain  is  propagated  to  the  first  four  dorsal 
areas;  in  angina  it  also  reaches  the  cervical  and  lower  dorsal  areas. 
Pain  along  the  idnar  nerve  to  the  fingers  may  precede  the  angina; 
it  is  usually  associated  with  some  motor  weakness  and,  in  Eichhorst's 
remarkable  case,  with  ulnar  atrophy.  Numbness  or  hyperaesthesia  of 
the  arm,  chest,  or  mammary  regions  is  frequent.     The  anginal  pain 


460  DISEASES  OF  THE  CIRCULATION 

produces  vasomotor  symptoms,  such  as  great  pallor,  low  temperature, 
and  profuse  sweating.  The  patient  may  fall,  perhaps  in  a  fatal 
syncope,  or  more  often  may  support  himself  for  a  few  seconds  or 
minutes  until  the  paroxysm  has  passed. 

(2)  The  mental  anguish,  the  angor  animi,  which  was  first  recognized 
by  Latham,  is  the  second  element  of  the  seizure  and  consists  of  a  sense 
of  dying,  with  great  anxiety,  complete  consciousness,  immobile  attitude, 
and  perhaps  inability  to  articulate. 

(3)  The  danger  of  sudden  death  is  the  third  element.  Death  may 
come  without  pain,  in  syncope  (syncope  anginosa)  in  the  first  seizure, 
after  subsequent  seizures  which  may  occur  years  after  the  initial 
paroxysm,  or  after  constantly  and  closely  repeated  attacks  (the  etat 
angineuse  of  Houchard,  which  is  analogous  to  the  status  epilepticus). 
Osier  has  called  the  anterior  branch  of  the  coronary  artery  the  "artery 
of  sudden  death. "  Death  in  angina  is  analogous  to  death  from  experi- 
mental injury  to  Kronecker's  point  in  the  septum.  It  usually  occurs  in 
the  second  or  third  attack. 

Other  Signs  and  Symptoms. — ^The  heart  is  variable,  is  sometimes 
normal  in  rate  and  strength,  and  again  shows  a  tense  or  weak,  slow  or 
rapid,  or  irregular  pulse.  The  left  radial  may  be  smaller  than  the  right. 
A  slow  pulse  usually  results  from  partial  "  heart-block. "  Dunin  found 
the  arterial  pressure  low  in  45  per  cent,  and  high  in  20  per  cent,  of  his 
cases.  Delirium  cordis,  gallop-rhythm,  and  shortening  of  the  long 
pause,  are  but  signs  of  cardiac  fatigue. 

The  second  aortic  tone  is  often  loud  and  metalhc;  a  rough  or  blowing 
systohc  (and  sometimes  a  diastolic)  murmur  is  heard  over  the  aorta, 
which  is  sometimes  dilated;  and  the  left  ventricle  may  be  dilated,  thus 
sometimes  relieving  the  attack  by  relative  mitral  leakage  (Broadbent 
and  Musser).  These  incidents  are  simply  evidences  of  arteriosclerosis 
and  its  sequences.  Constitutional  disturbance  very  frequently  occurs, 
as  disturbance  in  nutrition,  loss  in  weight,  color,  and  physical  endur- 
ance. Dyspnoea  is  not  a  part  of  angina  pectoris,  but  is  solely  sympto- 
matic of  heart  insufficiency.  Involuntary  evacuations  or  unsuccessful 
straining  at  stool  are  not  very  frequent.  The  urine  is  often  pale  and 
abundant  after  the  seizure.  Dysphagia,  singultus  or  gastric  symptoms 
are  due  to  sympathetic  participation  of  the  pneumogastric  and  phrenic 
nerves. 

Diagnosis. — When  the  attack  is  typical  and  severe,  there  is  little 
difficulty  in  making  a  diagnosis.  Mild  or  early  attacks  may  be  confused 
with  cardiac  asthma,  because  angina  may  be  preceded  by  cardiac 
distress,  or  associated  with  it.  Seizures  of  angina  involving  the  ab- 
domen (angina  abdominis)  or  legs  (angina  cruris)  are  easily  mistaken 
unless  the  case  is  closely  watched ;  these  forms  may  appear  first  or  may 
alternate  with  the  more  usual  type — angina  pectoris.  The  classical 
picture,  together  with  hardness  of  the  arteries  and  atheroma  of  the 
aorta  or  aortic  valves,  makes  the  diagnosis  practically  certain.  The 
respiration  is  essentially  normal  during  the  attack.  Atheroma  with 
cardiac  asthma  is  not  angina  pectoris. 


ANGINA  PECTORIS 


461 


Pseudo-angina  (Latham  and  Walshe)  is  the  most  frequent  cause  of 
diagnostic  error.  Its  varieties  are  (a)  nervous  pseudo-angina,  which 
occurs  in  cases  of  neurasthenia  and  hysteria,  in  other  neuroses,  and  in 
the  crises  of  tabes  (which  in  Oppenheim's  case  was  due  to  vagus 
neuritis).    Huchard's  widely  quoted  table  is  substantially  as  follows: 


True  Angina- 


-PSEUDO- ANGINA. 


Most  common  in  men  between  forty  and 
fifty. 

Paroxysms  induced  by  exertion,  etc.; 
diurnal;    few  in  number. 

Pain  intense,  of  short  duration,  pre- 
cordial, inarticulate;  immobile  atti- 
tude; sensation  of  cardiac  compres- 
sion. 

No  nervous  symptoms. 

Vasomotor  form  rare. 

Prognosis  grave  or  fatal. 

Lesions:  from    coronary   sclerosis. 

Arterial  medication. 


Commonest  in  women,  at  any  age. 


Spontaneous;      often     nocturnal     and 
periodic ;   frequent . 

Less  severe,  lasting  hours;    epigastric; 
agitation,  activity;  sensation  of  disten- 
tion. 


Neurasthenic  or  hysterical  stigmata. 

Common. 

Never  fatal. 

From  neuralgia. 

Neuralgic  medication  successful. 


(b)  Vasomotor  angina  (Nothnagel)  which  is  not  uncommonly  at- 
tended by  vasomotor  spasm,  coldness  and  numbness  in  the  extremities, 
a  feeling  of  faintness  and  great  pain  in  the  heart.  It  may  be  reflex  in 
origin. 

(c)  The  toxic  pseudo-angina  (Beau,  Graves  and  Stokes)  is  due  to 
coffee,  etc.,  but  especially  to  tobacco.  Vasomotor  symptoms,  amau- 
rosis, dyspepsia,  weak,  rapid,  or  irregular  heart  action,  palpitation,  and 
anginal  pain  are  common.  Functional  angina  from  tobacco,  which 
results  according  to  Huchard  from  coronary  spasm,  heals  when 
tobacco  is  withheld;  but  actual  coronary  disease,  due  to  tobacco  and 
other  heart  poisons,  is  not  curable,  (d)  The  crises  of  tabes  and  pre- 
cordial pain  due  to  brachial  neuritis,  vagus  involvement  or  gout,  etc., 
may  be  difficult  to  diagnosticate. 

The  prognosis  is  self-evident.  Death  is  frequent.  In  one  instance 
the  patient  lived  forty  years.    Few  clear  recoveries  are  reported. 

Treatment. — The  treatment  concerns  (a)  the  etiology,  in  which 
arteriosclerosis  is  the  essential  factor.  Vierordt  advises  that  the  possi- 
bility of  syphilis  should  always  be  considered.  Gout  and  diabetes 
necessitate  appropriate  diet  and  therapy,  as  colchicum.  Attention 
must  be  directed  to  the  question  of  stimulants.  Aside  from  syphilis, 
the  iodides  are  valuable  and  should  be  given  two-thirds  of  the  time,  for 
months  and  years.  Small  amounts  are  frequently  tolerated  less  well 
than  10  or  20  grain  doses.  Care  in  their  use  is  necessary  in  nephritis, 
and  even  when  they  are  well  diluted  gastric  disorder  may  result  and 
possibly  induce  an  attack  of  angina.    Nitroglycerine  or  its  derivatives 


462  DISEASES  OF  THE  CIRCULATION 

are  indicated  in  the  intervals,  in  doses  of  gr,  fho  to  gg  four  or  more 
times  daily,  but  it  should  be  remembered  that  its  effects  last  less  than 
an  hour.  It  may  cause  headache,  flushing,  or  (in  larger  doses)  cyanosis 
or  pallor,  muscular  relaxation,  dyspnoea  and  irregular  pulse.  Erythrol 
tetranitrate  in  doses  of  gr.  ss.  t.  i.  d.  has  a  more  lasting  effect  than 
nitroglycerine.  These  vasodilators  will  be  again  considered  under 
Arteriosclerosis,  (b)  The  causes  precipitating  paroxysms.  Pro- 
phylaxis should  be  maintained  regarding  (i)  exertion,  (ii)  excitement, 
worry,  (iii)  coitus,  (iv)  chilhng,  (v)  constipation,  and  (vi)  dyspepsia; 
late  suppers  and  foods  favoring  flatulency  should  be  avoided,  and 
a  light  evening  meal  should  be  taken.  The  patient  should  be  provided 
with  a  mixture  of  aromatics  in  order  to  dispel  gastric  flatulency;  a  single 
dose  is  contained  in  the  following: 

Spiritus  ammoniae  aromatici oss. 

Spiritus  chloroformi , 3ss. 

Spiritus  glycerylis  nitratis gtt.  i. 

Spiritus  setlieris  compositi 3ss. 

M.  et  S. — To  be  taken  in  hot  water. 

(c)  The  paroxysm.  Amyl  nitrite  was  first  advised  by  Brunton;  it  is 
an  analgesic  and  a  vasodilator ;  the  patient  should  carry  pearls  of  the 
drug,  which  were  invented  by  Solger  and  contain  three  minims  of  the 
remedy.  They  often  operate  powerfully  and  instantaneously,  though 
sometimes  they  are  useless.  It  may  be  better  to  have  the  patient  chew 
a  hypodermic  tablet  of  nitroglycerine  grain  iho,  for  the  physician  but 
rarely  sees  the  attack.  Some  member  of  the  patient's  family  should  be 
taught  how  to  give  a  hypodermic  injection  of  morphine.  Morphine  and 
chloroform  inhalations  have  been  held  dangerous,  especially  when 
brain  trouble  exists,  as  is  sometimes  the  case  in  the  Adams-Stokes  triad. 
Nevertheless  they  must  be  used  in  some  cases.  Yeo  called  attention 
to  the  large  doses  of  morphia  required  and  tolerated  by  subjects  having 
angina,  (d)  Cardiac  weakness,  which  is  treated  by  diffuse  stimulants, 
such  as  ammonia,  camphor,  alcohol  and  strychnine.  When  arterial 
tension  is  low,  digitahs  may  be  administered  between  paroxysms: 

Tr.  digitalis Oiv. 

Tr.  strophanthi 3ij. 

Tr.  Valerianae q.s.  ad  oiv. 

M.  et  S. — One  teaspoonful  after  meals. 

Vierordt  says  that  morphine  should  be  carried  in  one  hand  and 
stimulants  in  the  other.  Coffee  is  said  to  be  prophylactic  against  cardiac 
weakness  and  the  paroxysms.  Pseudo-angina  is  treated  according  to 
the  type.     Electricity  and  arsenic  are  valuable. 


ARTERIOSCLEROSIS  463 

DISEASES  OF  THE  ARTEEIES. 

ARTERIOSCLEROSIS. 

Synonyms. — Atheroma,  arteriocapillary  fibrosis  (Gull  and  Sutton), 
endarteritis  deformans  (Virchow),  angiosclerosis  (Thoma). 

Definition. — A  regressive  change,  evidenced  first  by  malnutrition  in 
the  walls  of  the  large  or  small  vessels  and  later  by  compensatory 
thickening,  either  localized  or  diffuse. 

Etiology. — 1.  Age. — Arteriosclerosis  is  the  essential  element  in 
senile  involution,  although  some  individuals  attain  their  hundredth  year 
with  no  arterial  change.  Though  usually  found  after  the  fiftieth  year, 
hereditary  influences  or  certain  infections,  as  syphilis,  may  develop 
hard  arteries  between  the  twentieth  and  fortieth  year.  Thoma  fre- 
quently found  a  moderate  degree  of  hardness  after  the  thirty-sixth  year. 
In  adolescence  or  even  in  infancy  it  is  sometimes  found  as  a  result  of 
the  acute  infections;  Chiari  found  it  in  27  per  cent,  of  those  under  25 
years. 

2.  Sex. — Eighty  per  cent,  of  cases  occurs  in  men,  from  causes  to  be 
enumerated  below.  In  women  it  usually  occurs  a  decade  later  than  in 
men.  In  factory  women  over  fifty,  Jusserand  found  even  a  larger  per- 
centage than  in  men. 

3.  Arterial  Poisons. — Chronic  alcoholism  causes  25  per  cent,  of  all 
cases  (Edgren) ;  it  is  not  known  how  the  arterial  poisons  operate;  they 
do  not  raise  arterial  pressure;  coffee,  tea,  and  tobacco  (which  is  said  to 
affect  especially  the  coronary  vessels),  are  causative  factors.  Angio- 
sclerosis has  been  produced  experimentally  by  adrenalin. 

4.  Overwork. — This  is  second  only  to  alcohol  in  importance.  Phy- 
sical exertion  brings  one-third  of  the  circulating  blood  to  the  muscles, 
thus  lowering  the  tension  in  other  vessels  (v.  i.  Thoma's  Theory), 
According  to  an  older  theory  exertion  raises  arterial  tension. 

5.  Poisons  Produced  Within  the  Body  by  Perverted  Metabolism. — ■ 
Interstitial  7iephritis  bears  a  threefold  relation  to  arteriosclerosis:  (a) 
it  results  from  diffuse  arterial  hardening;  (b)  it  raises  arterial  pressure 
mechanically  (Traube)  by  increased  peripheral  resistance  in  the  arter- 
ioles, or  by  alteration  in  the  quality  of  the  blood  (Bright);  (c)  both 
processes  are  coordinate  to  a  common  cause.  Gout  certainly  leads  to 
arteriosclerosis.  Diabetes  bears  a  double  relation,  being  either  a  rather 
rare  result  of  arteriosclerosis  of  the  pancreas  (Fleiner),  and  possibly  of 
the  brain  (Grabe),  or  itself  causing  arterial  hardening.  High  living, 
overeating ,  obesity,  and  overindulgence  in  meat  may  be  included  under 
this  head. 

6.  Specific  Infections. — Edgren  and  Camac  consider  syphilis  of  first 
etiological  importance  in  33  per  cent,  of  the  cases.  It  operates  by 
chronic  toxsemia  and  endarteritis.  Tuberculosis  (in  16  per  cent.)  may 
produce  changes  in  the  vessels;   for  instance,  tuberculous  meningitis 


464  DISEASES  OF  THE  CIRCULATION 

may  attack  them  from  the  perivascular  lymphatics,  especially  those 
about  the  middle  cerebral  artery  and  its  branches.  Typhoid,  rheuma- 
tism, influenza,  scarlatina  and  other  infections  are  held  by  French 
writers  to  have  some  bearing  on  vascular  sclerosis  and  endarteritis. 
Oppenheimer  has  recently  described  arteriosclerosis  in  children  nine 
and  ten  years  old,  obviously  due  to  acute  infections. 

7.  Other  Causes. — Nervous  factors  (worry,  high  tension,  neuras- 
thenia) cause  variations  in  blood  pressure.  Excessive  brain  effort 
tends  toward  cerebral  localization  precisely  as  digestive  excesses  may 
develop  changes  in  the  mesenteric  vessels,  just  as  working  with  the 
arms  (as  in  the  case  of  butchers)  may  develop  changes  in  the  brachials, 
and  as  excessive  walking  may  produce  arteriosclerosis  in  the  femorals. 
Extreme  heat,  as  in  the  work  of  bakers  and  stokers,  is  thought  to  induce 
sclerosis. 

Pathogenesis  and  Pathology. — (A).  Thoma considers  angiosclerosis 
a  compensatory  process  which  follows  widening  of  the  vessels  and 
alteration  of  the  blood.  To  restore  the  caliber  of  the  widened  vessels, 
the  tunica  media  contracts,  or  when  it  cannot  contract,  the  vessel 
increases  in  thickness  by  growth  of  the  subendothelial  connective 
tissue  of  the  intima.  Thus  in  the  foetus  there  is  no  connective  tissue 
in  the  tunica  intima,  but  it  appears  when  the  foetal  circulation  changes 
at  birth,  new  areas  of  circulation  being  opened  up.  All  bloodvessels 
have  a  nervous  supply  ending  in  the  Vater-Pacini  bodies.  They  respond 
to  persistent  low  pressure,  or  dilatation,  by  increased  proliferation  of  the 
connective  tissue.  Thoma  observed  arteriosclerosis  develop  in  cases 
of  experimentally  produced  aortic  insufficiency.  (B).  Others  regard 
arteriosclerosis  as  due  to  inflammation  in  the  nutrient  vessels,  the  vasa 
vasorum,  leading  to  growth  of  connective  tissue  (Huchard,  Koester, 
Hipp,  Martin),  i.  e.,  mesarteritis  and  periarteritis.  When  arteriosclero- 
sis is  seen  in  vessels  with  no  vasa  vasorum,  it  must  be  a  simple  regression 
or  degeneration. 

Conceptions  of  its  morbid  anatomy  differ  widely,  atheroma  of  the 
aorta  and  endarteritis  or  arteriocapillary  fibrosis  being  sometimes 
described  under  separate  headings,  but  the  difference  is  rather  ana- 
tomical than  pathological.  Large  vessels,  such  as  the  carotid,  contain 
more  elastic  than  muscular  tissue,  but  the  small  vessels  are  largely 
muscular.  Two  main  forms  are  distinguished,  (1)  the  diffuse,  and  (2) 
the  nodular.  Without  distinction  as  to  form,  Rokitansky  found  that 
arteriosclerosis  occurred  in  the  following  order  of  frequency :  ascending 
aorta,  arch,  thoracic,  abdominal  aorta,  splenic,  iliac,  femoral,  coronary 
(next  after  the  aorta,  according  to  Huchard  and  Sansom),  cerebral, 
uterine,  brachial,  spermatic  and  carotid  arteries.  It  is  rare  in  the 
gastric  and  in  the  mesenteric  and  hepatic  vessels  and  least  frequent 
in  the  pulmonary  trunk.  Bergmann  found  the  two  varieties  in  the 
following  percentages : 


ARTERIOSCLEROSIS  465 

Nodular 
Diffuse  Form.       (nodose)  Variety. 

Per  cent.  Per  cent. 

^ladial      89  2 

Ulnar 88  8 

Tibial 87  8 

Popliteal      64  25 

Splenic 64  17 

Femoral 58  14 

Axillary 53  16 

External  iliac      ....        49  15 

Brachial 49  9 

Subclavian 45  43 

External  carotid     ...        44  22 

Cerebral  .......        40  43 

Internal  carotid      ...       28  60 

Ascending  aorta.    ...       19  56 

Common  carotid     ...        10  69 

Abdominal  aorta    ...         0  75 

(Both  forms  may  coexist  in  the  same  vessel). 

It  will  be  noted  that  where  the  diffuse  variety  is  most  frequent  the 
nodular  form  is  least  observed  and  that  the  converse  is  true.  The 
diffuse  form  is  most  frequent  in  the  extremities  where  arterial  tension  is 
most  variable  and  more  collateral  circulation  prevails;  the  nodose  form 
is  most  common  in  the  aorta  and  its  primary  branches,  but  is  also  seen 
in  the  circle  of  Willis,  where  arterial  pressure  varies  greatly  (Meynert). 

To  the  naked  eye  the  intima  may  be  normal  and  smooth  but  most 
often  is  uneven  and  thickened.  Small  gelatinous  or  yellowish  fatty 
areas  are  seen  which  though  at  first  circumscribed  often  fuse  into  large 
plaques;  they  occur  where  arterial  pressure  is  greatest,  as  in  certain 
places  in  the  aortic  arch  (See  Aneurysm),  or  where  the  vessel  divides  or 
gives  off  branches,  as  the  subclavian  or  intercostal  branches.  These 
plaques  of  atheroma  or  nodular  arteriosclerosis  represent  nature's 
effort  to  fill  out  areas  of  degeneration  and  dilatation  and  thus  make 
even  the  caliber  of  the  vessel.  Microscopically  the  intima  may  be 
increased  three  or  four  fold  from  swelling  of  its  tissue,  increase  of 
connective  tissue  and  round-cell  infiltration.  Granular  detritis,  fatty 
needles  and  cholestearin  plates  are  seen  in  the  atheroma  plaques,  a 
name  indicating  their  pulpy,  grumous  appearance.  Formerly  they 
were  wrongly  called  atheromatous  abscesses.  An  atheromatous  area 
rupturing  into  the  lumen  produces  the  atheromatous  ulcer,  which  may 
cause  embolism,  thrombosis  or  occulsion.  Secondary  deposit  of  car- 
bonate or  phosphate  of  lime  in  the  atheromatous  areas  leads  to  calcifi- 
cation of  the  arteries  or  may  produce  rough  areas  in  the  aorta  which 
break  on  manipulation  or  if  handled  carelessly  may  cut  the  finger. 
The  lumen  of  the  smaller  vessels  is  often  decreased  or  obliterated 
(endarteritis  obliterans).  The  middle  and  outer  coats  of  the  smaller 
vessels  are  at  times  thickened  from  hyaline  degeneration  and  fibrous 
tissue;  the  muscular  coat  may  waste  and  all  elastic  tissue  may  dis- 
appear; the  essential  changes  are  those  in  the  elastic  tunic.  In  the 
larger  vessels  dilatation  or  even  aneurysm  may  develop  where  thick- 
ening of  the  intima  fails  to  protect  the  vessel  wall. 

30 


466  DISEASES  OF  THE  CIRCULATION 

The  general  results  of  arteriosclerosis  are  (1)  vascular,  and  consist  of 
loss  of  arterial  elasticity,  deformity,  tortuosity,  obliteration,  aneurysm 
and  high  arterial  tension,  and  (2)  visceral,  and  occur  in  the  heart,  brain, 
kidney,  and  other  organs  {v.  i.). 

Sclerosis  in  the  'pulmonary  artery  is  most  common  in  the  stasis  and 
in  the  increased  pulmonary  tension  of  mitral  lesions  and  emphysema; 
aside  from  these  cases,  the  older  writers  maintained  that  it  was  always 
the  result  of  general  arteriosclerosis.  The  rare  cases  of  Rhomberg, 
Klob  and  Neusser  have  shown  that  pulmonary  atheroma  may  occur 
alone,  sometimes  mth  aneurysmatic  dilatation  of  its  branches  and 
with  pulmonary  regurgitation. 

The  term  angiosclerosis  (Thoma)  also  includes  phlebosclerosis  ,which 
frequently  accompanies  arteriosclerosis  and  sometimes  occurs  inde- 
pendently; it  is  most  often  seen  in  the  lower  extremities  and  sometimes 
in  the  lung  and  in  the  portal  tributaries  in  cases  of  liver  cirrhosis  or 
pylephlebitis. 

SjTiiptoms  and  Diagnosis. — In  diffuse  forms  there  may  be  no 
symptoms  i.  e.  the  process  is  latent.  When  it  is  local,  visceral  symptoms 
may  develop.    The  clincial  picture  is  extremely  variable. 

1.  The  peripheral  arteries  may  be  involved  alone  or  there  may  be 
changes  in  the  aorta  and  in  the  heart,  brain  and  kidneys.  The  small 
arteries  are  visible  and  appear  tortuous,  pulsating  and  lengthened,  as 
do  the  temporals  or  brachials  when  the  elbow  is  flexed  and  the  arm  is 
rotated  outward.  Lifting  the  arm  is  said  to  decrease  the  pulsation, 
while  this  maneovre  increases  it  in  cases  of  aortic  regurgitation.  A 
distinction  must  be  made  between  hardness  of  the  vessel  walls  and 
increased  arterial  tension,  although  both  conditions  usually  occur 
together.  The  normal  systolic  blood  pressure  measures  125  mm. 
(Strassburger,  Sahli,  Fellner)  and  the  diastolic  measures  29  mm. 
Dunin  holds  that  the  systolic  pressure  ranges  between  130  and  150 
mm.,  and  that  21  per  cent,  of  cases  of  arteriosclerosis  have  normal  or 
decreased  arterial  tension.  It  is  asserted  that  increased  arterial  tension 
precedes  actual  sclerosis  of  the  vessels  but  in  these  early  cases  it  is 
probable  that  some  angiosclerosis  has  already  developed.  Pressing  on 
the  radial  with  one  finger  should  obliterate  the  pulse  beyond  that  point 
if  the  arteries  are  not  sclerotic,  unless  there  is  an  anastomotic  or  recur- 

FiG.  28. 


Pulse  tracing  in  arteriosclerosis. 


rent  pulse  from  the  ulnar  to  the  radial  vessel;  this  source  of  error  is 
easily  eliminated  by  simultaneous  pressure  on  the  ulnar  vessel.  The 
wall  of  the  artery  is  firm,  hard,  often  uneven  or  nodular,  and  the  serial 
atheromatous  plaques  sometimes  feel  like  a  rosary  or  the  trachea  of  a 
goose.  In  extreme  instances  the  vessel  feels  calcareous — the  "pipe 
stem  artery. "    The  Roentgen  rays  clearly  show  the  arterial  change. 


ARTERIOSCLEROSIS  467 

The  pulse  is  hard  {'pulsus  durus),  retarded  (pulsus  tardus),  or  slow 
{pulsus  rarus);  it  rises  slowly  and  is  long  maintained  (p.  rotundus), 
the  vessel  is  firm  between  the  pulse  beats  (Broadbent),  the  elastic  wave 
is  lessened  or  absent,  the  tracing  has  a  rounded  or  flat  top,  and  the  pulse 
in  the  two  radials  may  differ  (pulsus  differens).  Marked  slowing  of 
the  pulse  calls  attention  to  the  coronary  vessels.  The  bigeminal  pulse 
is  most  rare  unless  there  are  heart,  coronary,  or  brain  changes.  In  some 
cases,  either  from  vessel  obliteration  or  because  the  walls  are  absolutely 

Fig.  29. 


Pulse  tracing  in  extreme  arteriosclerosis  (Sahli). 

rigid,  the  pulse  cannot  be  felt.  Very  slight  pressure  on  the  vessels  often 
elicits  a  systolic  murmur  (Litten).  The  right  radial  is  normally  larger 
and  more  often  shows  changes  than  the  left.  It  must  be  remembered 
that  changes  may  occur  in  internal  vessels  without  change  in  the 
radials  (and  conversely). 

2.  There  may  be  heart  changes,  (a)  Simple  hypertrophy  of  the  left 
ventricle  may  occur,  with  heaving  apex,  loud  second  aortic  tone,  tense 
pulse,  and  thickness  of  the  arteries,  which  lead  to  a  certain  and  immedi- 
ate diagnosis.  Some  "  consensual "  right  heart  hypertrophy  is  common 
because  of  anastomosis  between  the  ventricular  muscular  fibers  or 
because  of  stasis  in  the  lungs  or  emphysema.  Those  cases  in  which 
there  is  increased  tension  in  the  aorta  without  increased  tension  in  the 
radials  are  more  difficult  of  diagnosis.  The  heart  is  not  hypertrophied 
in  all  cases  nor,  according  to  Rhomberg,  in  the  majority  of  cases; 
hypertrophy,  he  maintains,  does  not  necessarily  follow  arteriosclerosis 
in  the  extremities  or  brain,  but  most  often  occurs  when  the  splanchnic 
vessels  are  involved;  Hasenfeld  also  believes  that  cardiac  hypertrophy 
only  occurs  when  these  vessels  and  the  aorta  are  sclerosed.  The  apex 
may  sink  outward  and  to  the  left  when  the  patient  sits,  from  relaxation 
and  lengthening  of  the  aorta  (Traube).  (b)  Hypertrophy  plus  dilata- 
tion, with  heart  insufficiency,  dyspnoea,  scanty  urine,  and  hydrotho- 
rax,  is  very  common.  When  the  patient  in  this  stage  has  a  systolic 
murmur,  a  wrong  diagnosis  of  mitral  insufficiency  may  be  made.  Inter- 
stitial nephritis  (q.  v.)  may  be  the  cause,  in  part  at  least,  of  the  hyper- 
trophy and  dilatation.  (Edema  is  not  frequent.  Gallop-rhythm  is 
uncommon  without  coincident  coronary  or  renal  disease.  The  heart 
muscle  may  show  various  changes,  such  as  atrophy,  myocarditis, 
myofibrosis,  myomalacia  cordis,  the  cor  retiale,  senile  heart,  heart 
aneurysm,  angina  pectoris,  coronary  embolism,  cardiac  asthma,  fatty 
heart,  and  arrhythmia,  or  sudden  death  may  occur.  Two  forms  of 
visceral  sclerosis  may  be  distinguished:  (a)  inflammatory,  occurring 
about  the  vessels,  and  (b)  dystrophic  (malnutritive)  sclerosis,  which  is 
often  somewhat  distant  from  the  vessel  involved;  the  visceral  sclerosis 
is  best  illustrated  by  the  heart  changes,  such  as  myofibrosis  or  myo- 
malacia cordis,  induced  by  coronary  atheroma. 


468  DISEASES  OF  THE  CIRCULATION 

3.  In  the  aorta  dilatation  may  occur,  giving  slight  dulness  in  the 
second  {and  third)  right  intercostal  spaces;  this  is  confirmed  by  the 
fluoroscope;  the  aorta  may  be  felt  in  the  jugulum  or  abdomen.  The 
normal  aorta  may  be  felt  in  these  situations  when  the  heart  action  is 
strong,  but  when  there  is  atheroma,  plaques  or  even  a  crackling  may 
sometimes  be  felt.  The  subclavian,  or  innominate  arteries  may  be 
felt  even  through  their  entire  length  when  the  aorta  is  dilated.  A 
short  systolic  murmur  over  the  aorta  often  results  from  atheromatous 
roughening  or  dilatation,  and  the  second  aortic  tone  is  then  accentuated 
and  metallic.  Its  vibration  may  sometimes  be  felt;  when  much 
emphysema  is  present  it  is  best  heard  in  the  jugulum.  The 
accentuation  may  be  caused  by  increased  tension,  widening,  or 
rigidity  of  the  aorta.  The  murmur  and  sharp  tone  are  often  heard  in 
the  neck  and  back.  Aside  from  nervous  sensations,  a  burning  pain 
back  of  the  sternum  may  indicate  involvement  of  the  outer  coat  of  the 
vessel.  Atheroma  of  the  arch  may,  by  downward  extension,  cause 
aortic  stenosis  or  more  often  aortic  regurgitation. 

4.  Renal  findings  are  next  in  frequency.  The  kidneys  are  often 
contracted  (the  senile  arteriosclerotic  kidney  and  the  genuine  con- 
tracted kidney).  The  discussion  of  the  question  whether  the  renal 
findings  are  primary  or  secondary  is  a  separate  literature  in  itself  (see 
Interstitial  Nephritis).  The  urine  may  be  increased  as  a  result  of 
simple  increase  in  the  blood  pressure. 

5.  Brain  symptoms  are  next  in  importance.  Syncope,  vertigo, 
insomnia,  headache,  tinnitus,  neurasthenic  symptoms,  transient 
aphasia  or  hemiplegia  are  difficult  to  explain,  though  they  are  said  to 
be  caused  by  transient  ischsemia.  Brain  hemorrhage  and  miliary 
aneurysms  are  frequent  sequences.  Softening  of  the  brain  (encephalo- 
malacia)  results  from  embolism  or  thrombosis  of  the  cerebral  arteries. 
Brain  atrophy,  dementia  (cortical  sclerosis),  epileptic  seizures  and  the 
Adams-Stokes  triad  have  been  attributed  to  cerebral  atheroma.  Vas- 
cular brain  lesions  occur  fairly  often  in  cases  which  show  arteriosclero- 
sis in  the  extremities  and  temporal  vessels,  though  sclerosis  of  the  aorta, 
coronary,  or  splanchnic  vessels  occurs  more  often  without  peripheral 
angiosclerosis. 

Charcot's  claudication  intermittente  (Erb's  dysbasia  intermittens 
angiosclerotica,  intermittent  limping,  angina  cruris)  occurs  especially 
in  nervous  or  neurasthenic  subjects.  It  is  due  to  atheroma  in  the  ab- 
dominal aorta  and  its  branches  in  the  limbs.  It  is  seen  in  abdominal 
aneurysm  in  the  horse.  Erb,  reviewing  127  cases  in  1904,  found  that  94 
per  cent,  were  in  men  over  40  years  of  age;  heredity  is  sometimes 
causal:  33  per  cent,  were  Jews;  syphilis  (in  23  per  cent.)  was  less 
frequently  causal  than  tobacco;  alcohol  was  not  proven  an  etiological 
factor;  most  cases  developed  in  the  upper  classes.  Pain,  parsesthesise, 
and  sometimes  local  cyanosis,  occur  in  the  legs,  which  "give  way" 
after  moderate  exertion.  The  legs  are  most  comfortable  when  depend- 
ent. The  dorsalis  pedis,  sometimes  also  the  tibial  and  femoral  vessels, 
usually  cannot  be  felt.     Gangrene  may  result. 


ARTERIOSCLEROSIS  469 

Some  of  the  vasomotor  neuroses — as  erythromelalgia,  Reynaud's 
disease,  acroparsesthesia — and  some  forms  of  neuritis  and  neuralgia 
are  sometimes  associated  with  angiosclerosis. 

6.  The  gastro-intestinal  symptoms  probably  rank  next  in  frequency. 
Hasenfeld,  Huchard,  Allbutt,  Litten,  Edgren  and  others  have  described 
dyspepsia,  round  ulcer,  arteriosclerotic  gastritis,  gastro-intestinal 
hemorrhages,  intestinal  perforation  and  ulceration.  Severe  abdominal 
pain  (angina  abdominis)  has  attracted  some  attention  lately;  it  is  due, 
as  is  angina,  to  anaemia  (Oertner's  intermittent  claudication  of  the  ab- 
dominal vessels,  Schiitzler's  intermittent  dysperistalsis) ;  it  develops  in 
two  or  three  hours  after  eating,  and  is  often  accompanied  by  dyspnoea. 
Abdominal  angina,  in  the  writer's  experience,  is  rather  often  associated 
with  angina  pectoris  and  angina  cruris;  in  three  cases  these  conditions 
appeared  alternately. 

7.  The  retinal  vessels  are  not  infrequently  embolized,  narrowed,  or 
aneurysmatic,  which  lead  to  softening,  hemorrhage,  and  exudation. 

8.  In  the  respiratory  tract,  emphysema  is  common  and  is  sometimes 
regarded  as  a  compensatory  effort.  The  breathing  is  often  somewhat 
irregular.  Haemoptysis  is  referable  to  stasis,  infarction,  or  possibly  to 
atheroma  of  the  pulmonary  arterioles. 

9.  In  the  peripheral  vessels  the  so-called  spontaneous  or  senile 
gangrene  results  from  obliterating  endarteritis.  Thrombosis  or  em- 
bolism may  occur  in  the  aorta,  brain,  or  in  the  coronary,  pulmonary, 
mesenteric,  pancreaticoduodenal  and  other  arteries. 

10.  The  general  nutrition  varies.  Some  writers  distinguish  between 
(a)  a  plethoric  type,  which  occurs  in  elderly  individuals  and  the  symp- 
toms of  which  are  good  color,  wide  vessels,  increased  thirst,  hemor- 
rhages from  the  nose,  increased  urine,  respiratory  catarrh,  profuse 
sweats,  muscular  rheumatism,  headache,  enlargement  of  the  liver, 
emphysema,  tense  pulse,  thick  bloodvessels  and  marked  hypertrophy 
of  the  heart;  and  (6)  an  ancemic  type,  with  chlorotic  habitus,  anorexia, 
dyspepsia,  few  external  vascular  findings,  dilated  heart,  and  endarter- 
itis. This  type  occurs  in  individuals  between  30  and  50  years  of  age. 
French  writers  speak  of  a  cachexie  arterielle,  in  which  the  pallor  is 
distinguished  from  the  dusky  anaemia  of  cardiac  disease.  Alfred  Sten- 
gel has  noted  that  the  anaemia  is  more  often  apparent  (pseudo-anaemia) 
than  real. 

Prognosis. — The  prognosis  is  relatively  unfavorable,  because  the 
symptoms  are  frequently  latent  until  the  process  is  well  established  or 
far  advanced.  In  the  early  stages  arteriosclerosis  may  be  arrested  or 
may  remain  stationary  for  a  long  period,  but  there  is  constant  danger 
of  apoplexy,  angina  pectoris,  myocardial  paralysis,  "heart  block," 
heart  rupture,  or  uraemia.  It  is  a  most  common  finding  after  death 
from  acute  infections,  so  that  many  deaths  attributed  to  acute  affections 
are  more  properly  deaths  from  arteriosclerosis.  Increased  blood  pres- 
sure may  overcome  moderate  obstruction.  The  prognosis  is  most 
favorable  in  angiosclerosis  of  the  peripheral  vessels,  and,  as  a  rule,  is 
rather  unfavorable  in  atheroma  of  the  aorta,  because  of  the  danger  of 


470  DISEASES  OF  THE  CIRCl'LATIOX 

coronary  disease  and  aneurysm.  Intestinal  hemorrhage  is  ominous. 
A  slow  pulse  is  less  favorable  than  arrhythmia  and  moderate  increase 
in  rate.    The  plethoric  form  is  less  dangerous  than  the  anaemic. 

Treatment. — Prophylaxis  regarding  the  etiological  factors  and  the 
patient's  mode  of  life  is  most  important.  Alcohol  and  tobacco  should 
be  forbidden,  iodides  should  be  given  in  s^-philis,  the  diet  should  be 
regulated  in  diabetes,  colchicum  should  be  given  in  gout,  etc.  In  early 
cases  the  process  may  sometimes  be  arrested.  IMany  cases  seem  to  im- 
prove on  a  milk  diet,  although  Rumpf  claims  that  many  of  the  salts 
ingested  are  deposited  in  the  arteries.  He  found  that  milk  sufficient  to 
meet  the  needs  of  metabolism  fTOg  or  2,175  c.c.j  for  24  hours  contained 
over  one  dram  (5  gramsj  of  calcium  and  magnesium.  Iodide  of  potash 
has  been  advised,  especially  by  Huchard.  who  gives  1  to  15  to  45 
grains  dailv  for  twentv  davs;  then  after  ten  davs  intermission,  nitro- 
glycerine  is  used.  (SeeAxGiXA  Pectoris  axd  Treatment  of  Syph- 
ilis for  details.)  Iodides  are  also  used  in  cases  where  no  suspicion 
of  syphilis  exists.  Some  physicians  oppose  its  use  and  find  on  ex- 
perimentation that  it  has  no  vasodilator  effects.  Piosenbach  claims  that 
it  actually  irritates  the  endothelial  tissues.  In  some  cases  at  least  it  has 
beneficial  effects  and  in  a  non-syphilitic  series  of  personally  observed 
cases  the  walls  of  the  nodular  and  hard  vessels  distinctly  improved  with 
administration  of  iodides.  Rhomberg  thinks  that  iodides  operate  less 
as  vasodilators  than  they  do  to  decrease  the  viscosity  of  the  blood.  It 
has  been  recently  claimed  that  nitroglycerine  dilates  the  peripheral 
vessels  only,  but  on  this  assumption  it  is  hard  to  explain  the  cerebral 
flushing,  etc.,  which  follows  its  use.  Massage,  a  warm  climaie,  passive 
exercise,  and  the  Schott  method  of  treatment  may  be  employed  as  out- 
lined under  Dilatation  of  the  Heart.  It  is  interesting  to  note  that 
Skoda  employed  hot  hand-  and  foot-baths  to  reduce  peripheral  resist- 
ance.   Coffee  may  relieve  anginal  and  abdominal  pain. 

Iron  and  digitalis  not  only  are,  as  a  rule,  unavailing  but  also  are 
directly  injurious.  When  the  heart  action  is  weak,  Huchard  advises  the 
following  pill: 

Sodii  iodidi oj- 

Sparteinse  sulphatis gr.  x^\ 

Pulv.  glycjTThizse q.  s. 

M.  et  ft.  in  pil.  xl. 
S. — One  after  meals. 

Rest  is  more  efficaciotis  than  are  cardiants.  ^lorphine  is  a  valuable 
nervous  sedative  and  tonic  for  severe  cases  of  cardiac  asthma,  but  must 
be  used  with  great  care. 

ANEURYSM. 

Definition. — A  dilation,  usually  localized  and  sac-like,  of  an  artery. 

Etiology. — (a)  Arteriosclerosis  is  the  most  important  cause.  The 
importance  of  s^-philis  is  estimated  at  29  per  cent.  fM.  Schmidt), 
36  per  cent.  (Fraenkel;,  53  per  cent.  (Gerhardt),  80  per  cent.  (Malm- 


ANEURYSM  471 

sten),  and  100  per  cent.  (Dnimmond).  The  author  thinks  the  rela- 
tionship between  sj-phihs  and  aneurysm  is  as  well  established  as  that 
between  syphilis  and  locomotor  ataxia,  and  probably  with  the  same 
percentage,  for  the  majority  of  cases  coming  under  his  own  clinical 
and  autopsy  observation  give  a  clear  history  or  show  indubitable  stig- 
mata of  syphilis.  Sudden  effort  in  strong  men  T\4th  a  weakened  aorta  is 
a  direct  factor  in  partial  rupture  of  the  aorta  and  formation  of  aneu- 
rysm. (6)  Trauma  is  an  important  factor  but  is  probably  overestimated, 
(c)  Sex:  aneurysm  is  from  two  to  eight  times  as  frequent  in  males  as  in 
females,  {d)  Age:  the  old  statement  that  aneurysms  occur  before  the 
fiftieth  year  and  arteriosclerosis  after  that  age  is  still  valid ;  they  occur 
between  30  and  40  (Crisp),  30  to  50  (Orth),  30  to  60  (Rokitansky),  40 
to  50  (v.  Schroetter) ;  later  compilations,  however,  set  the  age  higher, 
50  to  60  (Emmerich),  60  to  70  (Juda),  and  even  after  70  (Barsdorff). 
It  is  said  that  but  60  cases  under  20  years  of  age  have  occurred,  (e) 
Embolic  and  mycotic  aneurysms  are  usually  small  and  may  be  multiple. 
Arterial  tuberculosis  was  found  by  Weinberger.  (/)  The  traction 
aneurysm  (Thoma)  at  the  ductus  arteriosus  Botalli  is  rare. 

(g)  The  arrosion  aneurysm,  in  which  the  inner  coats  bulge  out  when 
the  adventitia  is  eroded,  occurs  largely  in  tuberculous  cavities.  The 
"aneurysmal  diathesis"  is  spoken  of  by  older  writers;  Pelletier  found 
63  in  one  case.  Dieulafoy  considers  that  multiple  aneurysms  of  the 
arch  are  clearly  syphilitic. 

Pathology.— In  relation  to  the  lumen,  aneurysms  are  axial  or  periph- 
eral. According  to  Quain,  the  varieties  are:  (a)  true  aneurysm,  in 
which  the  sac  consists  of  one  or  more  coats.  Strictly  speaking,  a  true 
aneurysm  should  contain  all  three  arterial  coats  in  its  walls,  but  this 
is  most  uncommon.  The  sac  is  usually  (i)  fusiform  and  diffuse,  or  (ii) 
sacculated  and  circumscribed,  (b)  False  aneurysm,  in  which  all  the 
coats  rupture,  or  in  which,  according  to  some,  one  coat  ruptures 
through  the  others,  like  a  hernia.  These  are  circumscribed  or  diffuse, 
especially  in  the  transverse  arch  and  in  the  abdominal  aorta,  (c) 
Dissecting  aneurysm,  wherein  the  intima  of  the  vessel  ruptures  and  the 
blood  makes  a  channel  down  the  vessel  between  the  intima  and  media 
or  between  the  layers  of  the  latter.  It  is  a  partial  rupture.  The  rup- 
ture back  into  the  aorta  is  an  attempt  of  nature  toward  recovery;  the 
patient  may  live  for  years,  (d)  Varicose  aneurysm,  wherein  the  sac 
ruptures  into  a  vein,  especially  the  innominate  vein  or  vena  cava;  this 
form  is  also  called  arteriovenous  and  aneurysmal  varix,  because  the 
main  change  is  in  the  vein. 

Atheroma  is  held  to  be  a  common  cause,  though  it  occurs  very  fre- 
quently in  comparison  with  aneurysm.  It  is  thought  that  intimal 
changes  induce  aneurysm  when  the  outer  coats  do  not  undergo  vicari- 
ous thickening  f|uickly  enough  to  prevent  dilatation.  Koester  held  that 
mesarteritis  was  the  principal  change,  but  Eppinger  found  the  greatest 
change  to  be  loss  of  the  elastic  and  muscle-tissue  in  the  media.  Syphi- 
litic changes  are  discussed  under  Syphilis  and  are  very  important. 
In  the  sac  thrombi  form  from  the  rouc^hened  intima  and  slowed  circu- 


472  DISEASES  OF  THE  CIRCULATION 

lation  and  to  a  small  extent  guard  against  extension  and  rupture. 
Aneurysm  occurs  at  those  points  in  the  aorta  on  which  the  blood  stream 
impacts  most  strongly;  59  per  cent,  of  thoracic  aneurysms  occur  on  the 
anterior  surface  of  the  ascending  aorta,  29  per  cent,  on  the  convexity  of 
the  arch  and  12  per  cent,  on  the  posterior  surface  of  the  descending 
segment.  In  915  aneurysms  the  seat  was  in  the  pulmonary  artery  in 
but  0.4  per  cent.  (Crisp). 

S3nnptoins. — Bramwell  distinguishes  three  classes  of  cases:  (a) 
Those  which  are  entirely  latent,  and  become  manifest  .only  by  rupture 
or  at  the  autopsy,  (b)  Those  presenting  symptoms  of  intrathoracic 
pressure  but  giving  no  positive  physical  signs,  (c)  Those  signalized  by 
distinct  physical  signs,  e.  g.,  by  pulsating  expansile  tumor. 

The  Purely  Subjective  Evidences  of  Aneurysm. — The  clinical  signs  are 
most  variable,  and  often  change  or  disappear  entirely  when  the  aneu- 
rysm changes  the  direction  of  its  growth;  the  latency  of  a  large  pro- 
portion of  aneurysms  gives  a  disproportionate  value  to  symptoms  per  se. 

1.  Pain. — Pain  is  either  intrinsic,  resulting  from  subacute  aortitis, 
varying  with  the  arterial  tension,  relieved  by  reduction  of  the  circula- 
tion, localized,  and  dull  or  aching  in  character;  or  it  is  extrinsic,  result- 
ing from  pressure  on  nerve  trunks  especially  in  deep-seated  tumors,  or 
from  the  weight  of  the  aneurysm,  as  illustrated  by  a  case  of  Stokes  in 
which  pain  was  relieved  by  the  use  of  crutches.  Pain  in  addition  to 
progressive  enfeeblement  and  emaciation  is  of  some  diagnostic  value. 
Sudden  pain  in  the  left  chest,  whether  anginal  or  not,  if  it  does  not 
yield  to  treatment,  is  always  suggestive  of  aneurysm.  Pain  in  the  major- 
ity of  cases  is  the  first,  the  most  notable,  and  often  the  most  enduring 
symptom.  It  is  often  alleviated  by  iodides;  it  is  usually  paroxysmal, 
sharp,  lancinating,  or  boring  in  character  (when,  for  instance,  the  spine 
is  eroded);  it  is  augmented  by  movement,  but  may  cease  when  the 
part  compressed  is  entirely  eroded.  The  pain  is  local  or  is  reflected 
into  the  brachial  plexus,  the  arm,  neck,  or  along  the  intercostal  nerves 
and  may  cause  numbness  and  paresis  of  the  arm.  Though  it  is  more 
usual  anteriorly,  it  is  sometimes  felt  in  the  interscapular  region.  An- 
ginal pain  follows  involvement  of  the  cardiac  plexus.  Intercostal 
neuralgia  is  always  suggestive  of  aneurysm.  When  there  is  tenderness, 
care  is  imperative  lest  palpation  induce  embolism. 

2.  Dyspnoea. — Dyspnoea  is  frequently  out  of  all  proportion  to  the 
findings.  It  is  often  a  vagus  neurosis,  but  is  also  due  to  narrowing  of 
the  chest  space  by  compression  of  the  aneurysm  upon  the  heart, 
phrenic  nerve,  trachea,  bronchi,  lungs,  or  pulmonary  artery;  or  to  com- 
pression of  the  plexus  cardiacus  or  pulmonicus,  producing  bronchial 
spasm,  and  of  the  recurrent  nerve,  leading  to  laryngeal  spasm  or  paraly- 
sis. Dyspnoea  may  occur  with  change  of  posture  (Leube)  and  is 
paroxysmal ;  it  is  at  times  more  or  less  urgent,  or  may  sometimes  sub- 
side entirely. 

3.  Cough. — Cough  is  frequent,  but  is  one  of  the  least  distinctive 
features.  It  results  from  pressure  on  the  air  passages,  vagus  irritation, 
bronchitis  or  laryngeal  involvement.    It  is  often  unproductive.     Like 


ANE  URYSM  473 

all  other  eccentric  pressure  sj^mptoms,  it  varies  with  the  size  and 
direction  of  the  aneurysm;  it  is  paroxysmal  (Morgagni)  and  is  prone 
to  appear  or^disappear  hand  in  hand  with  the  pain  and  dyspnoea. 

4.  Difficult  Swallowing. — Dysphagia  is  relatively  infrequent.  It 
results  from  direct  compression  or  from  pressure  on  the  recurrent  laryn- 
geal nerve,  inducing  oesophageal  spasm.  It  occurs  particularly  in  low 
aneurysms  of  the  "recurrent  type"  (v.  i.  Larynx)  and  may  produce 
distinct  pulsations  in  a  water  tube  introduced  into  the  oesophagus.  One 
of  the  earliest  aneurysms  reported  by  Stokes  was  the  size  of  an  egg,  and 
produced  pain,  dysphagia,  and  compression  of  the  left  bronchus,  with 
rupture  into  the  latter.  Aneurysm  may  be  confused  with  carcinoma 
of  the  oesophagus.  Traube  described  a  case  of  obstruction  of  the  sub- 
clavian artery  and  compression  of  the  left  recurrent  laryngeal  nerve 
in  which  aneurysm  was  suspected;  but  the  autopsy  revealed  carci- 
noma of  the  oesophagus  embracing  in  its  regional  invasion  the  left  sub- 
clavian artery  and  the  recurrent  laryngeal  nerve.  Dysphagia  may  be 
intermittent  or  present  only  when  the  patient  is  in  one  posture.  Its 
infrequency  is  explained  by  the  ready  lateral  luxation  of  the  oesopha- 
gus ;  dysphagia  is  most  often  due  to  adhesions  between  the  aneurysm 
and  the  oesophagus.  The  danger  of  sounding  the  oesophagus  is  well 
known,  for  distressing  lethal  hemorrhages  have  occurred  in  the  physi- 
cian's consultation  room. 

5.  Compression  of  the  Vagus. — Vagus  compression  results  in 
asthma,  laryngeal  spasm,  vomiting,  stenocardiac  attacks,  hiccough, 
and  pulmonary  symptoms. 

The  Physical  Signs  of  Aneurysm. — 1.  Inspection. — Stokes  described 
two  areas  of  'pulsation  in  the  chest,  each  distinct  "like  two  separate 
hearts."  This  is  most  significant  when  the  cardiac  impulse  is  the 
weaker.  Inspection  is  most  advantageously  made  with  the  eye  just  be- 
low the  level  of  the  shoulder  and  near  the  chest.  The  typical  expansile 
pulsation  is  best  detected  in  superficial  thin-walled  aneurysmata  in  the 
ascending  arch,  or  in  those  presenting  in  the  jugulum.  Pulsation  is  less 
a  question  of  the  size  than  of  the  location  of  an  aneurysm,  and  therefore 
visible  pulsation  may  be  absent  even  in  the  largest  varieties,  for  deeply 
situated  aneurysms  give  diffuse  or  no  pulsation,  or  the  pulsation  appears 
only  during  expiration.  Throbbing  over  the  aorta  is  least  important 
when  there  is  also  marked  arterial  pulsation  (aortic  regurgitation). 
The  pulsation  must  be  expansile  to  render  the  diagnosis  absolutely 
sure,  though  at  autopsy  the  author  saw  one  case  which  presented  clinic- 
ally an  expanding  throbbing  aorta  and  dulness  over  the  arch  which 
was  due  to  an  enormous  mass  of  callous  connective  tissue  involving  the 
pleura  and  pericardium.  Another  instance  of  a  truly  expansile  pulsa- 
tion low  down  in  the  left  side  of  the  chest  as  well  as  near  the  spine  was 
one  observed  in  pernicious  ansemia ;  the  hands  which  had  been  placed 
over  it  were  lifted  widely  apart,  and  the  pulsation  was  seen  at  a  distance 
of  forty  feet;  the  autopsy  revealed  no  aneurysm.  Pulsation  lent  to  a 
tumor,  a  collapsed  lung,  the  liver,  or  a  pleural  exudate,  can  usually  be 
distinguished  without  difficulty. 


474  DISEASES  OF   THE  CIRCULATION 

2.  Palpation. — Pulsation  is  felt  slightly  later  than  the  heart  shock; 
this  interval  is  more  obvious  the  slower  the  heart  rate  becomes. 
The  expansile  character  of  the  pulsation  is  sometimes  more  easily 
detected  by  the  fingers  than  by  the  eye.  Palpation  may  reveal  remittent 
tension  of  the  sac,  tenderness  on  deeper  pressure,  resistance  caused  by 
thick  lamellated  thrombi,  and,  in  rare  cases,  elasticity  or  fluctuation  of 
the  tumor  during  the  diastole.  Pulsation  in  a  deeply  situated  aneurysm 
is  best  elicited  by  placing  one  hand  anteriorly  and  the  other  posteriorly 
on  the  chest.  A  thrill  may  be  felt  which  is  most  commonly  systolic. 
A  diastolic  shock  sometimes  occurs  in  the  jugulum  and  over  the  aortic 
area  (Lancisi),  and  this  is  not  due  to  recoil  from  the  aortic  valves,  but 
to  retraction  of  the  hypertrophic  aorta  lying  between  the  heart  and  the 
aneurysm  (Rosenbach).  It  is  possibly  due  to  the  retraction  of  the 
vessel  wall. 

3.  Percussion. — Dulness  (Walshe)  is  an  important  finding  only 
when  it  is  present  on  either  side  of  the  sternum,  but  not  when  confined 
to  the  sternum.  Dulness  may  be  detected  in  the  left  interscapular 
region,  though  in  this  case  percussion  is  less  A^aluable,  because  of  the 
thiclaiess  of  the  chest  walls.  Aneurysms  are  often  obscured  by  an 
emphysema,  and  they  may  grow  from  their  deep  origin  into  the  lung 
substance.  The  dulness  may  so  merge  with  that  of  the  spine,  heart, 
liver,  or  spleen,  that  no  certain  statement  can  be  made.  Dulness  when 
once  detected  may  cease  or  shift  to  another  place,  and  this  is  an 
almost  certain  indication  of  aneurysm,  though  it  may  occur  in  cysts 
(Bramwell). 

It  is  inexplicable  that  aneurysms  often  grow  toward  and  press  upon 
relatively  unyielding  structures,  while  the  softer  parts  in  their  immediate 
vicinity,  as  the  lungs,  are  less  compressed  (v.  Schroetter). 

4.  Auscultation. — Auscultation  is  sometimes  wholly  negative,  even 
in  large  sacs — ^explained  by  thrombi  in  the  sac,  and  weak  heart  action. 
Two  clear  tones  are  most  frequently  heard;  the  second  tone,  heard  over  a 
circumscribed  area,  is  pathognomonic  of  aneurysm  (v.  Schroetter),  and 
originates  in  the  aneurysm  itself;  some  writers  attribute  it  to  closure  of 
the  aortic  cusps;  it  is  most  often  heard  in  aneurysms  near  the  ascending 
arch.  Two  tones  in  the  abdominal  aorta  are  scarcely  ever  heard 
normally.  A  systolic  murmur  is  frequent,  and  is  usually  blowing, 
roaring,  or  scraping;  it  is  due  to  vibrations  in  the  aortic  wall,  to  en- 
trance or  exit  of  blood  from  the  aorta  into  the  sac,  to  blood  waves 
initiated  by  angles  in  the  direction  of  the  current,  by  thrombi,  or  more 
rarely  by  pressure  of  the  sac  upon  the  aorta  itself. 

The  less  frequent  diastolic  murmur  is  most  probably  caused  by 
(relative)  aortic  insufficiency,  when  the  aneurysm  lies  in  the  first  part  of 
the  aorta.  It  may  be  due  to  folds  in  the  aorta,  vibrations  of  clots,  dila- 
tation of  the  left  ventricle,  or  to  dissection  of  the  aneurysm  into  the  sinus 
Valsalvae  (Stokes,  jNIarey).  It  is  usually  combined  with  a  systolic  mur- 
mur. A  continuous  murmur  is  rare.  Of  132  cases  (Sansom)  in  which 
the  diagnosis  was  made,  only  12  presented  a  systolic  murmur,  25  gave 
systolic  and  diastolic  murmurs,  and  in  six,  diastolic  murmurs  alone  were 


ANEURYSM  475 

found.     Douglas-Powell  detected  murmurs  in  about  half  of  his  cases 
of  sacculated  aneurysms. 

The  Heart. — Its  position  varies  with  the  size  and  location  of  the 
aneurysm,  (a)  Large  aneurysms  of  the  ascending  aorta  not  only  de- 
press it,  but  cause  such  axial  rotation  that  the  left  lies  lower  than  the 
right  ventricle;  aneurysm  in  this  location  may  cause  atrophy  of  the 
right  ventricle  from  pressure,  (b)  Aneurysm  of  the  under  surface  of 
the  arch  may  dislocate  the  heart  to  the  median  line,  (c)  Aneurysm  of 
the  descending  segment  may  flatten  the  heart  against  the  chest  wall 
(Neusser),  thus  simulating  mitral  regurgitation,  (d)  Secondary  aneu- 
rysmatic  outgrowths  from  the  chief  aneurysm  complicate  the  physical 
findings;  these  growths  sometimes  attain  incredible  proportions  and 
produce  confusing  symptoms,  (e)  In  uncomplicated  cases,  myocardial 
alteration  is  entirely  accidental  (Stokes,  Key,  and  Skoda),  which  contra- 
dicts the  usual  statement  that  dilatation  of  the  vascular  system  induces 
hypertrophy.  Failure  of  the  heart  to  hypertrophy  is  explained  by 
anaemia,  arteriosclerosis,  coronary  disease,  or  compression  of  the 
pulmonary  artery,  thereby  decreasing  the  flow  of  blood  to  the  left 
heart  and  coronary  arteries.  Hypertro'phy  of  the  left  ventricle  bears 
an  intimate  relation  to  aortic  leakage;  it  may  in  rare  cases  result  from 
aneurysm  involving  the  entire  periphery  of  the  aorta.  Stokes  states 
that  the  most  violent  aneurysmal  pulsation  he  ever  witnessed  occurred 
with  marked  myocardial  atrophy.  Compression  of  the  pulmonary  ar- 
tery (early  observed  by  Rindfleisch  and  Obermeier)  may  cause  relative 
tricuspid  regurgitation  or  pulmonary  insufficiency  (v.  Schroetter). 

The  symptoms  of  aneurysm  are  given  in  their  entirety  in  Stokes's 
early  observations. 

The  Vessels. — The  pulsus  differens  is  very  frequently  physiological, 
due  to  slight  irregularities  in  the  size  or  branches  of  the  radial  vessels. 
When  one  radial  is  small,  its  fellow  ulnar  is  often 'Vicariously  larger. 
Stokes  explicitly  stated  that  the  right  radial  is  normally  larger  than 
the  left,  whence  if  the  right  radial  pulse  is  smaller,  it  means  more  than 
if  the  left  were  slightly  smaller.  A  pulse  may  grow  smaller  and  later 
return  to  its  normal  size;  this  is  due  to  change  in  the  size<and  the 
direction  of  the  aneurysm.  When  the  radials  differ  essentially  in 
volume  it  is  advisable  to  compare  the  brachials.  Asymmetrical 
sphygmographic  tracings  may  be  due  to  other  causes  than  aneurysm 
as  atheroma,  coagula,  embolism,  or  reduction  of  the  lumen  of  a  vessel 
to  a  mere  slit,  perhaps  by  the  dragging  of  the  aneurysm  or  compression 
of  the  aorta  or  its  branches  by  the  sac  itself;  v.  Schroetter  instances  a 
case  in  which  the  aorta  was  so  compressed  by  a  sac  lying  between  it 
and  the  spine  that  abdominal  pulsation  and  the  femoral  pulses  were 
obliterated.  Changes  are  observed  most  often  in  the  carotid  and  sub- 
clavian vessels.  The  pulsus  paradoxus  and  capillary  pulsation  may 
occur  in  large  aneurysmatic  sacs  (Quincke).  Retardation  of  the  pulse 
occurs  especially  in  fusiform  aneurysms.  The  location  of  an  aneurysm 
may  sometimes  be  determined  by  regarding  the  vessels  altered.  If 
pressure  is  exerted  upon  the  superior  cava,  dropsy  of  the  upper  portion 


476 


DISEASES  OF  THE  CIRCULATION 


Fig.  30. 


of  the  body,  of  one  or  both  arms,  swelHng  of  the  face  and  of  the  tongue, 
sometimes  exophthalmos  and  a  "brawny"  or  "coUar-hke"  distention 
of  the  neck  occur.  Obstruction  above  the  azygos  vein  causes  hvidity 
and  oedema  whjch  are  confined  to  the  head  and  arms;  when  it  occurs 
below  that  vessel  the  chest  is  also  congested.  Obliteration  of  the 
innominate  and  azygos  veins  or  the  venae  cavse  may  occur.  Rupture 
into  the  superior  cava  is  attended  by  cyanosis,  and  a  continuous  bruit 
like  the  bruit  de  diable  is  often  present;  in  Ewart's  case  (not  suspected 
during  life)  phlebotomy  was  performed,  and  bright-colored  blood 
escaped  in  jets.  The  continuous  murmur  may  also  occur  in  cases 
of  vascular  sarcomata. 

The  Respiratory  Tract. —  Tracheal  tugging,  described  by  Oliver  and 
Cardarelli  simultaneously,  is  elicited  by  lifting  the  larynx  with  the 

fingers;  a  tugging  sensation  in 
the  trachea  is  then  felt  with 
each  systole;  this  symptom  oc- 
curs in  cases  of  cardiac  over- 
action,  left  ventricle  hypertrophy, 
aneurysmata  of  the  arch  and  of 
the  innominate  and  carotid  ves- 
sels, and  in  adhesions  to  the 
trachea. 

Tracheal  pulsation  is  present 
in  many  cases  of  aneurysm  and 
may  be  demonstrated  by  the 
laryngoscope.  The  examination 
should  be  made  by  direct  sun- 
light, and  the  observer  should 
sit  before  the  standing  patient. 
Tracheal  pulsation  also  occurs 
in  tumors  which  compress  the 
trachea;  it  may  also  be  physio- 
logical. Drummond  has  de- 
scribed a  systolic  murmur  over 
the  trachea.  A  short  murmur, 
synchronous  with  the  systole, 
can  sometimes  be  heard  when 
the  patient  breathes  quietly  with 
the  mouth  open.  Schroetter, 
Dieuiaf9y's  diagram  of  tie  region  in  which  he  de-  gansom,  and  Others,  describe  it 

scnbes   his       recurrent  type"    of  aneurysm;  i     i     11  i 

posterior  view.     A,  aorta,  in  contact  with  the  aS       '  XScllck,         and     refer     it     tO 
trachea  and  left  bronchus;    L,  larynx  (seen  ,  •  i>  1  ^ 

from  behind);  p,  left  and  p' ,  right  vagus;  r,  propagation  irom  the  trachca. 
left  recurrent  laryngeal   nerve,  passing  under  r,  ,    ■,  ■,  j       . 

the  aorta,  and  r',  right  recurrent,  in  relation       Recurrent  laryngeal  paralysis 
to  the  subclavian  artery.  ^,^g  gj.g^  described  by  IMorgagui 

or  by  even  earlier  observers.  Todd  was  the  first  to  note  laryngeal 
muscular  atrophy  on  the  affected  side;  paralysis  may  exist  when  the 
larynx  is  anatomically  intact.  Unilateral  paralysis  with  the  cadaveric 
position  of  the  vocal  cords,  in  the  absence  of  obvious  cause,  is  quite 


ANEURYSM 


477 


Fig.  31. 


indicative  of  intrathoracic  aneurysm  or  neoplasm,  though  it  is  also  seen 
in  cases  of  mitral  stenosis.  The  cough  is  hoarse,  and  makes  a  clang- 
ing or  brazen  sound.  It  is  a  paralytic  cough,  i.  c,  an  imperfect 
expiration  which  lacks  forcible  closure  of  the  glottis  observed  in  ordi- 
nary coughing  efforts;  it  was  called  the  bovine  cough  by  Wyllie  from 
the  fact  that  cattle  have  no  false  cords  whose  closure  is  an  important 
mechanism  in  coughing.  The  right  recurrent  laryngeal  nerve,  curving 
around  the  subclavian  artery,  does  not  enter  the  thorax,  and  is  there- 
fore seldom  involved;  whereas  the  left  recurrent  nerve  passes  into 
the  chest  and  curves  between  the  aorta  and  left  bronchus;  Dieulafoy 
described  a  "recurrent  type  of  aneurysm,"  which  is  usually  sniall 
syphilitic  in  origin,  often  multiple,  involves  the  left  recurrent  neve, 
and  causes  spasm  of  the  larynx.  The  spasm  is  due  to  recurrent  lar  n  n- 
geal  irritation  which  contracts  the  posterior  transverse  arytenoid 
muscle  and  induces  dyspnoea  and  inspiratory  stridor.  Irritation  of 
other  vagus  branches  induces  spasmodic  dysphagia,  anginal  pain,  etc. 
Lung  Symptoms. — Stenosis  of  the  right  bronchus  is  less  frequent 
than  that  of  the  left,  for  the  latter  lies  nearer  the  aortic  arch.  The 
lung  moves  less  freely  than  normal;   it  suffers  inspiratory  retraction, 

and  the  breath  sounds  and  fremitus 
are  diminished.  When  a  short  note 
is  elicited  over  an  upper  lobe  (especi- 
ally the  left)  it  may  cause  suspicion  of 
an  aneurysmal  compression  with  re- 
laxation of  the  lung.  It  is  common  in 
the  "recurrent  type"  of  Dieulafoy. 

Rokitansky  concluded  that  large 
aneurysms  are  almost  never  associated 
with  jpulmonary  tuberculosis,  a  view 
disproven  by  Stokes,  Fuller,  Jaccoud, 
Herard,  Cornil,  Hanot,  and  Kartz. 
Tuberculosis  may  result  from  (a) 
trophic  change,  (6)  compression  of  the 
pulmonary  artery,  or  (c)  decreased 
lung  excursion.  It  is  found  in  13  per 
cent,  of  the  cases  of  aneurysm. 

Bronchiectasis,  hronchorrhcea,  and 
suppuration  of  the  lung,  is  well  called 
"aneurysmal  phthisis"  by  Osier.  Pul- 
monary retraction  is  observed  from  com- 
pression, adhesive  pleurisy  or  interstitial 

Dieulafoy-Multiple  syphilitic  aneurysms,   pncumouia.         Pkurisy      With      eflusion 

may  complicate  and  entirely  obscure  an 
aneurysm.  Pulmonary  gangrene  occurs  from  compression  of  the  aortic 
nutrient  artery  of  the  lung  or  stagnation  of  mucus.  Gangrene  of  the 
bronchial  mucous  membrane  also  occurs.  Gangrene  may  produce 
subcutaneous  emphysema.  Pulmonary  hemorrhage  may  occur  from 
gross  rupture  into  a  large  tube,  from  mere  granulations  in  a  compressed 


478  DISEASES  OF  THE  CIRCULATION 

tube,  or  from  an  aneurysm  slowly  leaking  into  the  parenchyma  of  the 
lung.  The  hemorrhage  may  be  fatal,  premonitory,  or  continuous;  it 
may  be  seen  as  flecks  in  the  sputum,  as  rusty  sputum  (but  more  abun- 
dant, more  frothy,  and  less  viscid  than  in  pneumonia),  as  prune-juice 
expectoration  with  alveolar  epithelium  (as  seen  in  valvular  disease), 
and  as  discharges  of  pure  blood  or  more  frequently  of  imperfectly 
coagulated  blood. 

Sympathetic  Symptoms. — The  pupils  are  often  involved;  myosis 
results  from  sympathetic  paralysis  and  mydriasis  from  sympathetic 
stimulation.  It  must  be  remembered  that  7  per  cent,  of  all  persons 
have  irregular  pupils.  Other  sympathetic  symptoms,  as  pallor  or 
redness,  and  sweating,  are  infrequent. 

Diagnosis. — The  clinical  signs  and  symptoms  are  most  variable 
(Stokes).  The  presence  of  an  aneurysm  should  be  suspected  when 
marked  pain  or  paroxysmal  dyspnoea  occur.  Variability  of  physical 
signs  is  suggestive  of  aneurysm. 

Diagnosis  of  Location. — 1.  Aneurysm  of  the  ascending  portion  is 
called  by  Broadbent  the  "aneurysm  of  physical  signs."  The  usual 
signs  are  most  often  observed  in  the  first  interspace  to  the  right  of  the 
sternum,  which  is  often  eroded.  Luxation  of  the  heart  to  the  left, 
slowing  of  both  radials,  right  recurrent  paralysis,  compression  of  the 
superior  vena  cava  and  of  the  pulmonary  artery  with  hypertrophy 
of  the  right  ventricle,  dyspnoea  and  phthisis  occur.  Anginal  or  other 
cardiac  symptoms  frequently  occur  (Gairdner),  and  the  aneurysm, 
though  small,  is  usually  rapidly  fatal  from  rupture  into  the  pericar- 
dium, pleura,  upper  cava,  or  heart-chambers.  Aneurysms  just  above 
the  valves  tend  to  grow  downward  because  of  the  reflux  of  blood  from 
the  aorta  whereas  those  located  higher  grow  upward,  because  of 
impact  of  blood  from  the  left  ventricle.  Sympathetic  involvement  is 
common. 

2.  In  the  arch,  the  "aneurysm  of  symptoms"  is  observed  with 
left  recurrent  paralysis  or  spasm,  stridor,  pulsation  in  the  jugulum, 
unusual  prominence  or  luxation  of  the  sternal  ends  of  the  clavicles, 
prominence  of  the  subclavian  arteries,  dulness  to  the  left  of  the  ster- 
num, myosis,  slomng  or  lessening  of  the  left  radial  pulse,  compres- 
sion of  veins  particularly  the  left  innominate,  of  the  trachea,  thoracic 
duct,  sympathetic  ganglia,  bronchi  and  left  upper  lobe,  and  disturb- 
ance in  the  brain  circulation  (hemiplegia)  when  the  carotid  artery  is 
occluded.     These  aneurysms  usually  grow  backward. 

3.  In  the  descending  segment,  the  "aneurysm  of  latency"  is  most 
often  encountered.  If  there  are  symptoms,  pulsation  in  the  left  inter- 
scapular region,  slowing  of  the  femoral  pulse,  pressure  on  the  azygos 
or  hemiazygos,  pressure  on  the  spine  with  erosion  and  tenderness  to 
touch, intercostal  neuralgia  (sometimes  with  recurrent  attacks  of  herpes 
zoster),  stenosis  of  the  left  bronchus  or  oesophagus,  pressure  upon 
the  heart  forcing  it  against  the  sternum,  and  increased  heart-rate 
from  plexus  pressure,  are  present.  The  .r-rays  alone  may  be  able  to 
detect  aneurysms  lodged  in  the  lung  substance. 


ANEURYSM  479 

Differentiation. — Differentiation  from  solid  tumors  is  determined  by 
their  propagated  non-expansile  pulsation,  their  more  rapid  develop- 
ment, leukocytosis,  and  cachexia.  In  aneurysm  the  lymph  glands 
are  rarely  enlarged  either  from  lymph  stasis  or  from  inflammation; 
adenopathy  is  frequent  in  mediastinal  tumor,  and  continued  increase 
is  directly  indicative  of  neoplasm.  Pain,  recurrent  paralysis  and 
dysphagia  are  common  to  all  tumors,  both  aneurysmatic  and  neo- 
plastic. Venous  ectasia  is  more  common  in  tumor.  A  few  rare 
instances  of  coincidence  of  tumor  and  aneurysm  are  observed.  The 
pulsation  in  carcinoma  is  rarely  associated  with  a  diastolic  "back 
stroke,"  which  is  frequent  in  aneurysm.  An  unequal  pulse  indicates 
aneurysm  or  atheroma.  The  bruit  in  tumor  is  usually  systolic,  but 
murmurs  are  frequently  absent  in  aneurysm.  Tugging  is  present  in 
both  but  more  common  in  the  latter.  Signs  of  aortic  atheroma  argue 
in  favor  of  aneurysm.  Aneurysm  runs  a  much  more  protracted  course 
than  tumors.  Exploratory  puncture  and  diagnosis  ex  juvantibus  with 
iodide  are  of  differential  importance. 

Other  causes  for  'pulsation,  such  as  a  dynamic  throbbing  (aortic 
regurgitation),  throbbing  in  acute  aortitis,  pulsation  in  an  aorta  dis- 
located from  kyphosis,  and  pulsation  in  pneumonia  (Graves)  or  in 
tumor  of  the  lung  or  pleura,  are  usually  differentiated  when  all  symp- 
toms and  signs  are  carefully  considered.  In  'pulsating  empyema  the 
dulness  is  usually  low  in  the  chest  and  largely  left-sided;  puncture 
reveals  the  presence  of  pus  and  stops  the  pulsation. 

Prognosis. — Recovery  is  rare,  though  spontaneous  cure  is  possible 
by  organization  and  calcification  of  thrombi  in  the  sac  or  by  its  inflam- 
mation. Sometimes  one  aneurysm  obliterates  another.  The  course 
usually  lasts  more  than  a  year.  Patients  have  been  known  to  live 
and  work  hard  ten  or  twenty  years.  The  author  has  watched  for 
twelve  years  a  blacksmith  who  has  worjied  though  he  had  an  aneurysm 
of  the  ascending  aorta,  which  was  as  large  as  his  fist,  and  which  pro- 
truded beyond  the  ribs.  The  size  of  the  sac  is  of  no  prognostic  value. 
Those  of  the  small  "recurrent  type"  are  most  dangerous,  and  large 
ones  may  be  protected  by  connective  tissue.  Arteriosclerosis  is  prog- 
nostically  unfavorable. 

Mechanism  of  Death. — (a)  Rupture  occurs  in  75  per  cent,  of  cases: 
20  per  cent,  into  the  left  and  13  per  cent,  into  the  right  pleura;  16 
per  cent,  into  the  left  bronchus;  12  per  cent,  into  the  pericardium; 
9  per  cent,  into  the  left  lung;  6  per  cent,  externally;  5  per  cent,  into 
the  oesophagus;  4  per  cent,  into  the  trachea;  (h)  suffocation:  (c) 
viarasmus,  especially  in  large  aneurysms;  (d)  intercurrent  disease; 
(e)  embolism;  and  (/)  brain  lesions,  are  also  immediate  causes  of 
death.  Hemorrhage  usually  shortens  the  course,  but  in  one  case 
rupture  into  the  bronchus  occurred  five  years  before  death.  Another 
patient  suffered  external  rupture  of  the  sac;  he  collected  the  blood 
in  a  basin  and  though  he  fainted  from  the  hemorrhage  he  lived  four 
months,  only  to  die  of  typhus  fever.  Stokes  descril^ed  an  instance  of 
external  rupture  in  which  the  presence  of  mind  of  the  nurse,  in  stuffing 


480  DISEASES  OF  THE  CIRCULATION 

ing  some  cloth  into  the  sac,  kept  the  patient  ahve  for  a  considerable 
time. 

Treatment. — 1.  The  Tufnell  treatment  of  rest,  low  diet,  and 
limited  fluid  is  the  result  of  the  methods  used  by  Morgagni,  Albertini, 
Valsalva  and  Bellingham,  without  the  venesection  recommended  by 
Valsalva.  Absolute  mental  and  physical  rest  is  required  for  several 
months,  and  food  should  be  reduced  to  the  minimum.  The  heart 
action  and  blood  pressure  are  greatly  lessened.  The  treatment  is  of 
value  only  in  cases  of  sacs  with  small  necks.  Active  individuals  will 
not  tolerate  this  method.  Relative  quietness,  and  moderation  in  every 
phase  of  life  must  then  be  insisted  upon.  Ergotin,  hypodermatically, 
has  little  effect.    Tr.  aconite  tij  i  to  iv  may  relieve  the  throbbing, 

2.  The  iodides  have  been  given  prominence  by  Balfour,  though 
they  were  used  first  by  Bouillaud  and  later  by  Graves,  Nelaton,  and 
others.  It  is  not  clear  how  they  operate.  They  are  of  equal  value  in 
syphilitic  and  non-syphilitic  cases.  They  increase  the  secretions  but 
do  not  inspissate  the  blood.  It  is  questionable  from  the  experimental 
standpoint  whether  arterial  tension  and  dilatation  of  the  sac  are 
lessened.  Possibly  the  sac  wall  is  thickened  or  clotting  is  facilitated. 
However,  it  is  certain  that  pain  is  alleviated.  Ten  to  twenty  grains 
are  given  at  a  dose  as  in  arteriosclerosis.  The  dose  is  lessened  if  the 
pulse  rate  increases.  Aside  from  rehef  of  pain,  the  iodides  are  useless 
in  large  aneurj^sms  with  wide  communications  or  in  fusiform  varieties. 

3.  Cold  applications  may  relieve  pain  when  the  sac  is  near  the 
surface.  Supports  may  relieve  the  pain  and  protect  against  rupture. 
Calcium  chloride  in  doses  up  to  ten  or  fifteen  grains  has  been  used  to 
promote  coagulation,  but  apparently  without  effect. 

4.  Gelatin  injections  (1  or  2  per  cent,  solution)  are  recommended 
by  Lancereaux  to  produce  coagulation  in  the  sac.  It  cannot  be  said 
that  the  results  are  convincing.  Gelatin  has  been  used  for  centuries 
in  China  and  Japan  to  aid  coagulation.  There  is  danger  of  embolism 
and  23  deaths  from  tetanus  are  reported  by  Dieulafoy,  1903. 

5.  Electrolysis,  introduction  of  fine  wire,  compression  and  surgical 
intervention  have  given  discouraging  results.  A  few  cases  of  recovery 
are  reported  but  one  cannot  help  comparing  their  small  number  with 
the  probably  equal  number  of  spontaneous  recoveries  (Boerger,  in 
1906,  compiled  19  cases  of  dissecting  aneurysms  of  the  aorta  which 
recovered).  Fatal  thrombosis  may  follow  what  in  a  lesser  degree  of 
thrombosis  might  have  been  beneficial.  Total  embolism  of  the  aorta 
may  also  occur. 

6.  Dyspnoea  is  treated  as  in  cardiac  disease.  Venesection  may 
afford  temporary  rehef,  and  morphine  is  finally  indicated.  Tracheot- 
omy may  be  necessary  in  laryngeal  spasm  (reflex  recurrent  irritation) 
but  the  actual  compression  by  the  sac  is  usually  too  low  for  operative 
interference.     Digitalis  is  at  all  times  contra-indicated. 


ABDOMINAL  ANEURYSM  481 


Abdominal  Aneurysm. 

This  type  constitutes  5  per  cent,  of  aneurysms  of  the  aorta.  Over 
two-thirds  occur  in  the  upper  part  of  the  abdomen  and  40  per  cent, 
either  at  or  above  the  coeHac  axis.  The  average  size  is  that  of  an  orange 
and  the  tumor  develops  from  the  anterior  surface  of  the  vessel,  less 
frequently  from  its  lateral  or  posterior  wall,  and  grows  downward. 
Most  of  them  are  false  aneurysms. 

Sjnnptoms  and  Signs. — Four  per  cent,  of  abdominal  aneurysms  are 
latent  clinically;  a  good  sized  sac  may  be  hidden  under  the  arch  of 
the  diaphragm.  Pain  is  usual,  and  is  constant  and  boring,  or  paroxys- 
mal. It  may  become  less  severe  after  hemorrhage  from  rupture. 
Relief  is  sometimes  obtained  by  lying  on  the  stomach.  Indefinite 
symptoms  are  common  in  the  stomach  though  they  are  less  frequent 
than  in  the  duodenum,  where  obstruction  and  hemorrhage  may  occur. 
Inspection  does  not  show  expansile  pulsation  and  tumor  in  all  cases. 
Palpation  brings  out  the  expansile  pulsation  and  in  some  cases  a 
thrill.  Percussion  may  reveal  dulness  but  the  close  relations  to  the 
liver,  spine,  kidneys  and  heart  are  prone  to  give  indefinite  findings. 
The  diaphragm  bounds  the  aneurysm  above;  the  kidney  to  the  left; 
the  liver,  pancreas  and  kidney  to  the  right;  and  the  stomach,  pancreas 
and  colon  in  front.  The  tissues  about  the  sac  thicken  and  produce 
adhesions.  On  auscultation,  a  systolic  murmur  (or  two  tones)  is  com- 
mon and  may  reach  the  spine  or  loins;  a  diastolic  murmur  is  some- 
times heard.  Rupture,  diffusion  by  dissection,  great  thickening  of  the 
sac,  and  thrombi  formation  may  easily  obscure  all  auscultatory  signs. 

Diagnosis. — 1.  Compression  Symptoms. — Compression  symptoms, 
gastric  and  duodenal,  have  been  mentioned.  Abdominal  aneurysm 
may  be  mistaken  for  gastric  ulcer  or  cancer.  The  spine  is  eroded  in 
10  per  cent,  of  cases;  lumbar  neuralgia,  lumbago  muscular  rheuma- 
tism, myelitis.  Pott's  disease,  and  spinal  tumor  may  be  simulated. 
Pulsation  should  be  searched  for  along  the  spine.  Symptoms  in  the 
renal  region  may  suggest  renal  colic,  kidney  tumor,  perinephritis  or 
psoas  abscess  (fluctuating  blood  from  rupture).  The  ureter  may  be 
compressed.  Pressure  on  the  splenic  vein  may  produce  much  splenic 
enlargement.  The  heart  is  rarely  compressed  and  dyspnoea  is  un- 
common. Retardation  or  absence  of  the  femoral  pulse  may  be  of 
value  in  differentiation. 

2.  Abdominal  Pulsation. — "Instead  of  being  your  first,  it  should  be 
your  last  idea  that  abdominal  pulsation  is  due  to  aneurysm"  (Jenner). 
Epigastric  pidsation  may  be  confused  with  hypertrophy  of  the  right 
heart  or  pulsation  of  the  liver.  The  greatest  danger  of  error  lies  in 
diagnosticating  as  aneurysm  the  pulsation  which  is  so  often  seen  in 
acute  hemorrhage,  or  especially  in  neurasthenic  subjects,  who  com- 
plain of  pain  and  throbbing  and  in  whom  thrills,  systolic  and,  accord- 
ing to  Rosenbach,  even  diastolic  murmurs  may  be  felt  and  heard, 
especiallv  when  atheroma  is  developing.     Rosenbach  especially  em- 

31 


482  DISEASES  OF  THE  CIRCULATION 

phasizes  the  diagnostic  importance  of  "intermittent  dilatation  of  the 
aorta"  which  is  frequently  diagnosticated  as  aneurysm.  The  pulsation 
must  be  distinctly  expansile  (even  then  occasional  errors  are  made) 
and  a  definite  sac  must  be  felt.  Otherwise  constant  errors  will  be 
made.  The  dynamic  pulsation  of  aortic  regurgitation  concerns  the 
same  points. 

3.  Communicated  Throbbing. — Communicated  throbbing,  lent  to 
a  tumor  of  the  stomach  lying  on  the  aorta,  may  also  be  attended  by 
systolic  murmur  but  the  differentiation  is  usually  made  with  ease, 
except  in  certain  soft  neoplasms.  Tumors  are  often  felt  to  better 
advantage  when  the  subject  is  in  the  genupectoral  attitude;  they  are 
more  movable,  more  often  produce  dilated  veins,  ascites,  and  peri- 
toneal friction.  Aneurysm  of  the  abdominal  aorta  or  of  its  branches 
may,  in  exceptional  cases,  be  movable.  Stokes  held  that  tumors 
developed  upward  and  aneurysms  downward. 

4.  Aneurysm  of  the  Branches  of  the  Abdominal  Aorta. — (a)  Aneu- 
rysms of  the  ca'liac  axis  are  difficult  or  impossible  to  distinguish  and 
may  occur  with  aneurysm  of  the  main  trunk.  More  than  20  cases  are 
recorded.  They  are  often  traumatic  or  embolic  (mycotic).  (6)  Super- 
ior (20  cases,  Baccelli,  1904)  or  inferior  mesenteric  aneurysms  are  very 
uncommon;  they  occur  most  frequently  in  children,  from  sepsis,  (c) 
Over  20  cases  of  splenic  aneurysm  are  recorded.  The  spleen  is  often 
enlarged,  {d)  In  the  hepatic  artery  (35  cases,  Grunert  1903)  it  is 
induced  by  acute  infections  (73  per  cent.),  trauma,  embolism,  or  gall- 
stones; 41  per  cent,  develop  in  the  main  trunk  and  25  per  cent,  in  its 
right  branch;  there  is  but  one  case  in  which  it  developed  in  the  artery 
of  the  cystic  duct.  Pain,  vomiting, hemorrhage, icterus,  and  large  spleen 
have  been  noted:  in  79  per  cent,  rupture  occurred  (in  10  cases  into 
the  peritoneum) ;  they  never  pulsate,  and  in  only  one  case  was  there 
a  systolic  murmur;  Kehr  operated  on  one  case  successfully,  (e)  Over 
10  cases  of  aneurysm  of  the  coronary  artery  of  the  stomach  are  re- 
corded. (/)  In  the  renal  artery  (26  cases,  Skillern,  1906)  aneurysm  is 
rare.  Three  cases  were  successfully  operated  on.  Von  Schroetter 
found  only  1  case  in  nearly  20,000  autopsies. 

Prognosis. — Death  is  usual  and  the  clinical  course  averages  one 
to  three  years.  Rupture  occurs  in  66  to  75  per  cent,  of  cases:  33  per 
cent,  into  the  peritoneum;  16  per  cent,  into  the  pleura,  though  the  crura 
of  the  diaphragm  offers  considerable  resistance;  7  per  cent,  into  the 
duodenum;  and  7  per  cent,  into  the  retroperitoneal  tissue.  Death  does 
not  necessarily  nor  at  once  follow  rupture  even  into  the  peritoneum. 

Treatment.^Treatment  is  as  in  the  thoracic  type.  From  its  acces- 
sibihty,  operative  procedures  are  more  common  and  somewhat  more 
successful.  Continued  compression  of  the  aorta  has  benefited  cases 
of  aneurysm  located  low  in  the  abdomen. 


AORTITIS  AND  ARTERITIS    T  483 


-i 


ACUTE  AORTITIS  AND  ARTERITIS. 

These  are  rare  lesions,  occurring  in  the  aorta  as  part  of  a  sepsis, 
benignant  or  maHgnant  endocarditis,  or  in  the  peripheral  vessels  after 
influenza  or  other  infections.  Acute  aortitis  was  often  confused  with 
chronic  atheroma,  acute  arteritis,  and  with  organizing  thrombi  in  the 
arteries.  Syphilis  {q.  i>.)  is  a  factor  in  aortitis,  of  which  the  symptoms 
are  retrosternal  burning,  actual  anginal  pain,  dyspnoea,  anxiety,  and 
acute  dilatation  of  the  arch  without  violent  throbbing  of  its  branches. 
The  diagnosis  is  uncertain  and  the  treatment  symptomatic. 

Periarteritis  nodosa  was  first  described  by  Kussmaul  and  Maier 
and  is  called  "arteritis  proHferans  nodosa"  by  Fletcher.  This  is  a 
rare  affection  of  which  Vers^  in  1905  could  find  but  20  published 
cases;  it  consists  of  localized  proliferation  and  round  cell  infiltration 
of  the  intima  with  its  rupture  through  the  other  coats,  and  leads  to 
thrombosis  or  aneurysm.  It  is  probably  an  infection.  It  occurs  largely 
in  men  between  twenty  and  thirty-five  years  of  age;  one  case  occurred 
in  an  infant  three  months  old.  The  nodes  are  seen  in  the  vessels  of 
the  muscles,  heart,  kidney,  intestines,  and  skin;  they  produce  hydrops, 
nephritis,  dyspepsia,  alimentary  hemorrhage,  epigastric  pain,  low 
temperature,  and  a  rapid  pulse.  The  affection  is  fatal  within  six  to 
twelve  weeks,  and  treatment  is  purely  symptomatic.  In  one-quarter 
of  the  cases  there  were  syphilitic  antecedents  and  Schmorl  saw  one 
cure  with  the  use  of  mercury. 


JRUPTURE  OFJTHE  AORTA. 

p[;  Rupture  of  the  aorta  may  be  traumatic  or  the  result  of  severe  strain, 
endarteritis,  or  narrowing  of  the  vessel.  Tolot  and  Sarvonat  (1904) 
collected  but  six  cases  of  rupture  of  a  sound  aorta.  All  coats  may  be 
ruptured  and  this  usually  occurs  in  a  transverse  direction.  If  the  rup- 
ture is  partial,  a  dissecting  aneurysm  results  which  may  burrow  even 
to  the  popliteal  arteries.  It  most  often  occurs  in  the  first  segment 
whence  hsemopericardium  results.  Rupture  into  the  lung,  medias- 
tinum or  retroperitoneal  connective  tissue  may  occur.  The  symp- 
toms are  sudden  pain,  a  sense  of  "something  ruptured,"  and  the  signs 
of  hemorrhage;  sudden  death  usually  occurs,  though  prolongation  of 
life  for  from  one  to  eleven  years  has  been  recorded  in  cases  of  dis- 
secting aneurysm. 

Einholism  of  the  aorta  has  a  close  relation  to  thrombosis,  being  due 
to  impaction  of  atheromatous  plaques,  tumor  tissue,  echinococcus 
cysts,  endocarditic  plugs  or  ordinary  thrombi.  It  is  very  uncommon. 
Sudden  death  results  if  the  site  is  in  the  first  part  of  the  vessel.  If 
it  occurs  near  the  division  of  the  iliacs,  collateral  circulation  is  possible. 
There  are  pain  and  stiffness  in  the  legs,  sensory  disturbances,  paresis 
and  contractures  from  anaemia  of  the  spinal  cord.    The  femoral  pul- 


484  DISEASES  OF  THE  CIRCULATION 

sation  is  absent.  The  clot  may  back  up  toward  the  heart  or  it  may 
resorb.  The  bladder  and  rectum  are  disturbed.  Hemorrhage  from 
the  stomach,  bowels  and  kidneys  has  been  observed.  The  prognosis 
is  bad,  and  the  treatment  is  symptomatic. 

Thrombosis  usually  results  from  several  coincident  causes,  as  acute 
infections,  weak  heart,  aneurysm,  atheroma,  or  compression.  Most 
cases  occur  in  the  transverse  arch  between  the  left  carotid  and  sub- 
clavian vessels  or  in  the  abdominal  aorta  at  its  point  of  division.  The 
pain,  paraplegia,  or  anaesthesia  produced  are  sometimes  confused  with 
spinal  cord  disease.  It  may  be  sudden;  if  gradual,  collateral  cir- 
culation may  be  established. 


SEOTIOK  III. 


DISEASES  OF  THE  RESPIRATORY  TRACT, 


DISEASES  OF  THE  NOSE. 

(A).  ACUTE  RHINITIS,  CORYZA. 

Definition.— An  acute,  probably  infective  nasal  inflammation. 

Etiology. — (a)  It  is  an  independent  infection,  sometimes  epidemic 
and  popularly  held  as  contagious;  it  occurs  often  est  in  the  spring 
and  fall  and  is  promoted  by  variations  in  temperature.  Cold  is 
probably  only  a  predisposing  factor;  various  bacteria  are  held  causa- 
tive, but  Thompson  and  Hewlitt  have  shown  that  84  per  cent,  of  cul- 
tures are  negative.  (6)  It  is  a  concomitant  of  various  infections, 
notably  of  influenza,  measles,  pertussis,  glanders,  syphilis,  etc.  (c) 
Toxic  factors,  as  iodides,  bromides,  ipecac  dust,  digitalin,  dust, 
chemicals,  etc.,  may  cause  coryza.  (d)  Local  disease,  as  chronic 
catarrh,  polyps,  ulceration,  etc.,  and  possibly  gout,  are  predisposing 
factors. 

Symptoms. — The  initial  symptoms  are  malaise,  depression,  anorexia 
chilliness,  fever  of  101°  to  102°,  pains  in  the  limbs,  and  sometimes, 
in  the  young,  delirium  and  convulsions.  The  mucosa  is  dry,  reddened, 
burning,  painful,  swollen  and  obstructed.  There  is  repeated  sneezing 
and  anosmia.  Herpes  is  common.  There  follows  a  clear,  watery, 
nasal  discharge  {coryza)  for  one  or  two  days,  which  subsides  at  night 
and  recurs  in  the  morning;  within  two  days  it  becomes  thickened 
and  purulent.  Extension  may  occur  to  the  eyes,  frontal  sinus,  antrum 
of  Highmore,  ear  by  the  Eustachian  tube,  or  to  the  pharynx  or  larynx. 
In  infants  nasal  occlusion  prevents  nursing  and  may  cause  dyspnoea 
or  suffocation,  because  the  tongue  lies  high  in  the  mouth  near  the 

485 


486  DISEASES  OF  THE  RESPIRATORY  TRACT 

palate.  Acute  rhinitis  lasts  one-half  to  one  week  and  is  seldom  con- 
fused except  with  incipient  measles. 

Treatment. — At  the  very  onset  lavage  with  simple  hot  water  is 
often  sufficient;  Dobell's  solution  (sod.  borat  and  sod.  bicarb,  aa  3ij- 
ac.  carbolici  5ss  to  water  5x),  diluted  freely  to  avoid  irritation,  is  bene- 
ficial; adrenalin  solution  1  to  1,000  is  excellent  (excessive  applica- 
tion of  adrenalin  may  induce  oedema  of  the  throat  and  epiglottis). 
A  cocaine  solution  (the  plain  alkaloid  gr.  j  to  albolene  §j)  relieves 
turgescence  and  frontal  pain,  but  is  a  dangerous  remedy  to  give  into 
the  patient's  hands.  Dover's  powder  gr.  x,  a  saline  aperient  and  a 
hot  bath  at  the  onset,  usually  give  relief,  specially  when  followed 

Extr.  belladormse gr.  iiss. 

Fluidextr.  aconiti       n^x. 

Phenacetini gr.  xv. 

Camphorse  monobrom gr.  xv. 

M.  et  ft.  capsiilse  x. 
S. — One  capsule  every  hour  for  five  or  six  doses. 

Drugs  are  often  of  little  use  unless  the  patient  remains  in  bed  to  relieve 
internal  congestion  and  to  avoid  extension  or  recurrence.  Salicylates 
mitigate  the  frontal  pain.  Cool  baths  or  rubs  aid  in  averting  recur- 
rent attacks. 

(B).  HAY  FEVER. 

Catarrhus  sestivus,  or  summer  catarrh,  was  first  described  by  Bos- 
tock  (1819).  Morill  Wyman  first  described  the  "June"  or  "rose 
cold." 

Etiology. — Its  etiology  is  not  known,  but  the  disease  has  long  been 
associated  with  the  pollen  of  various  plants  and  grains.  Dunbar  be- 
lieves that  it  is  toxic,  resulting  from  albumoses  in  the  pollen.  It  pre- 
vails especially  in  England  and  the  United  States,  develops  in  persons 
between  fifteen  and  thirty  years  of  age,  and  occurs  twice  as  frequently  in 
males  as  in  females.  It  is  more  common  in  the  upper  educated  classes, 
and  perhaps  in  gouty  individuals;  it  is  most  prevalent  in  the  warm 
months,  and  in  cities.  Three  special  factors  are  noted:  (a)  A  predis- 
position, either  in  the  family  in  the  form  of  nervous  instability  or  other 
systemic  tendency,  (b)  An  irritability  or  other  nasal  abnormality,  as 
undue  nasal  turgescence,  or  irritability  to  dust,  smells,  etc.,  hyper- 
sesthesia  of  the  inferior  turbinates,  polyps,  or  septal  irregularities; 
Austin  Flint  became  asthmatic  from  sleeping  on  feather  pillows,  (c) 
The  exciting  cause,  or  irritant,  as  pollen,  dust,  sudden  change  of  tem- 
perature, and  apparently  in  some  cases  mental  excitement.  Strepto- 
cocci have  been  sometimes  found  in  the  nasal  secretion. 

Ssnnptoms. — The  onset  is  that  of  the  vulgar  coryza,  but  the  disease 
is  attended  by  more  constitutional  reaction  and  greater  depression. 
Injection  of  the  eyes  with  lachrymation  and  photophobia  usually  accom- 
panies or  precedes  the  coryza.    The  throat,  larynx,  and  bronchi  are 


HAY  FEVER  487 

dry  and  burning.  Moderate  fever,  100°  to  101°,  is  fairly  common. 
There  is  pain  over  the  frontal  sinuses  and  sometimes  over  the  temporal 
and  occipital  regions.  The  nasal  vessels  are  congested,  and  the  nose 
itself  becomes  swollen  and  injected,  resembling  closely  the  alcoholic 
facies.  In  many  cases  cough  develops;  this  is  frequently  followed  by 
asthmatic  seizures  which  simulate  bronchial  asthma.  Recurrences  are 
usual  and  attacks  of  coryza  may  alternate  with  asthmatic  paroxysms. 
With  the  first  frost  the  affection  stops,  as  if  by  magic.  The  outlook 
is  good  as  to  life,  for  only  isolated  instances  of  death  from  asthma  are 
recorded;   as  to  recovery,  the  outlook  is  much  less  favorable. 

Treatment. — (a)  Prophylactic  treatment;  cauterization  of  irritable, 
congested  or  hypertrophic  areas,  and  correction  of  polypoid  or  other 
abnormalities  cure  some  cases  and  alleviate  suffering  in  others,  (b) 
Nasal  treatment;  much  relief  may  be  given,  when  curative  measures 
fail,  by  nasal  douches,  by  painting  or  irrigating  the  nose  with  1  to 
1,000  adrenalin  and  astringent  solutions;  suprarenal  extract  in  doses 
of  gr.  ij  to  V  has  been  recently  used  internally,  as  has  nearly  every 
drug  in  the  Pharmacopoeia,  (c)  The  general  physiological  resistance 
is  increased  by  fresh  air,  by  cool  rubs,  and  by  tonics  and  nervines. 
(d)  Change  of  climate  is  advisable  before  the  date  on  which,  with 
certain- regularity,  hay  fever  appears;  a  sojourn  at  the  sea-side,  in 
Northern  Michigan,  in  Canada  and  especially  in  a  high  altitude,  often 
greatly  relieves  or  sometimes  wholly  checks  the  symptoms,  (e)  Asthma 
(v.  Bronchial  Asthma).  (/)  Dunbar's  serum,  patented  as  pollantin,  is 
used  in  the  nose  (not  hypodermatically)  every  morning,  as  a  powder. 
Lubbert  (1904)  in  505  cases  claims  that  59  per  cent,  recovered,  28 
per  cent,  were  benefited,  and  13  per  cent,  were  unaffected. 


(C).  CHRONIC  RHINITIS. 

Chronic  nasal  catarrh  properly  comes  under  the  care  of  the  special- 
ist, but  minor  cases  are  treated  by  the  practitioner;  some  are  due  to 
scrofula,  syphilis,  anaemia  or  to  other  constitutional  causes.  Chronic 
catarrh  may  develop  from  repeated  acute  attacks,  or  may  be  chronic 
from  the  onset. 

The  Hypertrophic  Form. — The  nasal  mucosa  is  red,  swollen,  spongy, 
and  is  covered  with  thick,  gray-yellow  secretion  which  may  dessicate 
and  sometimes  form  the  basis  of  rhinoliths.  Microscopically,  the 
bloodvessels  are  wide  and  are  surrounded  by  round  cells,  and  the 
submucosa  is  thickened.  The  nasal  obstruction  necessitates  oral 
breathing,  partially  nasal  speech,  obtunded  taste  and  smell,  and 
produces  an  elevation  of  the  hard  palate  and  a  peculiar  facial  expres- 
sion. The  secretion  is  usually  thick,  yellow  and  purulent,  rarely  thin 
and  abundant  (rhinorrhoea).  This  type  is  often  associated  with 
adenoids  and  follicular  hyperplasia  in  the  pharynx.  The  lachrymal 
duct  may  be  obstructed,  and  Eustachian  occlusion  may  induce  perma- 
nent deafness;    laryngitis,  bronchitis,  bronchial  asthma,  polyps,  and 


488  DISEASES  OF  THE  RESPIRATORY  TRACT 

sinus  disease  are  not  infrequent  complications.  Nasal  disease  may  be 
the  cause  of  blepharospasm  or  other  facial  spasms,  limitation  of  the 
field  of  vision,  vertigo,  and  mental  depression;  and  even  psychoses  are 
attributed  to  nasal  reflexes.  Fliess  attributes  many  dysmenorrhoeas  to 
chronic  rhinitis.  In  its  treatment  possible  constitutional  factors,  as 
ana?mia,  syphilis  or  scrofula,  are  to  be  considered.  Douches  of  car- 
bolic acid,  insufilations  of  equal  parts  of  alum  and  calomel,  and  cauter- 
ization by  the  galvanic  cautery  or  by  chromic  acid,  are  indicated. 
Douches  should  be  given  under  low  pressure,  lest  fluid  reach  the  middle 
ear. 

The  Atrophic  Form. — It  is  disputed  whether  this  form  begins  as 
an  atrophic  process  or  results  from  hypertrophic  disease.  It  is  more 
frequent  in  females  and  usually  begins  early  in  life.  The  mucosa  is 
pale  and  dry,  its  epithelium  is  lost  or  has  suffered  marked  metaplasia, 
the  erectile  tissue  wastes,  the  nasal  passages  are  unduly  roomy  and 
there  is  but  little  secretion,  which  dries  in  the  nose  and  emits  a  most 
offensive  odor  (ozosna).  Its  actual  cause  is  not  determined.  Various 
of  the  common  microorganisms  have  been  found,  but  the  Bacillus 
foetidus.  Bacillus  mucosus  and  Bacillus  fluorescens  liquefaciens  are 
believed  to  be  causative  factors.  Grosheintz  and  Meiser  have  noted 
its  association  with  a  widening  of  the  face  in  33  per  cent,  of  cases. 
Its  sequences  are  similar  to  those  of  the  hypertrophic  variety. 

Treatment. — The  results  of  treatment  are  not  satisfactory.  Douches 
of  a  1  per  cent,  permanganate  of  potash  solution,  iodoform  insufflations, 
massage  with  iodine  one  part,  potas.  iodide  10,  and  glycerine  100 
parts,  and  packing  with  gauze  soaked  in  balsam  of  Peru  are  usually 
employed.  Paraffin  injections  beneath  the  mucous  membrane  have 
lately  been  recommended  to  restore  the  normal  lumen  of  the  nasal 
passages. 

(D).  RHINITIS   FIBRINOSA. 

Rhinitis  fibrinosa  has  been  spoken  of  in  connection  with  nasal  diph- 
theria, to  which  it  is  most  often  due.  It  may  result  from  streptococcus 
and  staphylococcus  infection;  it  is  observed  in  measles,  scarlatina, 
pneumonia,  and  typhoid,  and  it  also  occurs  as  an  independent  lesion. 
Irrigation  with  1  per  cent,  carbolic  acid  or  1  to  1 ,000  sublimate  solu- 
tion is  usually  efficacious.  Antitoxin  is  indicated  in  infection  by  the 
Klebs-Loeffler  bacillus. 

(E).  EPISTAXIS. 

Epistaxis  is  a  symptom  only.  Its  causes  may  be  grouped  as  follows: 
(a)  Local  nasal  lesions,  trauma,  chronic  and  acute  catarrh,  picking 
of  the  nose,  foreign  bodies,  ulcerations  (simple,  tuberculous,  syphilitic, 
carcinomatous),  and  angioma.  Osier  reports  cases  of  epistaxis  asso- 
ciated with  telangiectasis  of  the  skin  and  nasal  mucosa.  (6)  Hyper- 
cemia,  either  venous  as  in  cardiac,  respiratory  and  other  obstructive 


ACUTE  CATARRHAL  LARYNGITIS  489 

lesions,  or  arterial  as  in  hypertrophy  of  the  left  ventricle  caused  by 
aortic  leakage,  and  as  in  interstitial  nephritis,  atheroma,  apoplectic 
habitus,  and  gout.  Some  cases  are  seemingly  vicarious  to  suppressed 
menstruation  or  hemorrhoidal  bleeding,  (c)  Acute  infections,  prin- 
cipally typhoid,  less  frequently  the  others,  (d)  Hemorrhagic  diseases, 
as  pernicious  anaemia,  chlorosis,  leukaemia,  pseudoleuksemia,  scurvy, 
haemophilia,  Werlhof's  disease  and  cachexias,  (e)  Other  conditions, 
as  liver  cirrhosis,  pregnancy,  icterus,  diabetes,  weakly  constitution, 
and  puberty;  baloon  ascensions  or  high  altitudes  are  also  causative 
factors. 

The  most  frequent  point  of  hemorrhage  is  the  lower  anterior  part 
of  the  cartilaginous  septum.  The  symptoms  are  chiefly  the  local 
hemorrhage  from  the  anterior  nares,  but  occasionally  bleeding  may 
occur  further  back  in  the  nose,  and,  trickling  into  the  pharynx,  may 
simulate  hemorrhage  from  the  stomach  when  vomited,  from  the 
intestine  when  passed  with  the  stool,  or  from  the  lung  when  coughed  up. 

Occasionally  urgent  acute  anaemia  or  even  death  may  occur,  espe- 
cially when  there  is  "blood  dissolution"  as  in  blood  diseases. 

Treatment. — The  patient  should  be  kept  quiet,  in  the  semi-erect 
posture.  After  douching  the  nose  with  hot  or  ice-cold  water  to  which 
adrenahn  1  to  1,000  or  some  tr.  ferri  chloridi  has  been  added,  the 
nose  should  be  tamponed  by  Bellocq's  catheter,  or  in  less  serious 
cases  the  patient  should  be  enjoined  not  to  blow  the  nose,  for  this 
only  dislodges  the  forming  clot.  Gelatin  may  be  injected  into  the  nose, 
besides  being  injected  hypodermatically.  Internal  remedies,  as  ergotin, 
are  very  unsatisfactory.     Erosions  or  ulcers  may  later  be  cauterized. 


DISEASES  OF  THE  LAEYNX. 

(A).  ACUTE  CATARRHAL  LARYNGITIS. 

Etiology. — Though  acute  catarrhal  laryngitis  is  observed  at  every 
age  and  in  all  climates,  most  cases  occur  in  males  between  twenty 
and  forty,  and  in  cold,  windy,  changeable  weather,  (a)  Cold  is  fre- 
quently an  apparent  factor,  but  probably  operates  only  by  lessening 
the  resistance,  and  this  occurs  .to  a  greater  extent  in  delicate  than 
in  robust  subjects;  the  bacteriology  of  these  "rheumatic"  cases  is 
unknown  but  its  occasionally  epidemic  prevalence  is  suggestive  of  an 
infection,  (b)  Acute  laryngitis  may  complicate  acute  (or  chronic) 
affections  such  as  measles,  scarlatina,  pertussis,  typhoid,  hay  fever  or 
syphilis,  tuberculosis,  and  lupus,  (c)  Exterision  may  be  caused  per 
contiguitatem  from  the  nose,  pharynx  or  bronchi;  oral  breathing  is  a 


490  DISEASES  OF  THE  RESPIRATORY  TRACT 

somewhat  predisposing  factor,  (d)  Chemical,  thermal,  or  mechanical 
agents,  as  dust  of  all  kinds,  foreign  bodies,  trauma,  overuse  or  abuse 
of  the  voice,  alcoholism,  inhalation  of  tobacco  smoke,  chlorine  or 
bromine,  and  internal  use  of  iodides  are  etiological  factors,  (e) 
Stasis  from  thoracic  lesions  or  enlarged  thyroid,  local  ulcerations  in 
the  larynx,  nephritis,  liver  disease,  chlorosis,  and  rhachitis  are  also 
causes. 

Sjmiptoms. — A  sudden  onset,  with  fever,  chill,  rapid  pulse  or  dys- 
pnoea is  seldom  observed.  The  local  symptoms  are  a  sense  of  rawness 
or  tickling,  dry,  even  spasmodic  cough,  and  moderate  pain  on  breath- 
ing, as  the  larynx  is  hypersensitive;  sometimes  external  tenderness  or 
some  dysphagia  may  occur,  usually  from  coincident  pharyngitis.  After 
a  day  or  so  a  thin,  transparent,  and  slightly  cellular  sputum  appears, 
which  later  becomes  purulent,  yellow  or  in  very  rare  cases,  hemor- 
rhagic. Some  cases  void  no  sputum  (laryngitis  sicca).  The  voice 
becomes  hoarse  or  is  wholly  lost.  The  laryngoscope  reveals  diffuse 
or  circumscribed  redness,  viscid  mucus,  some  swelling,  and  occasion- 
ally epithelial  erosions.  The  false  cords  are  often  swollen.  The  true 
cords  lose  their  smooth,  glistening  appearance  and  become  injected 
and  uneven,  so  that  their  even  coaptation  is  hindered.  The  swollen 
mucosa  may  get  between  the  cords,  and  their  infiltrated  muscles  are 
often  paretic.  The  acute  symptoms  last  for  a  day  or  two  and  the 
catarrh  remains  about  a  week  longer. 

Diagnosis. — Diagnosis  is  usually  easy;  nervous  aphonia  and  cordal 
paralysis  are  distinguished  by  means  of  the  mirror  (see  Vagus  Dis- 
ease, under  Nervous  System). 

Treatment. — Prophylaxis  covers  the  etiological  factors;  alcohol 
and  tobacco  should  be  forbidden.  The  general  resistance  is  increased 
by  cold  rubbings,  douches  or  baths,  and  exposure,  locally,  of  the  neck; 
mufflers  should  be  avoided  and  cold  water  should  be  applied  over 
the  larynx.  The  voice  must  be  used  carefully  and  the  nose,  uvula 
and  pharynx  should  be  examined  for  predisposing  lesions. 

The  therapy  of  the  established  lesion  is  as  follows:  At  the  onset 
sweating  should  be  induced  by  hot  drinks  and  by  a  hot  bath;  Dover's 
powder  and  quinine,  each  gr.  x,  or  aconite,  are  indicated  as  in  coryza; 
rest  in  bed  is  necessary.  The  voice  must  not  be  used.  If  the  symp- 
toms persist,  an  ice-bag  should  be  applied  locally;  codeine  or  morphine 
with  bromides,  and  inhalations  of  moist  air  or  steam  should  be  given, 
as  described  under  Acute  Bronchitis. 

Heroin  hydrochloratis gr.  j. 

Terpene  hydratis      • gr.  xl. 

Ammonii  chloridi ' oss. 

Extr.  glycyrrhizse 5j. 

M.  et  ft.  capsulae  xv.  ' 

S. — One  after  meals. 

Painting  the  larynx  with  a  3  per  cent,  silver  nitrate  solution  is  recom- 
mended by  some  physicians  and  is  condemned  by  others  as  promoting 
submucous  extension. 


ACUTE  CATARRHAL  LARYNGITIS     ■  491 

In  children  acute  laryngitis  is  often  attended  by  great  swelling 
above  and  below  the  cords  and  by  stenotic  manifestations  in  the  small, 
infantile  larynx.  The  symptoms  closely  approach  those  of  genuine 
croup  (laryngeal  diphtheria),  from  which  it  is  distinguished  as  false 
croup,  faux  croup  (Guersant)  or  laryngite  striduleuse  (Bretonneau). 
After  an  attack  of  mild  laryngitis,  coryza  or  sore  throat,  the  child 
becomes  restless  and  anxious,  usually  during  the  night  when  the 
secretion  accumulates.  Inspiratory  dyspnoea  develops,  there  is  inspir- 
atory retraction  of  the  interspaces  and  epigastrium,  the  accessory 
muscles  of  respiration  come  into  play,  cyanosis  appears  and  asphyxia 
seems  to  be  imminent.  The  paroxysm  subsides,  spontaneously  or 
after  an  emetic  has  been  given,  but  it  occurs  again  on  the  next  two 
or  three  nights.  The  catarrhal  symptoms  may  last  from  three  days  to 
a  week.  Trousseau  remarked  that  there  is  rarely  the  complete  aphonia 
which  is  observed  in  laryngeal  diphtheria.  The  diagnosis  is  made  from 
the  history  of  coryza;  the  absence  of  diphtheritic  patches  in  the  phar- 
ynx, for  diphtheria  is  eminently  a  descending  infection;  the  absence 
of  diphtheria  bacilli,  found  in  diphtheria  even  when  the  throat  seems 
normal;  and  the  absence  of  severe  constitutional  reaction.  Laryn- 
gismus stridulus  {v.  Vagus  Nerve)  is  not  attended  by  fever,  laryngitis, 
or  aphonia.  The  laryngoscope  may  reveal  the  simple  oedematous  laryn- 
gitis, but  examination  is  notoriously  difficult  in  easily  frightened  chil- 
dren. Treatment  is  the  same  as  in  acute  laryngitis  of  adults;  hot 
drinks,  inhalation  of  steaming  water  and  ipecac  should  be  given  to 
induce  vomiting  and  evacuation  of  laryngeal  secretion ;  von  Niemeyer 
awakened  the  patient  at  intervals  and  gave  a  hot  drink  to  evacuate  the 
mucus.  Widerhofer  also  noted  excellent  results  from  washing  away 
any  pharyngeal  mucus,  which  he  considers  causative  of  the  attacks. 
The  attendant  should  be  prepared,  in  doubtful  cases,  for  intubation 
or  tracheotomy. 

Other  acute  forms  are  (a)  laryngitis  acuta  nodosa,  which  is  observed 
in  acute  rheumatism  and  which  yields  to  salicylates,  (b)  Laryngitis 
fibrinosa,  which  is  usually  diphtheria,  but  which  may  be  caused  by  a 
streptococcus  infection  in  measles,  scarlatina  or  other  infections,  and 
which  sometimes  results  from  inhalations  of  steam,  or  chlorine,  (c) 
Laryngitis  suhmucosa  acuta  invades  the  submucous  tissues  and  is 
seropurulent.  This  rare  affection  may  develop  as  an  independent 
lesion,  may  follow  a  similar  process  in  the  pharynx,  or  may  represent 
a  septic  localization.  During  invasion  the  symptoms  are  severe,  with 
fever,  rigor,  delirium  and  other  septic  phenomena.  The  laryngoscope 
shows  injection  and  yellow-white  bulging  areas  of  submucous  suppura- 
tion which,  without  operation,  almost  invariably  cause  death  by  oedema 
of  the  larynx  or  by  sepsis,  for  spontaneous  rupture  is  exceptional. 
For  treatment  (a)  an  ice-bag  should  be  placed  over  the  larynx,  mor- 
phine should  be  given  for  pain,  and  whisky  for  the  sepsis;  (6)  incision 
of  the  foci  is  indicated;  and  (c)  if  necessary,  intubation  or  tracheotomy 
should  be  performed. 


492  DISEASES  OF  THE  RESPIRATORY  TRACT 


(B).   CHRONIC   CATARRHAL  LARYNGITIS. 

Etiology. — The  etiology  of  this  type  is  practically  identical  with 
that  of  the  acute  form,  of  which  it  frequently  follows  repeated  attacks ; 
it  is  often  associated  with  or  is  dependent  on  pharyngitis  or  rhinitis. 

Symptoms. — The  symptoms  are  those  of  the  acute  form,  though 
less  intense.  Hoarseness  alternates  with  fairly  normal  phonation.  By 
the  mirror  there  may  be  seen  injection,  darker  than  in  the  acute  form, 
swelling,  secretion,  and  sometimes  stains  from  small  hemorrhages. 
There  are  forms  with  no  secretion  {laryngitis  sicca  chronica);  the 
secretion  is  rarely  like  that  of  ozsena,  with  glandular  atrophy.  In 
some  forms  granules  appear,  less  from  glandular  hyperplasia  than  from 
proliferation  of  connective  tissue  (laryngitis  granulosa).  Erosions  and 
rhagades  may  develop  on  the  edges  of  the  cords,  or  arytenoid  carti- 
lages.    Ulcers  are  most  often  syphilitic  or  tuberculous. 

Treatment. — Treatment  of  the  cause  and  prophylactic  measures  are 
the  same  as  in  the  acute  form.  Inhalations  of  1  per  cent,  tannic  acid 
or  of  1  per  cent,  turpentine  and  sod.  bicarbonate  in  solution;  insuffla- 
tions of  tannic  acid,  lead  acetate  and  alum  aa  gr.  i;  and  according 
to  some  physicians,  painting  the  larynx  every  third  day  with  a  2  to 
10  per  cent,  solution  of  silver  nitrate  with  the  aid  of  the  laryngoscope, 
are  valuable.  Terpine  hydrate  gr.  iij  t.  i.  d.  is  often  helpful.  Cold 
water  applied  over  the  larynx,  faradization,  compressed  air,  and  sea 
air  may  be  beneficial. 

Other  Chronic  Forms. — Chorditis  tuherosa  occurs  as  small  grayish 
nodes  on  the  cordal  edges  at  the  junction  of  their  anterior  and  middle 
thirds,  especially  in  singers  and  in  alcoholics  (Stoerk) ;  they  are  com- 
posed of  fibrous  and  epithelial  hypertrophy.  Scarification  and  lactic 
acid  are  indicated  {v.  Tuberculosis). 

Pachydermia  laryngis  (Virchow)  is  an  increase  of  the  submucous 
tissue  and  transformed  epithelium  into  which  connective  tissue  grows; 
it  is  circumscribed  or  diffuse.  Warty  excrescences  are  common  between 
the  arytenoids,  and  the  thick  mucosa  is  sometimes  umbilicated  and 
may  resemble  cancer.  Topical  application  of  salicylic  or  lactic  acid, 
iodine  in  glycerine,  electrolysis  and  the  cautery  are  indicated.  Polyps 
may  result  from  chronic  laryngitis. 

Laryngitis  hypertrophica  inferior  is  a  hyperplasia  of  the  mucous 
and  submucous  tissue  below  the  cords,  and  is  identified  by  some 
clinicians  with  nasal  rhinoscleroma,  which  is  due  to  the  extension  of 
the  rhinoscleroma  bacillus  from  above  downward.  It  may  cause 
stenosis  of  the  larynx,  which  the  author  saw  in  one  of  Kolisko's  autop- 
sies. It  is  treated  by  scarification,  dilitation,  prolonged  intubation, 
iodides,  or,  when  extreme,  by  tracheotomy. 


(EDEMA  OF  THE  LARYNX  493 


(C).  (EDEMA  OF  THE  LARYNX. 

(Edema  laryngis  is  a  more  proper  designation  than  oedema  glottidis, 
as  the  vocal  cords  are  very  seldom  involved.  It  is  most  marked  where 
the  submucous  tissue  abounds  and  is  greatest  therefore  about  the 
epiglottis  and  ary-epiglottidean  folds;  it  may  develop  under  the  cords. 
It  varies  with  its  cause,  and  may  be  bilateral,  unilateral,  diffuse  or 
circumscribed.  x4LCcording  to  Sestier,  70  per  cent,  of  cases  occur  in 
males  and  89  per  cent,  in  those  over  fifteen  years. 

Etiology. — There  are  three  etiological  forms  besides  some  obscure 
cases,  (a)  Inflammatory  oedema  results  from  various  inflammatory  dis- 
eases of  the  larynx,  submucous  suppuration,  or  perichondritis;  from 
typhoid,  syphilitic,  tuberculous  or  cancerous  ulceration;  from  iodides; 
from  trauma,  surgical  measures,  thermic,  chemical  and  allied  causes; 
from  extension  from  pharyngitis,  parotitis,  or  cervical  cellulitis;  and 
from  infections,  as  typhoid  or  measles,  (b)  Congestive  and  hydrcemic 
forms  result  from  chronic  heart  and  lung  disease,  from  tumors  and 
nephritis,  in  which  it  may  antedate  oedema  elsewhere,  or  from  cachec- 
tic conditions  as  carcinosis  or  amyloidosis,  (c)  Angioneurotic  oedema, 
as  in  R.  S.  Morris's  fatal  case,  is  the  last  type. 

Symptoms. — Symptoms  appear  with  varying  acuity,  sometimes 
most  suddenly,  as  in  Bright's  disease,  at  other  times  more  gradually  but 
progressively,  and  again  quite  slowly.  Hoarseness  or  aphonia,  and  a 
metallic  cough  are  common.  The  chief  sign  is  inspiratory  dys'pnoea, 
which  characterizes  nearly  all  forms  of  laryngeal  stenosis.  It  is  usually 
stridulous  or  wheezing;  and  is  attended  by  retraction  of  the  inter- 
spaces, cyanosis,  up-and-down  excursion  of  the  larynx  and  ultimate 
suffocation.  The  mirror  shows  a  pallid  swelling  in  the  parts  enumer- 
ated, incision  of  which  allows  the  escape  of  a  clear  serum.  OEdema 
of  the  epiglottis  and  ary-epiglottidean  folds  may  be  felt  with  the  finger 
if  the  mouth  is  held  open  and  the  tongue  drawn  forward,  or  it  may  be 
seen  even  without  the  mirror  if  the  larynx  is  pushed  up  and  the  tongue 
deeply  depressed. 

Treatment. — Treatment  is  urgent,  irrespective  of  the  cause,  for  the 
large  mortality  (75  per  cent.)  is  due  to  delay  until  the  patient's  strength 
is  exhausted.  The  placing  of  ice  over  the  larynx,  the  swallowing  of  ice, 
drastic  purgatives  and  painting  the  larynx  with  10  per  cent,  silver 
solution  are  at  best  palliative.  The  oedematous  tissue  should  be  fully 
incised,  and,  in  case  this  should  fail,  intubation  or  tracheotomy  should 
be  performed. 

(D).  PERICHONDRITIS  LARYNGIS. 

Purulent  inflammation  beneath  the  perichondrium  of  the  cartilages 
of  the  larynx  is  very  seldom  primary,  but  nearly  always  results  second- 
arily to  various  inflammations  or  ulcerations.  Pus  accumulates 
between  the  perichondrium  and  cartilage,  most  frequently  the  aryte- 


494  DISEASES  OF  THE  RESPIRATORY  TRACT 

noid  or  cricoid,  or  less  frequently  the  thyroid  or  epiglottic.  It  may 
burrow;  the  cartilage  may  become  secondarily  necrosed.  Perichon- 
dritis laryngis  most  often  develops  in  males  between  twenty  and  forty 
years  of  age. 

Symptoms. — Its  symptoms  are  commonly  obscured  by  the  causal 
disease.  The  rare  primary  cases  are  the  most  acute.  Well  localized 
pain  and  tenderness  are  peculiarly  significant.  Dysphagia,  especially 
from  arytenoid  involvement,  is  frequent,  and  even  aphagia  may  result. 
Phonation  is  impaired  by  the  fundamental  disease,  by  cord  paresis  and 
muscular  infiltration.  The  cervical  glands  sometimes  tumefy.  Stenosis 
and  dyspnoea  are  present.  The  mirror  discloses  focal  accumulation  of 
pus,  swelling,  redness,  oedema  and  perhaps  fistulse  which  signify  intra- 
laryngeal  rupture.  The  probe  may  elicit  tenderness  or  may  scrape 
on  eroded  cartilage.  The  diagnosis  from  laryngitis  and  oedema  is 
often  impossible,  or  at  best  but  probable  unless  definite  pus  pockets  are 
seen.  The  outcome  may  be  suddenly  fatal  from  rapid  oedema;  pus  and 
cartilage  fragments  may  rupture,  thus  giving  relief  or  perhaps  oc- 
cluding the  larynx;  fistulse,  internal  or  external,  may  remain,  and 
may  burrow  to  the  mediastinum,  or  sepsis  may  follow;  aspiration 
pneumonia  is  not  uncommon,  and  if  immediate  recovery  ensues,  a 
distorted  or  stenosed  larynx  may  remain. 

Treatment. — Treatment  is  similar  to  that  of  acute  laryngitis;  the 
pain  should  be  relieved  by  opiates,  but  early  incision  under  cocaine  is 
necessary,  and  the  physician  should  be  prepared  to  perform  trache- 
otomy or  intubation. 


(E).  ULCERATIONS  AND  NEOPLASMS  OF  THE  LARYNX. 

The  tuberculous  and  syphilitic  ulcers  have  been  considered. 
Superficial  erosions  may  follow  catarrh;  deep  ulcers  result  from  sub- 
mucous suppuration  or  from  perichondritis,  pressure  ulcers  from 
foreign  bodies  or  laryngeal  "bed  sores"  (v.  Typhoid);  some  clinicians 
consider  the  latter  to  be  an  ulceration  analogous  to  intestinal  ulcer- 
ation.   There  are  also  the  specific  ulcerations  of  leprosy,  glanders,  etc. 

Tumors  include  benign  single  or  multiple  papillomata  located  on  the 
true  cords  (singer's  nodes  -y.s.), fibromata,  cysts,  amyloid  accretions,  en- 
chondromata,lipomata,  and  the  malignant  tumors,  of  which  carcinoma 
is  far  more  frequent  than  sarcoma.  Primary  cancer  develops  slowly  on 
the  posterior  third  of  the  cords  or  in  other  locations,  as  an  excrescence 
which  gradually  assumes  a  cauliflower  appearance;  the  basis  of  the 
later  ulceration  is  nodular  and  there  is  no  scar  formation  (v.  Syphilis, 
Larynx)  ;  hoarseness  is  an  early  symptom ;  all  kinds  of  incipient  tumors 
are  frequently  mistaken  for  laryngitis.  Pain  which  may  radiate  to  the 
ears  or  temples,  cough,  and  dysphagia  are  constant  in  the  advanced 
stage.  Early  operation,  either  intralaryngeal  or  by  splitting  the  thy- 
roid, will  alone  afford  relief;  inoperable  cases  must  necessarily  be 
narcotized. 


ACUTE  BRONCHITIS  495 

Nervous  aphonia,  the  'paralyses  and  spasms  of  the  larynx  are  con- 
sidered under  affections  of  the  vagus  nerve;  syphihs  and  tuberculosis 
have  already  received  consideration. 


DISEASES  OF  THE  TRACHEA  AND  BRONCHI. 

The  trachea  is  seldom  involved  alone.  Tracheitis  is  frequent,  v^^ith 
inflammation  of  the  larynx  and  bronchi.  Henibrrhage  may  result  from 
diapedesis  or  from  ruptured  varices.  Tuberculosis,  syphilis  and 
tumors  are  very  infrequent. 

(A).  ACUTE  BRONCHITIS. 

Acute  bronchitis  is  a  most  frequent  primary  or  secondary  disease,  in 
some  localities  constituting  10  to  15  per  cent,  of  all  diseases.  It  occurs 
most  frequently  in  cold,  dusty  or  variable  weather;  three-fourths  of  all 
cases  occur  between  December  and  April.  Its  forms  are  (a)  inflam- 
mation of  the  larger  air  tubes,  bronchitis,  tracheobronchitis  or  macro- 
bronchitis,  and  (b)  inflammation  of  the  smaller  tubules,  known  as 
bronchiolitis,  capillary  bronchitis  or  microbronchitis,  which  in  children 
is  identical  with  bronchopneumonia  (q.  v.). 

Etiology. — (a)  It  is  a  symptom  of  various  infections,  as  measles, 
pertussis,  influenza  and  typhoid;  it  also  occurs  frequently  in  scarlatina, 
variola,  malaria,  pneumonia,  diphtheria,  erysipelas,  syphilis,  tuber- 
culosis, sepsis,  glanders,  actinomycosis,  and  anthrax.  In  these  maladies 
bronchitis  is  secondary  and  results  from  the  germs  or  their  toxins.  (6) 
It  may  result  from  the  toxic  effects  of  potassium  iodide  or  bromide, 
tobacco,  less  often  carbolic  acid,  cantharides,  mercury  and  alcohol, 
which  according  to  Hoffman,  acts  locally  on  the  air  passages,  (c) 
Mechanical  irritants  are  dust,  and  other  foreign  particles,  as  flour  dust, 
particles  of  wool, metals, stone,  etc.,  which  exist  in  many  factories;  over- 
use or  abuse  of  the  voice  is  also  a  mechanical  irritant,  {d)  Constitu- 
tional conditions,  as  obesity,  nephritis,  rhachitis,  gout,  scrofula,  anajmia, 
diabetes,  malnutrition  and  cachexia  of  various  kinds,  such  as  cancer, 
syphilis,  or  scurvy,  are  important  etiological  conditions,  (e)  Venous 
stasis  in  the  lesser  circuit  favors  bronchitis,  by  congesting  the  pulmo- 
nary veins,  which  empty  chiefly  into  the  vena  cava  superior  and  vena 
azygos;  mitral  lesions  are  the  most  important,  but  other  valvular  dis- 
ease, arteriosclerosis,  scoliosis,  abdominal  tumors,  ascites  or  pleurisy, 
all  of  which  affect  the  diaphragmatic  excursion,  are  possible  factors. 
(/)  Respiratory  diseases,  as  pneumonia,  tuberculosis,  abscess  or  gan- 


496  DISEASES  OF  THE  RESPIRATORY  TRACT 

grene  of  the  lung,  asthma,  bronchial  stenosis,  and  bronchiectasis  are 
usually  associated  with  bronchitis.  (g)  Cold  and  bacteria  are  also 
etiological  factors.  It  is  disputed  whether  cold  alone  is  an  adequate 
factor  without  the  cooperation  of  bacteria,  but  it  at  least  plays  a 
potent  predisposing  part.  Even  in  cases  of  apparently  primary  bron- 
chitis, the  pneumococcus,  pyogenic  cocci,  Friedlander's  pneumo- 
bacillus  and  other  bacteria  are  found  {v.  s.).  Pfeiffer's  micrococcus 
catarrhalis  is  found  in  59  per  cent,  of  cases  (Ghon,  Pfeiffer);  it 
is  larger  than  the  staphylococcus  and  often  occurs  in  pairs,  (h)  Age 
is  a  factor.  Acute  bronchitis  may  develop  at  any  time  of  life,  but  is 
peculiarly  frequent  in  the  aged  and  in  children  between  six  months  and 
three  years  old. 

Symptoms. — 1.  Acute  bronchitis  of  the  larger  tubes  (macrobron- 
chitis  or  tracheobronchitis)  begins  (a)  with  some  constitutional  depres- 
sion, sometimes  with  fever  and  chilliness  or  in  children  even  with 
marked  toxsemic  symptoms.  It  often  follows  acute  coryza  or  pharyn- 
gitis, (b)  The  local  symptoms  are  substernal  rawness  or  tickling;  actual 
pain  or  tenderness  over  the  sternum  is  mostly  tracheal  or  muscular,  for 
the  bronchi  have  apparently  no  nerves  for  perception  of  pain.  On  in- 
spection of  the  trachea  there  is  visible  inflammation,  redness,  diffuse  or 
circumscribed  injection,  submucous  ecchymosis,  swelling  and  laxness 
of  the  mucosa,  and  dryness,  which  is  followed  by  the  appearance  of 
a  viscid  transparent  glairy  mucous  secretion;  the  mucous  glands  are 
often  distended  by  globules  of  mucin  which  slightly  resemble  young 
tubercles;  most  of  these  findings  are  also  noted  in  the  bronchi  in  the 
rare  cases  which  come  to  autopsy,  but  injection  and  redness  largely 
disappear  after  death.  Microscopically  the  cardinal  signs  of  inflam- 
mation are  found,  such  as  paresis  of  the  vessels,  round  cell  emigra- 
tion, desquamation  of  the  ciliated  epithelium,  and  compensatory  efforts 
at  restoration  by  multiplication,  (c)  The  cough  is  at  first  dry  and  un- 
productive and  may  remain  so.  Later  a  viscid,  transparent  sputum 
is  raised,  consisting  almost  wholly  of  mucin  and  very  few  white  cells 
(sputum  crudum).  A  day  or  two  later  the  coughing  efforts  become  less 
severe  as  the  sputum  grows  more  abundant  and  mucopurulent  (sputum 
coctum) ;  it  contains  polymorphonuclear  and  sometimes  abundant 
eosinophilic  leukocytes,  epithelial  cells  showing  myeloid  degeneration, 
and  rarely  ciliary  epithelium  or  hemorrhagic  spots.  Localized  inflam- 
mation at  the  tracheal  bifurcation  causes  special  irritation  (Nothna- 
gel).  (d)  The  symptoms  resulting  from  cough  are  disturbed  sleep; 
hoarseness  from  forcible  closure  of  the  glottis  in  coughing  efforts; 
pain  in  the  side  or  at  the  diaphragmatic  insertion,  from  unusual 
strain  on  the  expiratory  muscles  during  coughing;  venous  stasis  which 
induces  headache,  vertigo,  swollen  cervical  veins,  cyanosis  and  epis- 
taxis;  mechanical  sequences,  as  vomiting,  involuntary  urination,  es- 
pecially in  weak  and  old  subjects;  and  in  women,  even  abortion, 
uterine  prolapse,  or  hernia  may  occur.  (e)  Physical  findings  are 
usnSiWj  bilateral;  unilateral  signs,  though  possible,  suggest  other  lesions, 
especially  tuberculosis.     Auscultation    reveals   rhonchi,  which    result 


ACUTE  BRONCHITIS  497 

from  swelling  of  the  bronchial  mucosa,  from  slight  stenosis  by  bron- 
chial secretion  and  from  air  passing  through  or  dislodging  the  secretion. 
The  rhonchi  at  first  are  dry  (r.  sicci),  and  later  moist  (r.  humidi). 
Over  the  large  tubes  these  rales  are  sonorous,  in  the  smaller  tubules 
they  are  sibilant,  and  in  both  they  vary  acoustically.  They  may  be 
heard  simultaneously  over  the  large  and  small  passages,  or  success- 
ively, over  the  large  and  then  over  the  small  tubules.  These  rales,  large 
and  small,  may  be  felt  with  the  hand  (mucous  fremitus)  or  may  be 
heard  without  the  stethoscope.  The  breathing  may  be  ''cog-wheel," 
lengthened,  slowed  or  sometimes  increased  by  fever,  but  in  quality  it  is 
only  exaggerated  or  puerile,  never  bronchial.  Percussion  is  wholly 
negative.  Macrobronchitis  lasts  but  a  few  days,  possibly  a  little 
longer  than  a  week. 

2.  Microbronchitis  or  capillary  bronchitis  is  essentially  the  same 
pathological  process  as  macrobronchitis  but  will  be  considered  under 
bronchopneumonia,  because  of  its  great  tendency,  especially  in 
children,  toward  pulmonary  inflammation. 

Treatment. — In  the  early  stage  a  full  hot  hath  may  be  given,  followed 
by  a  hot  alcoholic  drink.  A  hot  Turkish  bath  should  never  be  taken, 
for  exposure  afterward  is  dangerous.  Hot  jomentations  over  the 
sternum  are  beneficial;  a  hot  water  bag  or  a  large  poultice  may  be 
applied  over  the  sternum,  but  cold  packs  over  the  neck  and  chest  are 
even  more  efficacious.  Patients  should  always  be  kept  in  bed,  for  but 
few  cases  recover  promptly  without  this  treatment.  A  mild  laxative 
should  be  given  early.  A  drink  or  two  of  well  diluted  whisky  is 
valuable.  When  the  initial  symptoms  appear  gr.  x  of  Dover's 
powder  should  be  given;  it  not  only  relieves  pain  and  coughing  but  also 
appears  to  inhibit  or  modify  the  inflammation;  in  children  it  should  be 
given  with  great  caution  because  of  the  frequently  unequal  mixture  of 
its  constituents,  and  the  peculiar  susceptibility  of  the  youthful  nervous 
system  to  narcotics;  in  the  aged  it  should  likewise  be  administered 
with  care,  because  the  kidneys  in  old  persons  excrete  slowly,  and  cere- 
bral atheroma  may  induce  sudden  urgent  symptoms,  as  psychical  dis- 
turbance, Cheyne-Stokes  breathing,  and  other  basilar  disturbances. 
The  administration  of  opiates  should  be  followed  by  some  valine 
aperient.  Muscidar  pain  necessitates  massage  and  administration  of 
opiates.  Other  treatment  is  frequently  superfluous,  but  if  the  symptoms 
and  cough  persist  or  if  the  initial  symptoms  are  rather  severe  we  ad- 
minister: 

Vini  antimonii oiv. 

Heroin  hydrocUoratis gr.  iss. 

Vini  ipecacuanhse ov. 

Syr.  tolutani q.s.  ad   Bij. 

M.  et  S. — One  teaspoonful  every  three  or  four  hours.    The  patient  should  be 
watched  lest  gastric  symptoms  appear. 


32 


498  DISEASES  OF  THE  RESPIRATORY  TRACT 

Potassii  citratis 5iiss.    3j- 

Codeinse  sulphatis gr.  iv,  gr.  j. 

Syrupi  ipecacuanhse ; oiv.      5iss. 

Succi  limonis 5j-        oss. 

Aquse q.s.  ad   oij.      oij. 

M.  et  S; — One  teaspoonful  every  two  hours.    The  first  column  is  the  dosage  for 
adults,  the  second  for  children. 

The  fever  rarely  requires  treatment;  if  high,  aconite  and  belladonna 
may  be  given,  as  in  coryza,  but  tepid  sponging  is  more  beneficial.  A 
kettle  should  be  kept  boiling  in  the  room  to  moisten  the  atmosphere,  or 
a  steam  tent  may  be  advisable  as  in  croup  (see  Diphtheria).  If  the 
bronchitis  lingers  longer,  the  formulae  given  under  chronic  bronchitis 
will  be  useful. 

(B).  CHRONIC  BRONCHITIS. 

Etiology. — The  etiology  is  essentially  that  of  the  acute  type.  Chronic 
bronchitis  is  more  common  in  advanced  life,  and  may  develop  slowly  as 
a  chronic  process,  or,  more  often,  may  follow  repeated  acute  attacks. 
It  may, be  manifest  during  the  entire  year,  but  most  often  develops  on 
change  of  weather  or  in  the  cold  season,  as  the  "winter  cough." 

Pathology. — The  larger  and  medium  sized  bronchi  are  most  in- 
volved. Their  color  is  a  gray  red  or  brown;  the  bloodvessels  are 
thickened,  and  the  bronchi  become  thicker  from  extravasation  of 
leukocytes  and  proliferation  of  the  peribronchial  connective  tissue; 
the  mucous  membrane  is  sometimes  hypertrophied,  and  even  protrudes 
in  polypoid  and  papillary  excrescences,  or  is  atrophied,  and  appears 
thin  and  pale  like  a  serous  membrane.  Erosions  are  not  common  but 
are  sometimes  seen  at  the  tracheal  bifurcation,  especially  in  the  aged. 
Stagnation  of  secretion  is  common.  The  inner  surface  of  the  bronchi 
is  at  times  reticular,  due  to  the  prominence  and  hyperplasia  of  some 
elastic  fibers  and  the  wasting  and  sinking  of  other  elastic  or  muscular 
fibers.  Emphysema  and  some  interstitial  fibrous  overgrowth  are 
frequently  found  at  autopsy. 

Symptoms. — Fever  and  pain  are  absent,  except  in  the  frequent  acute 
exacerbations.  The  usual  intrinsic  physical  findings  in  chronic  macro- 
bronchitis  are  large  sonorous  rales,  and  sibilant  rales  when  acute 
exacerbations  cause  invasion  of  the  finer  tubules.  The  cough  varies  with 
the  intensity  of  the  inflammation,  with  the  amount  and  character  of  the 
secretion,  or  with  changes  in  the  weather.  The  sputum  varies  greatly, 
and  upon  its  character  is  based  the  division  into  the  following  forms : 
(a)  Dry  bronchitis,  the  bronchitis  sicca  of  Laennec,' which  is  seen  in  the 
aged  and  is  almost  always  associated  with  emphysema;  in  this  type 
the  sputum  is  either  wholly  absent  or  is  very  scant  and  viscid.  (6) 
Bronchorrhcea,  in  which  the  excessive  bronchial  secretion  may  be 
miucous,  serous,  or  purulent ;  in  the  serous  form  the  secretion  is  thin 
and  transparent,  as  in  Laennec's  case,  in  which  two  quarts  were  raised 
'daily  for  twelve  years;  Struempell  observed  a  serous  bronchorrhcea 


CHRONIC  BRONCHITIS  499 

resulting  from  enlarged  peribronchial  glands;  the  purulent  form  may 
be  confused,  on  account  of  its  abundant  sputum,  with  bronchiec- 
tasis, lung  abscess,  or  rupture  of  an  empyema  into  the  bronchi. 
(c)  Putrid  bronchitis,  which  has  been  described  by  Laennec,  Andral  and 
Traube.  It  may  complicate  chronic  bronchitis  but  occurs  more  often 
with  bronchiectasis,  foreign  intrabronchial  bodies  and  tuberculosis; 
in  this  form  the  sputum  stinks  and  is  acidulous  particularly  when  first 
voided.  It  consists  of  three  layers;  the  upper  one  is  foamy,  the  middle 
layer  is  serous,  and  the  lower  one  consists  of  granular  gray-green  or 
bluish  sediment,  in  which  are  also  the  mycotic  plugs  of  Dittrich  (1850); 
these  plugs  contain  various  bacteria,  leptothrix  staining  violet  with 
iodine,  strepto-  and  staphylococci.  Bacillus  coli  and  Bacillus  putridus 
and  sometimes  monads.  Bacilli  which  retain  fuchsin  after  treatment  with 
mineral  acids  ("acid-fast"  bacilh)  are  found  in  putrid  bronchitis  and 
in  gangrene  of  the  lung.  They  closely  resemble  tubercle  bacilli,  though 
they  are  narrower,  more  pointed  at  their  ends  and  do  not  give  inocu- 
lation results.  Fat  and  myelin  droplets,  fatty  needles,  leucin,  and 
tyrosin  are  also  present.  The  amount  of  sputum  may  even  reach  a 
pint.  Fever  is  common,  "drum  stick"  fingers  may  develop,  and  com- 
plications may  follow,  as  lung  induration,  diphtheroid  ulceration, 
gangrene,  pleurisy,  haemoptysis,  cerebrospinal  abscess,  meningitis  or 
pseudorheumatism.  The  fever  frequently  recurs,  (d)  Blood-stained 
sputum  occurs  particularly  in  the  brown  induration  of  the  lungs,  which 
is  due  to  stasis  (v.  Cardiac  Stasis). 

Chronic  emphysema  (v.  i.)  is  an  almost  regular  complication  and  is 
marked  by  its  usual  signs,  such  as  a  tympanitic  percussion  note,  volum- 
inous lungs,  prolonged  and,  on  exertion,  difficult  expiration,  weakened 
vesicular  murmur,  hypertrophy  of  the  cervical  muscles,  swollen  neck 
veins,  signs  of  right  heart  hypertrophy  and  dilatation,  and  eventually 
tricuspid  insufficiency,  liver  congestion,  and  oedema. 

Diagnosis. — The  diagnosis  is  generally  easy.  Determination  of  its 
relation  to  tuberculosis  and  other  causal  features  is  most  important. 
In  every  case  chronic  nephritis  should  be  considered. 

Prognosis. — -The  prognosis  depends  on  the  etiological  factors.  Ab- 
solute recovery  is  most  unlikely. 

Treatment. — 1.  Prophylaxis.  Causal  affections  require  treatment. 
Woolen  underwear  should  be  worn  to  protect  against  sudden  changes 
of  temperature. 

2.  Climate. — When  feasible,  a  dry,  warm,  even  climate  is  beneficial, 
as  that  of  Florida,  Southern  California,  New  Mexico,  the  Carolinas, 
Egypt,  and  the  Riviera. 

3.  Cough. — ^^Codein,  morphine,  creosote,  cod-liver  oil  and  other 
remedies  are  employed  as  in  tuberculosis  {q.  v.).  Ammon.  carb.  {v. 
Pneumonia)  gr.  iij.  can  be  given  with  syr.  senegne  3j;  syr.  scillaj  5j  is 
incompatible  with  ammon.  carb.  but  may  be  combined  with  ammon. 
chlor.  sfr.  v  to  x. 


500  DISEASES  OF  THE  RESPIRATORY   TRACT 

^  ..  .   . 

Ammonii  chloridi oiss. 

Mist  urge  glycyrrhizse  comp oiv. 

M.  et  S. — One  teaspoonful  after  meals. 

The  mistura  glycyrrhizee  comp.  (Brown's  mixture)  contains  twelve 
parts  of  paregoric,  six  parts  of  antimonial  wine  and  three  parts  of  sweet 
spirits  of  nitre,  which  enhance  its  sedative  action.  It  may  be  given  in 
doses  of  from  one  to  four  drams.  If  the  heart  is  weak,  it  is  contra- 
indicated  because  of  the  antimony  it  contains.  In  all  cough  prepa- 
rations, the  stomach  may  become  deranged  by  ammonium,  syrups, 
etc.  Chloroform  is  particularly  valuable  in  paroxysmal  unproductive 
coughs,  which  opiates  may  not  alleviate  because  they  dry  up  the 
secretion. 

Ammonii  carbonatis oj- 

Spiritus  chloroformi oiss. 

SjTui^i  senegae q.s.  ad  oiij- 

M.  et  S. — One  teaspoonful  in  liot  water  as  indicated. 

Apomorptdnse  hydrochloridi gr.  ss. 

Heroin  hydrochlorat gr.  j. 

Spiritus  cUoroformi oj- 

Aquae q.s.  ad   5ij. 

M.  et  S. — One  teaspoonful  two  or  three  times  a  day. 

Syr.  scillee  comp.  also  contains  senega  and  tartar  emetic  and  is  given  in 
doses  of  gtt.  XX  to  xl.  The  antimony  it  contains  may  depress  the  heart. 
Terpin  hydrate  is  excellent,  gr.  iii  to  v  (x).  t.  i.  d.,  given  in  capsules  with 
equal  amounts  of  benzoic  acid.  The  balsams  are  even  more  efficacious, 
as  ol.  terebinthinae  rtjii].  in  milk  (see  formula  for  emulsion  under 
Typhoid,  Treatment  of  Tympaxt)  ;  ol.  santali  tt]^  x  to  xx  in  emul- 
sion is  less  likely  to  disturb  the  kidneys  than  is  turpentine;  balsamum 
Peru^danum  5ss  or  bals.  tolutanum  3j  to  iv.  The  balsams  and  creosote 
are  directly  indicated  in  foetid  bronchitis.  Retention  of  secretion 
which  does  not  yield  to  the  action  of  drugs,  may  be  treated  by  rhyth- 
mical compression  of  the  chest  during  expiration.  Potas.  iodide  gr. 
V  to  X  t.  i.  d.  is  often  excellent. 

4.  Cardiac  Weakness. — Cardiac  weakness  is  relieved  most  eflSca- 
ciously  by  strychnine,  which  is  more  valuable  than  digitalis. 

5.  Coincident  Emphysema. — Coincident  emphysema  and  asthma 
(q.  V.)  necessitate  the  prolonged  use  of  iodides  and  belladonna. 


(C).  FIBRINOUS  BRONCHITIS. 

Etiology. — There  are  three  types  of  fibrinous  or  croupous  bronchitis, 
(a)  The  primary  form  is  an  infrequent  disease,  of  which  but  few  more 
than  100  cases  are  recorded;  it  occurs  in  males  (66  per  cent,  of  cases) 
principally  in  those  between  ten  and  thirty  years,  and  in  weakly  and 
anaemic  subjects;   it  results  from  bacteria,  as  the  Bacillus  diphtheriae, 


FIBRINOUS  BRONCHITIS  501 

pneumococcus,  strepto-  and  staphylococcus,  aspergillus  fungus,  and 
protozoa,  or  from  their  toxins,  (b)  The  secondary  type  develops  by 
extension  frpm  laryngeal  and  pulmonary  disease,  or  in  infections,  as 
pneumonia,  typhoid,  measles,  and  scarlatina;  tuberculosis  causes  50 
per  cent,  of  this  group ;  some  cases  occur  in  skin  diseases,  (c)  Mechan- 
ical, thermal,  and  chemical  agents  are  causative  factors  in  a  few  cases, 
and  some  have  occurred  in  connection  with  valvular  heart  disease  and 
exophthalmic  goitre.  Fibrinous  bronchitis  was  first  described  by  Clark, 
in  1697. 

Symptoms. — The  early  symptoms  are  those  of  bronchitis,  sometimes 
with  fever,  chills  and  haemoptysis,  but  they  are  ambiguous  until  bron- 
chial casts  of  fibrin  or  mucin  are  expectorated;  this  usually  happens 
after  a  severe  coughing  paroxysm.  The  casts  may  measure  even  eight 
inches  long,  and  may  be  as  thick  as  a  lead  pencil  or  a  finger;  their  upper 
and  larger  parts  are  circular  or  somewhat  flattened,  solid  or  hollow, 
but  the  lower  small  portions  are  branched,  solid,  spiral  and  often 
clubbed  at  their  tips.  Though  usually  termed  fibrinous  or  croupous, 
many  casts  do  not  take  Weigert's  fibrin  stain  but  respond  to  tests  for 
mucin;  these  are  then  cases  of  bronchitis  mucinosa  or  pseudomem- 
branacea.  Liebermeister  (1904)  holds  that  fibrinous  is  more  frequent 
than  mucous  formation.  The  microscopic  appearance  of  the  casts  is 
hyaline,  their  texture  is  fibrillar,  and  their  surface  is  often  covered  with 
blood  disks,  hsematoidin,  or  Charcot-Leyden  crystals.  Smaller  casts 
may  not  be  seen  until  the  sputum  is  agitated  in  water,  which  washes  off 
the  adherent  blood,  pus  or  mucus ;  this  may  explain  their  frequency  as 
an  accidental  finding.  Pending  their  evacuation,  there  are  signs  of 
unilateral  bronchial  stenosis,  dyspnoea,  cyanosis,  and  inspiratory  re- 
traction, and  there  are  no  breath  sounds  in  the  corresponding  lung 
area.  Slipping  or  moving  of  the  casts  in  the  bronchus  may  cause 
peculiar  rales.  After  their  evacuation  new  casts  form  in  one  or  more 
days.  Niemeyer  observed  the  daily  shedding  of  a  complete  cast  of  a 
bronchus  and  its  divisions. 

Diagnosis. — In  some  cases  casts  are  not  voided  during  life,  so  that 
the  autopsy  alone  determines  the  diagnosis.  Asthma  (q.  v.)  and  bron- 
chitis fibrinosa  have  certain  common  symptoms,  as  paroxysmal 
occurrence,  eosinophilia  and  the  crystals  and  spirals,  but  are  usually 
differentiated  with  ease. 

Course  and  Prognosis. — In  the  acute  form,  which  lasts  two  weeks  or 
less,  there  is  great  risk  of  sudden  asphyxia  during  the  evacuation  of  the 
casts;  there  is  a  death  rate  of  75  per  cent,  in  the  young  and  50  per  cent. 
in  adults.  In  chronic  forms  the  process  lasts  for  months  or  even  years, 
(cases  of  twenty-three  and  twenty-five  years'  duration  have  been 
observed).  The  prognosis  is  uncertain.  Complications  include 
splenic  tumor,  pneumonia,  pleurisy,  emphysema,  and  albuminuria 
which  results  from  dyspnoea. 

Treatment. — Treatment  is  unsatisfactory  if  not  wholly  futile.  In- 
halation of  steam  and  alkaline  vapors  and  pilocarpin  should  be  given 
in  order  to  loosen  the  casts.     Emetics  may  be  employed  to  facilitate 


502  DISEASES  OF   THE  RESPIRATORY  TRACT 

their  evacuation,  and  iodides  and  mercurial  inunctions  to  inhibit  their 
reformation.    The  iodides  are  the  most  effective. 


(D).  BRONCHIAL  DILATATION,  BRONCHIECTASIS. 

Etiology  and  Pathology. — Laennec  first  described  bronchiectasis,  in 
1819.  It  is  found  in  2  per  cent,  of  autopsies  and  is  always  secondary 
(a)  to  bronchial  disease,  stenosis,  catarrh,  inhalation  of  dust,  foreign 
bodies,  or  pressure  from  aortic  aneurysm;  (b)  to  lung  disease,  tuber- 
culosis, interstitial  pneumonia  (Corrigan),  hypostasis,  or  atelectasis; 
(c)  to  pleural  disease,  such  as  adhesions  pulling  on  the  bronchi.  Nearly 
all  cases  are  acquired,  and  occur  mostly  in  middle  aged  males  (77  per 
cent.).  Rare  congenital  cases  are  recorded.  These  may  be  divided 
into  (i)  the  unilateral,  universal  or  diffuse  form  (Grawitz),  (ii)  those 
due  to  congenital  atelectasis  (Heller),  and  (iii)  those  resulting  from 
prenatal  bronchial  (syphilitic)  stenosis. 

There  are  two  forms  of  bronchiectasis :  (a)  the  cylindrical  or  fusiform, 
multiple  or  pater  nosier  form,  which  develops  from  the  atrophy  of  the 
muscular  and  elastic  fibers  induced  by  protracted  severe  coughing  and 
perhaps  by  stagnation  of  secretion;  it  may  follow  measles,  catarrhal 
pneumonia,  whooping  cough  or  emphysema.  (6)  The  rarer  sacculated 
form,  in  which  the  bronchus  may  reach  a  diameter  of  even  3  inches, 
and  which  might  be  called  a  bronchial  aneurysm.  The  connective 
tissue  usually  disappears,  the  ciliated  epithelia  are  replaced  by  flat  cells 
and  the  mucosa  is  thin,  red,  and  swollen,  and  sometimes  presents 
villosities  and  varicosities.  The  sacs  may  become  closed  at  their  necks, 
particularly  when  caused  by  aneurysm,  syphilis,  or  tuberculosis;  this 
converts  them  into  sacs  filled  with  gelatinous,  cheesy  or  calcareous 
contents.  They  are  known  as  lung  stones,  and  consist  of  calcium  car- 
bonate and  phosphate  with  traces  of  magnesia;  they  have  an  organic 
nucleus  and  sometimes  cause  "  bronchial  colic,"  or  symptoms  like  those 
of  phthisis. 

Bronchiectasis  is  seldom  single;  in  multiple  bronchiectasis  the  lung 
sometimes  resembles  a  sponge  or  porous  cheese.  It  occurs  principally 
in  the  lower  lobes  and  in  bronchi  of  the  third  and  fourth  order.  It  may 
be  bilateral  (60  per  cent.)  but  the  congenital  pleuritic  and  pneumonic 
forms  are  always  unilateral.  Adhesions  are  very  coramon  when  the 
cavity  reaches  the  pleura. 

S3miptoms. — Most  cases  are  not  discovered  clinically,  and  Weil 
therefore  concluded  that  "most  cavities  escape  detection  and  most 
diagnoses  of  cavities  are  incorrect."  Sacculated  forms  produce  more 
symptoms  and  signs  than  do  the  cylindrical  forms,  which  are  almost 
always  impossible  to  recognize. 

1.  Sputum  and  Cough. — The  sputum  and  cough  are  paroxysmal. 
When  secretion  fills  the  sac  and  flows  over  onto  the  normal  sensitive 
mucous  membrane  beyond  it,  cough  develops  and  quantities  of  muco- 
pus  are  voided  in  the  "mouth  full"  fashion  described  by  Wintrich. 


BRONCHIAL  DILATATION,  BRONCHIECTASIS  503 

Change  of  posture  produces  similar  effects.  The  largest  amount  is 
raised  in  the  morning  and  this  is  frequently  followed  by  vomiting.  The 
daily  quantity  may  amount  to  a  quart.  Its  odor  is  acid,  sweat-like,  and 
offensive,  but  it  does  not  attain  the  foetor  of  putrid  bronchitis  nor  the 
mature  foulness  of  gangrene.  When  collected  it  forms  in  three  layers; 
the  upper  one  is  foamy,  the  middle  one  is  serous,  and  the  lower  one  is 
purulent.  A  nummular  or  globular  sputum  may  be  noted  as  in  tuber- 
culosis, but  if  put  in  water  it  is  more  flocculent,  more  granular,  and  air- 
less; and  microscopically  it  contains  altered  leukocytes  and  fatty 
needles,  occasionally  red  cells,  haematoidin  crystals,  and  very  rarely, 
when  the  bronchial  wall  is  ulcerated,  elastic  fibers. 

2.  Physical  Examination. — (a)  Inspection  may  reveal  diminished 
respiratory  movement,  inspiratory  retraction  over  the  cavity,  or  flattening 
of  the  chest  wall.  The  patient  leans  toward  the  diseased  side, and  rarely 
inclines  toward  the  sound  side  or  sits  erect,  in  order  to  lessen  the 
trickling  out  of  the  secretion.  In  the  rare  cases  of  bronchiectasis  in  an 
upper  lobe  the  constant  escape  of  the  secretion  results  in  exhausting 
and  most  unfavorable  coughing  (Skoda).  The  x-rays  may  show  the 
location  of  the  cavity,  (b)  Palpation  and  (c)  percussion  give  variable 
results  depending  on  whether  the  cavity  is  full  or  empty.  Dulness 
prevails  when  it  is  full;  when  it  is  empty  a  tympanitic  note  results.  A 
higher  note  on  opening  the  mouth,  on  inspiration,  or  on  change  of 
posture  has  the  same  value  as  in  cases  of  tuberculous  cavity  (q.v.). 
(d)  On  auscultation,  bronchial  or  metallic  breathing  may  be  heard  when 
the  cavities  are  superficial  but  it  is  absent  in  dilatations  which  are 
small,  deep,  or  full  of  secretion.  Large  and  small  rales,  if  heard  per- 
sistently in  the  same  locality,  are  suggestive  of  a  deep  bronchiectasis. 
The  sound  tissue  over  the  cavity  imparts  a  metallic  consonance.  Meta- 
morphosing breathing  is  a  certain  sign  of  a  cavity. 

3.  Complications. — The  general  nutrition  sometimes  remains  nor- 
mal; slight  cyanosis  together  with  anaemia  is  frequent.  Hectic  fever 
is  often  absent,  but  death  may  result,  with  symptoms  resembling  those 
of  phthisis.  Putrid  bronchitis  is  frequent.  Hsemoptysis  from  ulcer- 
ation of  ruptured  varices  occurs  in  40  per  cent,  of  cases;  pneumo- 
thorax, pleurisy,  empyema,  lung  induration  or  gangrene,  emphysema, 
lobular  pneumonia,  amyloidosis  and  hypertrophy  and  dilatation  of 
the  right  ventricle  are  fairly  common.  Marie's  osteo-arthropathie 
hypertrophiante  pneumonique,  rheumatoid  affections  (Senator),  sup- 
purative meningitis  or  abscesses  in  the  brain  and  cord  are  occasional. 
In  rare  cases  the  cavity  may  bulge  through  the  interspaces. 

Diagnosis. — Diagnosis  depends  upon  the  character  of  the  sputum, 
its  paroxysmal  voidance,  and  the  signs  of  cavity  formation.  Differ- 
entiation is  required  (a)  from  tuberculous  cavities;  this  is  made  by 
means  of  family  history,  habitus,  the  presence  of  elastic  fibers  and 
tubercle  bacilli  in  the  sputum,  which  are  definitely  determined  by  in- 
oculation ;  the  tuberculous  cavities  are  most  often  apical,  but  frequently 
bilateral;  they  void  less  sputum  and  suffer  less  rapid  variation  in  their 
physical  signs.    Bronchiectatic  cavities  occur  mostly  in  the  lower  lobes. 


504  DISEASES  OF  THE  RESPIRATORY  TRACT 

void  more  sputum,  less  often  induce  hemorrhage  and  more  frequently 
cause  right  heart  changes,  (b)  From  'perjorating  era'pyeina,  in  which 
cholestearin  and  hsematoidin  crystals  are  far  more  frequent  than  in 
bronchiectasis;  (c)  from  abscess;  (d)  from  gangrene  of  the  lung  (v.  i.); 
(e)  from  putrid  bronchitis,  in  which  there  is  no  sudden  volume  of 
evacuated  sputum  nor  signs  of  cavity;  (/)  from  encapsulated  pyopneu- 
mothorax, which  may  be  very  difficult  of  differentiation. 

Prognosis. — The  immediate  prognosis  is  rather  favorable,  but  ulti- 
mate recovery  is  exceptional. 

Treatment. — The  therapeutic  indications  are  (a)  evacuation  of  the 
secretion,  for  which  expectorants  and  expiratory  compression  of  the 
chest,  as  in  bronchitis,  are  somewhat  useful;  sedatives  should  never 
be  given,  lest  gangrene  develop;  (6)  modification  of  putrescence  by 
balsamic  remedies,  as  in  foetid  bronchitis;  inhalations  of  creosote  may 
be  given,  though  they  are  most  irritating  at  first ;  a  dram  of  creosote 
is  slowly  vaporized  over  a  flame,  and  the  patient,  in  a  closed  room,  in- 
hales the  fumes  with  the  eyes  closed  and  the  anterior  nares  plugged; 
the  procedure  may  be  gradually  lengthened  from  a  few  minutes  to  half 
an  hour;  (c)  surgical  drainage.  An  accessible  cavity  may  be  incised 
and  drained,  though  accurate  diagnosis  of  its  location  is  difiicult.  In 
Garre's  collection  of  57  cases  (1902),  63  per  cent,  recovered  and  37  per 
cent,  died;  {d)  change  oj  climate  (v.  Tuberculosis). 


(E).  TRACHEAL  AND  BRONCHIAL   STENOSIS. 
1.  Tracheal  Stenosis. 

Etiology. — The  cause  is  less  often  within  than  without  the  trachea. 
Tracheal  causes  are  rhinoscleroma  (Stoerk,  1874),  syphilis  which  in 
40  per  cent,  of  cases  also  implicates  the  bronchi,  tumors  (cancer,  polyp, 
fibroma,  enchondroma,  sarcoma,  cancer  or  aberrant  thyroid) ,  foreign 
bodies,  tracheotomy  granulations,  and  in  rare  cases  perichondritis. 
Causes  outside  the  trachea  are  more  frequent,  as  thyroid  enlargement 
particularly  the  retrosternal,  cystic  and  circular  forms,  or  struma  in 
which  hemorrhage  or  inflammation  has  occurred ;  in  some  cases  sudden 
death  results,  notably  when  the  cartilages  have  been  absorbed.  Aneu- 
rysm, adenopathies,  mediastinal  tumors,  vertebral  tumor  or  caries 
and  thymus  hyperplasia  are  other  factors. 

Symptoms. — The  symptoms  may  be  ranged  in  three  series  or  stages; 

(a)  when  there  are  no  symptoms  or  when  they  occur  only  on  exertion ; 

(b)  when  there  is  constant  dyspnoea,  and  (c)  when  suffocative  attacks 
terminate  in  final  asphyxia.  The  dyspnwa  is  of  a  mixed  type,  i.  e.,  it 
is  both  inspiratory  and  expiratory;  the  number  of  respirations  is 
lessened,  there  is  inspiratory  stridor  and  intercostal  retraction,  all  the 
accessory  muscles  come  into  play,  the  head  is  held  well  forward  and 
there  is  little  or  no  laryngeal  excursion.    The  pulse  is  more  tense,  varies 


TRACHEAL  AND  BRONCHIAL  STENOSIS  505 

in  rate,  and  is  sometimes  of  the  paradoxical  type.  Tracheoscopy  may 
reveal  the  location  of  the  lesion.  This  is  done  most  advantageously  in 
the  strong  sunlight;  the  patient  should  stand  with  his  back  to  the  light 
and  with  the  head  bent  forward,  and  the  observer  should  be  seated  on  a 
low  seat  before  him.  Fraenkel  affirms  that  in  25  per  cent,  of  tracheal 
stenoses  due  to  tumor  or  aneurysm,  there  is  coincident  paralysis  of  the 
vocal  cords. 

2.  Bronchial  Stenosis. 

Etiology. — Intrabronchial  causes  are  most  common  and  consist  of 
pus,  mucus,  blood,  fibrin  and  foreign  bodies;  obstruction  due  to  the 
latter  is  laryngeal  in  33  per  cent.,  tracheal  in  26  per  cent.,  and  bronchial 
in  41  per  cent.,  of  the  cases.  Extrabronchial  factors  are  next  in  fre- 
quency; aneurysm,  mediastinal  lymphosarcoma  and  perilymphade- 
nitis  leading  to  fibrosis  occur  most  often ;  less  common  are  pericarditis 
with  effusion,  dilatation  of  the  left  auricle,  cancer  of  the  oesophagus, 
tumor  of  the  lung,  and  thyroid  or  thymic  strumas.  Twenty  cases  have 
been  reported  in  which  lymph  glands  ruptured  into  the  trachea  or 
bronchi,  causing  suffocation;  only  three  were  saved  by  tracheotomy, 
Interhronchial  causes  (i.e.,  in  the  bronchial  wall)  are  the  least  common, 
as  syphilis,  glanders,  rhinoscleroma  and  tumors.  Thirty-six  cases  of 
primary  cancer  are  recorded.  The  right  is  stenosed  nearly  twice  as 
often  as  the  left  bronchus. 

Symptoms. — Occlusion  of  a  bronchus  lessens  the  amount  of  air  en- 
tering the  lung  which  it  supplies,  whence  the  vocal  fremitus  and  breath 
X  sounds  are  immediately  weakened  or  suspended  and  the  respiratory 
excursion  and  Litten's  diaphragmatic  sign  are  decreased.  There  is 
inspiratory  retraction  of  the  intercostal  spaces  on  the  affected  side. 
Inspiratory  dyspncea  occurs,  particularly  in  acute  cases.  The  head  is 
thrown  forward  and  the  larynx  moves  up  and  down  but  little.  The 
percussion  note  is  not  essentially  altered,  and  this  excludes  many 
causes  of  dyspnoea,  as  pneumonia,  etc.;  after  a  time  a  somewhat 
tympanitic  note  may  result  from  relaxation  of  the  lung  or  acute  emphy- 
sema. A  local  stenotic  murmur  over  the  bronchus  is  present  in  a  few 
cases.  Paroxysmal  dyspnoea  may  result  from  stagnating  secretion. 
The  pulse  is  more  tense  and  often  slower.  The  a;-rays  may  locate  the 
obstruction.  Bronchoscopy  is  sometimes  helpful,  but  it  is  difficult  to 
perform  even  for  the  experienced  specialist.  Death  results  from  (a) 
the  original  disease,  as  aneurysm  or  tumor;  (b)  failure  of  the  right 
heart,  (c)  asphyxia,  with  delirium,  cyanosis,  convulsions  or  Cheyne- 
Stokes  breathing,  or  (d)  pulmonary  oedema,  abscess,  gangrene,  tuber- 
culosis, lobular  pneumonia,  lung  induration  or  hemorrhage. 

Diagnosis. — (a)  Of  the  location  oi  stenosis:  in  laryngeal  obstruction, 
there  are  local  findings  and  free  up-and-down  excursion;  the  subject 
holds  the  head  well  back,  and  the  ingress  of  air  to  both  lungs  is  equally 
impaired;  tracheoscopy,  bilateral  lung  involvement,  the  absence  of 
laryngeal  excursion,  and  the  holding  of  the  head  forward  are  sufficient 


506  •        DISEASES  OF   THE  RESPIRATORY  TRACT 

proof  of  tracheal  obstruction ;  in  bronchial  stenosis  but  one  lung  suffers 
for  air,  the  larynx  is  nearly  immobile,  and  the  head  is  thrown  forward. 
(6)  Of  the  nature  of  stenosis,  exact  diagnosis  is  more  difficult,  and  is 
impossible  without  distinct  physical  signs,  as  those  of  aneurysm,  or 
without  history  of  the  presence  of  foreign  bodies. 

The  prognosis  depends  on  the  cause. 

Treatment. — Treatment  is  also  largely  that  of  the  cause,  as  syphilis, 
tuberculosis,  etc.  Thyroid  extract  and  iodine  are  efficacious  in  over 
50  per  cent,  of  cases  of  thyroid  swellings.  When  the  obstruction  is 
aneurysmatic,  rest,  mercury,  iodides,  venesection  and  gelatin  injections 
often  afford  considerable  relief.  When  there  are  foreign  bodies,  the 
patient  should  be  inverted,  sharply  struck  on  the  back,  and  shaken; 
the  physician  should  have  long  forceps  and  tracheotomy  instruments 
in  readiness.  The  mortality  from  the  presence  of  foreign  bodies  in  the 
lower  air  passages  is  52  per  cent,  with  expectant  treatment,  and  23  per 
cent,  with  operation. 

Bronchial  and  lung  stones  (v.s.)  result  from  tuberculosis  of  the 
bronchial  glands,  from  bronchiectasis,  petrification  of  the  bronchi, 
calcification  and  ossification  of  the  lungs,  and  from  gout  and  the 
presence  of  foreign  bodies.  Symptoms  are  frequently  absent  or  are 
those  of  the  primary  disease ;  purulent  bronchitis,  asthma  ("  bronchial 
colic"),  hectic  fever  and  haemoptysis  mark  some  cases. 

Stenosis  of  the  bronchioles  may  result  from  bronchiolitis  fibrinosa 
obliterans  (Lange  and  Fraenkel). 


(F).  BRONCHIAL  ASTHMA. 

Definition. — A  paroxysmal  dyspnoea,  due  to  stenosis  or  spasm  of  the 
smaller  bronchioles,  which  is  nervous  or  reflex  in  origin  and  is  charac- 
terized by  expiratory  dyspnoea,  slowing  of  respiration,  congestion  of  the 
bronchioles,  a  peculiar  mucous  exudation  and  acute  emphysema.  It 
is  also  known  as  asthma  spasmodicum  or  nervosum,  to  distinguish  it 
from  other  so-called  asthmas,  as  the  cardiac  or  renal  types. 

Etiology. — When  due  to  no  obvious  cause,  asthma  is  termed  essential 
or  primary,  and  when  due  to  a  clear  cause  it  is  called  syrtiptomatic  or 
reflex  asthma  (which  occurs  through  the  vagus),  (a)  Nasal  and  naso- 
pharyngeal disease  is  the  source  of  the  reflex  asthma  in  numbers  of 
cases,  as  proven  by  Voltolini,  Hack,  Haenisch,  Porter,  Daly,  Roe  and 
others;  it  may  be  caused  by  rhinitis,  tonsillar  hypertrophy,  adenoids, 
or  pharyngitis  granulosa;  the  nose  may  be  so  hypersensitive  that  the 
odor  of  flowers,  dust,  hot  air  or  smoke  precipitate  an  attack.  (6) 
Asthma  may  be  initiated  by  pressure  on  the  vagus  trunk,  resulting 
from  thyroid  tumors  or  from  enlargement  of  the  bronchial  glands, 
following  tuberculosis,  measles,  pertussis,  or  rickets,  (c)  Abdominal 
diseases  are  possible  though  not  frequent  causes;  the  asthma  dyspepti- 
cum  of  Henoch,  Meyer  and  Pribram  has  been  especially  emphasized 
of  late  by  Hayem  who  describes  asthma  resulting  from  gastric  dila- 


BRONCHIAL  ASTHMA  507 

tation.  Ovarian  and  uterine  disease  and  pregnancy  have  been  con- 
sidered causal  factors,  {d)  Asthma  toxicum  has  been  reported  in  lead 
and  mercurial  poisoning;  urcemic  and  gouty  asthma  are  also  due  to 
toxins,  (e)  It  occurs  especially  in  weakly,  anaemic,  nervous,  scrofulous 
and  rhachitic  subjects,  in  males  (66  per  cent.)  between  the  age  of  twenty 
and  forty  (though  it  has  recently  been  claimed  that  33  per  cent,  of  the 
asthma  cases  develop  under  ten  years),  in  the  upper  classes,  and  in 
professional  men. 

There  are  various  theories  as  to  the  mechanism  of  the  asthmatic 
attack;  these  are  as  follows:  (a)  it  is  a  spasm  of  the  bronchial  muscles 
(Trousseau,  Rhomberg  and  Biermer).  Trousseau  spoke  of  asthma  as 
"an  epilepsy  of  the  lungs";  (b)  it  is  a  very  acute  catarrh  (Louis  and 
Traube);  Stoerk  found  the  larynx  and  trachea  deeply  injected;  (c)  it 
is  a  vasomotor  disturbance  (Weber) ;  or  (d)  an  acute  exudative  bron- 
chitis, causing  bronchial  spasm  (Curschmann,  Lebert).  Its  pathology 
is  uncertain,  as  but  half  a  dozen  autopsies  are  recorded;  the  ciliated 
epithelium  is  desquamated,  the  bronchioles  are  congested  and  there  is 
eosinophilic  exudation. 

Symptoms. — The  attack  begins  very  suddenly,  often  at  night  and 
with  or  without  such  causes  as  fright,  cold,  heat,  change  of  residence,  etc. 
Sometimes  there  are  prodromes,  as  conjunctivitis,  coryza  or  flatulence 
and  sometimes  the  attack  coincides  with  the  menses,  (a)  Dyspnoea  is 
the  first  and  the  essential  symptom;  though  at  first  slight,  it  soon  be- 
comes urgent;  the  patient  opens  the  windows,  sits  upright,  grasps  the 
arms  of  the  chair  to  brace  the  accessory  respiratory  muscles,  and  ex- 
hibits extreme  distress,  anxiousness  and  pallor,  which  is  followed  by 
cyanosis;  the  dyspnoea  is  expiratory,  and  the  abdominal  muscles  are 
board-like  during  expiration ;  inspiration  is  somewhat  lengthened,  and 
expiration  is  greatly  prolonged,  wheezing,  and  whistling;  respiration  is 
not  usually  increased,  but  may  reach  30  or  40.  (6)  There  is  marked 
cyanosis  in  the  face  and  extremities,  the  cervical  veins  bulge  out  like 
cords,  the  skin  is  clammy,  and  the  pulse  indicates  poor  oxygenation 
by  its  tenseness,  smallness  and  frequency;  carbon  dioxide  intoxication 
causes  the  occasional  headache,  delirium,  tinnitus,  twitchings,  convul- 
sions and  coma,  (c)  The  cough  is  dry  and  unproductive,  (d)  The  voice 
is  faint  and  hoarse  and  the  trachea  is  red.  (e)  Other  physical  signs  are 
as  follows:  On  palpation,  the  vocal  fremitus  is  found  to  be  decreased 
by  the  bronchial  spasm  or  secretion;  rales  are  often  felt.  The  normal 
percussion  note  is  replaced  by  a  tympanitic  note,  due  to  acute  pul- 
monary emphysema;  the  lungs  are  voluminous,  and  distend  the  thorax, 
cover  the  heart  and  push  down  the  diaphragm,  whose  excursion  is  thus 
reduced  to  a  minimum.  On  auscultation,  the  vesicular  murmur  is 
usually  found  to  be  faint  or  absent  (Laennec)  because  of  secretion  in 
the  bronchioles,  and  loud  whistling,  piping,  or  sibilant  rales  are  heard 
often  without  the  stethoscope  and  largely  during  expiration.  They  are 
due  to  bronchial  stenosis.  (/)  Sputum  is  voided  for  the  first  time 
toward  the  end  of  the  attack;  this  occurs  as  a  species  of  crisis  to  the 
threatening,    but    very    seldom    fatal,    asphyxia.     A  few  drams  of 


508 


DISEASES   OF   THE  RESPIRATORY   TRACT 


tenacious  mucus,  resembling  egg  albumin  or  gelatin,  are  voided. 
Minute  gray  balls  are  seen;  these  are  the  "perles"  of  Laennec;  when 
unrolled  the  "pearls"  are  seen  to  contain  the  spirals  of  Leyden,  Ungar 
and  Curschmann;  they  are  best  detected  with  the  naked  eye,  and  on  a 
black  background;  they  measure  2  or  3  to  10  x  ^  to  1  mm.;  they 
are  mucin  casts  of  the  bronchioles,  to  which  may  cling  leukocytes, 
epitheha,  fat  or  myelin  droplets;  some  show  a  central  band  of  mucin; 
it  is  thought  that  they  occur  from  the  passage  of  mucin  through  the 


Spirals  and  crystals  in  bronchial  asthma.     B,  Charcot-Leyden  crystals;  A,  spirals  magnified, and 

C,  their  natural  size. 

contracted  bronchioles ;  they  disappear  within  a  day  or  two ;  spirals  are 
also  present  in  catarrhal  or  fibrinous  bronchitis  and  in  pneumonia. 
The  Char  cot-Ley  den  crystals  may  be  seen  in  yellow  dots  in  the  sputum; 
their  origin  is  still  disputed;  they  are  pointed  and  octahedral,  consist  of 
an  organic  basis  with  phosphoric  acid,  and  are  also  seen  in  leuksemic 
tissues,  in  normal  bone  marrow,  and  in  semen.  Hsemosiderin  may  be 
found  in  the  sputum.  The  eosinophile  leukocytes  are  increased  in  the 
sputum  and  blood,  constituting  a  quarter  to  more  than  half  of  the 
white  cells.  The  crystals,  spirals,  and  the  occasional  fibrinous  casts  are 
a  result  rather  than  a  cause  of  the  asthma.     (Plate  X.) 

The  attacks  last  from  a  few  minutes  to  several  hours  and  may  be 
repeated  at  long  or  short  intervals.  In  the  hebdomadal  form,  attacks 
recur  every  Sunday  or  Monday;  they  are  probably  due  to  change  in 
routine  or  to  digestive  excesses.  The  urine  after  the  attack  contains 
increased  uric  acid;  constipation  and  flatulence  may  result  from 
fatigue  of  the  diaphragm  and  expiratory  muscles. 

Diagnosis. — The  diagnosis  is  made  by  (a)  the  paroxysmal  occurrence 
of  asthma,  {h)  the  expiratory  dyspnoea,  and  (c)  the  acute  transient 
emphysema. 

DifEerentiation. — (a)  All  diseases  causing  inspiratory  dyspnoea  can  be 
at  once  excluded,  such  as  oedema  or  spasm  of  the  glottis,  paralysis  of  the 
post,  crico-arytenoid  muscles,  and  tracheal  and  bronchial  stenosis  from 


PLATE  X. 


i^t. 


» 


^'^ 


^JiEf- 


Ijti, 


'it 


sputum  from  a  Case  of  Bronchial  Asthma,  showing  large  numbers 
of  Eosinophilic  Leukocytes  and.  Free  Granules.    (Simon). 

It  will  be  noted  that  the  leukocytes  are  all  mononuclear.     (Eye-piece  1,  objective  1-8,  Bausch  &  Lomb.) 


BRONCHIAL  ASTHMA  509 

aneurysm.  In  spasm  of  the  glottis,  the  spasm  is  inspiratory  and  of  short 
duration,  the  larynx  moves  up  and  down,  and  the  epigastrium  retracts 
during  inspiration;  there  is  no  emphysema,  and  no  spirals  are  found. 
Spasm  of  the  diaphragm  is  very  rare  (v.  Phrenic  Nerve);  it  lasts  a 
much  shorter  time,  the  epigastrium  bulges  during  inspiration,  there  is 
spasm  of  all  the  inspiratory  muscles,  hysterical  stigmata  are  often 
observed,  and  the  lungs  are  normal.  (6)  Expiratory  dyspnoea  may  also 
occur  in  (i)  chronic  bronchitis  with  emphysema.  In  these  cases  the 
emphysema  is  constant,  the  lungs  show  constant  rales  and  fewer 
eosinophiles  are  present  in  the  sputum,  (ii)  It  also  occurs  in  immov- 
able tumors  below  the  vocal  cords  which  may  turn  upward  during 
expiration  (this  is  shown  by  the  laryngoscope),  (c)  Asthma  cardiale 
(so-called)  is  of  a  mixed  type,  i.  e.,  inspiratory  and  expiratory,  and 
is  therefore  readily  differentiated.  The  "lungenstarr"  or  lung  dis- 
tention {v.  Signs  of  Valvular  Heart  Disease),  due  to  its  engorged 
vessels,  may  simulate  the  emphysema  of  bronchial  asthma.  Cardiac 
asthma  may  occur  either  with  high  or  low  arterial  tension,  whence 
the  condition  of  the  pulse  is  no  certain  criterion.  The  eosinophiles 
are  not  increased  to  the  same  degree  as  they  are  in  bronchial 
asthma. 

Prognosis. — The  prognosis  is  uncertain  and  depends  on  the  etiolog- 
ical accessibility  of  the  asthma.  It  is  more  favorable  in  young  individ- 
uals than  in  those  of  advanced  years.  Cases  which  recurred  for  64 
years  are  recorded.  Chronic  bronchitis  and  emphysema  are  likely  to 
develop. 

Associated  affections  may  include  epilepsy,  migraine,  angina  pectoris 
or  vasomotor  disturbances. 

Treatment. — 1.  Of  the  Attack. — A  hypodermic  injection  of  morphine, 
gr.  J,  with  atropine  gr.  so  and  nitroglycerine  gr.  so,  gives  the  most  prompt 
and  reliable  results.  Other  measures  are  purely  accessory.  Chloral  is 
almost  useless,  for  the  condition  usually  requires  single  doses  of  gr. 
XXX  to  xl,  which  are  too  large  for  safety.  Fresh  air,  strong  coffee, 
whisky,  a  cigar  or  cigarette,  the  application  of  cocaine  to  the  nose, 
fluid  extract  of  grindelia  tt^.  x  to  xx  especially  in  bronchitic  types,  nitrite 
of  amyl  pearls,  or  a  few  whiffs  of  chloroform,  sometimes  give  relief. 
The  vexing  question  arises  as  to  leaving  chloroform  or  mor^^hine  in 
the  hands  of  the  patient  whose  attacks  often  come  and  go  without 
medical  aid;  as  a  rule  they  should  never  be  left  with  the  patient. 
Inhalation  powders,  which  are  burned  like  incense,  are  very  generally 
used;  they  all  contain  some  such  palliative  as  lobelia,  stramonium, 
belladonna,  hyoscine,  etc.  (Lobelia,  powdered  black  tea  and  powdered 
stramonium  leaves,  each  one  ounce;  soak  well  in  two  ounces  of  a  satur- 
ated solution  of  potassium  nitrate;  dry.)  Excellent  cigarettes  are  made, 
containing  arsenic,  potas.  nitrate,  belladonna,  and  stramonium;  their 
antispasmodic  effects  on  deep  inhalation  of  the  smoke  is  sometimes 
remarkable. 

According  to  Burney  Yeo,  the  celebrated  Cigarettes  d'Espic  are  said 
to  be  made  of  the  following  ingredients: 


510  DISEASES  OF   THE  RESPIRATORY  TRACT 

Belladonna  leaves 5^  parts. 

Hyoscyamus  leaves 2|  parts. 

Stramonium  leaves 2 1  parts. 

Phellandrium  aquaticum 1    part. 

Extract  of  opium ^  part. 

Cherry-laurel  water a  sufficiency. 

Oxygen  is  occasionally  efficacious  and  strong  coffee  may  sometimes 
abort  the  attack. 

2.  Of  the  Tendency. — {v.  Etiology.) — The  nose  requires  especial 
attention;  cauterization  of  sensitive  areas,  even  when  there  are 
no  gross  lesions,  is  imperative.  The  diet  should  be  regulated;  the 
evening  meal  should  be  light,  and  carbohydrates  and  tea  should  be 
restricted ;  an  emetic  may  abort  an  attack  of  the  gastric  type.  Nervines 
(valerian,  arsenic,  bromides)  may  be  used  when  necessary.  The  best 
remedy  between  attacks  is  potassium  iodide;  this  treatment  should  be 
continued  for  months;  potassium  iodide  is  combined  to  advantage 
with  Fowler's  solution  and  belladonna,  not  only  to  correct  the  action 
of  the  iodides  on  the  skin  and  secretory  glands,  but  also  for  their 
direct  nervous  and  antispasmodic  effects: 

Liq.  potassii  arsenitis oj-  . 

Tr.  belladonnae 5j. 

Potassii  iodidi oij- 

Fluidextr.  grindelise  robustse 5  vj . 

Aquse q.s.  ad  Biv. 

M.  et  S. — One  teaspoonful  after  meals,  in  water. 

Alkalies  may  be  vaporized  and  inhaled,  as  sodium  bicarbonate  or 
sodium  chloride.  Climatic  treatment  is  as  beneficial  as  in  bronchitis; 
a  low  level  near  the  sea  and  in  a  semitropical  climate  is  an  ideal  loca- 
tion. General  hygiene  and  the  hardening  of  the  patient  by  fresh  air 
and  cold  rubs  are  important. 


DISEASES  OF  THE  LUNG. 

(A).  EMPHYSEMA. 

Definition. — A  permanent  disease  of  the  lungs,  characterized  patho- 
logically by  atrophy  of  the  alveolar  walls  and  great  distention  of  the 
alveoli,  and  clinically  by  a  large  chest  of  the  inspiratory  type,  distended 
lungs  with  poor  excursion,  and  hypertrophy  and  dilatation  of  the  right 
ventricle.  Emphysema  means  a  "blowing  up"  or  distention  of  the 
lungs,  of  which  the  various  types  will  be  considered  under  Differ- 
entiation. It  was  first  described  by  Laennec  (1826).  It  constitutes 
/o  per  cent,  of  all  autopsies  (Virchpw). 


EMPHYSEMA  511 

Etiology.— Substantive  or  alveolar  emphysema  occurs  mostly  in 
individuals  over  30  or  40  years  of  age,  in  men  more  than  in  women,  and 
in  cold  climates.  The  immediate  cause  is  chronic  bronchitis  and 
bronchiolitis  (Laennec),  catarrhe  sec;  it  may  follow  pertussis  or  bron- 
chial asthma;  its  comparative  infrequency  is  not  generally  understood, 
whence  many  writers  assume  a  congenital  or  hereditary  weakness  or 
hypoplasia  of  the  elastic  tissue  of  the  lung.  Coughing,  blowing,  as  in 
the  use  of  wind  instruments,  straining  during  parturition  or  physical 
toil,  artificial  respiration  in  the  new-born,  and  alcoholism  are  also  con- 
sidered to  be  causes. 

Pathology. — On  opening  the  chest  at  autopsy,  the  lungs  are  found 
distended  {volumen  pulmonwm  auctum,  Traube);  they  overlap  the 
heart,  depress  the  diaphragm,  and  narrow  the  mediastinum.  Their 
surface  is  pale  rose-colored,  is  somewhat  anaemic,  and  presents  numer- 
ous small  vesicles,  ^  to  3  or  4  mm.  in  diameter,  representing  the  fusion 
of  several  alveoli.  Some  large  bullous  areas  are  found  under  the  pleura. 
The  lungs  crepitate  slightly  to  the  fingers,  under  which  they  feel,  as 
Laennec  put  it,  "like  a  pillow  of  down."  The  lungs  collapse  but  little 
on  section.  In  some  places  the  pigment  deposit  is  less  than  usual;  this 
is  called  albinism  by  Virchow.  Emphysema  is  most  marked  on  the 
surface  of  the  lung,  particularly  over  the  upper  lobes,  on  their  convex 
anterior  aspect,  and  behind  near  the  spine.  The  normally  thin  edges 
of  the  lung  are  greatly  rounded.  Histologically,  two  findings  are  char- 
acteristic: (a)  There  is  atrophy  of  the  interalveolar  elastic  tissue,  so 
that  the  alveoli  fuse,  corresponding  to  the  vesicles  seen  on  the  surface ; 
slight  intercommunication  of  the  alveoli  is  normal,  but  the  coalescence 
of  several  alveoli  into  one  is  extreme  in  emphysema;  these  changes 
account  for  nearly  all  the  clinical  findings  in  the  lung,  (b)  The 
capillaries  are  obliterated  by  thrombosis,  and  become  fatty,  which 
explains  the  clinical  hypertrophy,  dilatation  and  ultimate  failure  of  the 
right  heart.  The  bronchi  are  frequently  inflamed,  thickened,  shortened, 
and  sometimes  dilated. 

Pathogenesis. — It  is  not  wholly  clear  whether  the  elastic  wasting  or 
the  vascular  occlusion  is  the  primary  change;  or,  if  the  elastic  atrophy 
is  primary,  whether  it  is  acquired  or  congenital.  The  changes  may  be 
brought  about  (a)  mechanically  by  forced  inspiration  (Laennec,  Roki- 
tansky,  Gairdner)  or  by  forced  expiration  (Jenner,  Mendelsohn). 
This  theory  is  most  favored  by  clinicians,  though  pathologists  think 
that  emphysema  is  due  to  (6)  nutritive  alterations,  as  vascular  changes, 
or  atrophy  of  elastic  or  muscular  tissue;  calcification  of  the  costal  carti- 
lages is  probably  more  sequential  than  causal. 

Symptoms. — Symptoms  may  be  considered  under  two  general 
headings:  (1)  Those  of  expiratory  insufficiency  of  the  lungs,  due  to 
their  distention  which  results  in  turn  from  the  loss  of  elastic  tissue;  and 
(2)  those  of  cardiac  insufficiency,  which  follow  the  above  and  result 
from  obliteration  of  the  vessels  in  the  lesser  circuit. 

1.  Expiratory  Pulmonary  Insufficiency. — Normally  expiration  is 
wholly  passive,  resulting  from  the  elasticity  of  the  lungs  and  collapse  of 


512  DISEASES  OF   THE  RESPIRATORY   TRACT 

the  chest.  Expiration  in  emphysema  is  incomplete,  as  shown  by 
Waldenburg's  pneumotometry  and  Riegel's  stethography ;  in  the  latter 
the  curve  resembles  one  resulting  from  division  of  the  vagus.  The 
cyrtometer  shows  that  the  chest  is  more  circular;  the  spirometer  shows 
a  decrease  of  20  to  60  per  cent,  in  the  normal  vital  capacity  (2-4000  c.c); 
and  mensuration  shows  a  decided  reduction  in  the  normal  expansion  of 
2  to  3  inches.  Upon  inspection,  dyspnoea  is  the  most  conspicuous 
finding;  it  is  expiratory  and  is  due  to  the  loss  of  lung  elasticity  and 
consequent  impairment  of  lung  circulation  and  oxygenation;  it  is 
increased  by  exertion,  by  bronchial  catarrh,  by  accessions  of  true 
asthma,  and  by  cardiac  insufficiency.  If  emphysema  develops  gradually 
it  may  cause  no  dyspnoea  (Traube).  The  frequency  of  respiration  is 
increased  to  twenty-five  or  thirty  and  the  type  is  costal.  The  fades 
and  habitus  are  most  characteristic;  the  eyes  are  somewhat  prominent, 
the  nose  is  bluish  and  slightly  thickened,  the  head  is  thrown  back  and 
the  chest  forward  to  give  play  to  the  accessory  muscles  of  respiration, 
and  the  skin  is  cyanotic  even  during  rest  and  when  dyspnoea  is  not 
urgent.  A  network  of  dilated  veins  is  often  seen  over  the  lower  chest, 
resulting  merely  from  venous  obstruction.  The  jugular  veins  fill 
enormously  on  expiration  and  often  pulsate  during  the  diastole.  The 
neck  is  short,  and  the  hypertrophied  sternomastoids,  scaleni  and  trape- 
zii  protrude  rigidly.  The  back  and  abdominal  muscles  are  rigid,  and 
thus  supplement  the  inadequate  action  of  the  diaphragm.  The  shoul- 
ders are  elevated,  though  stooped;  the  chest  is  of  the  permanent  inspira- 
tory type  and  is  usually  barrel-shaped  (from  loss  of  the  elastic  tissue), 
rarely  of  the  paralytic  type;  the  anteroposterior,- oblique,  and  some- 
times the  transverse  dimensions  of  the  chest  are  increased.  The  raised 
clavicles  accentuate  the  supraclavicular  notches,  in  which  the  apices 
sometimes  protrude,  on  coughing,  as  hernial  tumors.  The  angle  of 
Louis  is  prominent  and  the  interspaces  are  wider  in  the  upper  and 
narrower  in  the  lower  parts  of  the  chest,  and  retract  with  each  inspira- 
tion. The  lower  thorax  shows  a  groove  indicating  the  attachment  of 
the  expiratory  muscles.  The  play  of  the  diaphragm  is  limited,  as 
shown  by  the  a;-rays  and  by  the  absence  of  Litten's  sign.  Palpation 
detects  the  rigidity  and  dilatation  of  the  thorax,  its  poor  excursion,  the 
hardness  of  the  muscles,  the  thick,  often  calcified  costal  cartilages,  and 
decreased  vocal  fremitus.  The  edge  of  the  liver  may  be  found  de- 
pressed, though  the  spleen  is  seldom  palpable.  Percussion,  absolutely 
essential  to  a  diagnosis,  gives  a  note  which  is  loud  and  deep — hyper- 
resonant — or  on  the  sides  and  back  it  is  actually  "  6ox-/iA;e  "  or  tympan- 
itic; it  is  also  described  as  muffled  or  wooden  and  in  extreme  cases 
impresses  one  as  dull  (Skoda).  The  voluminous  lungs  narrow  or 
wholly  cover  the  cardiac  dulness,  depress  the  upper  level  of  the  splenic 
and  hepatic  dulness,  invade  Traube's  space,  and  show  either  no 
respiratory  excursion  or  movement  not  exceeding  a  finger's  breadth. 
At  the  back  the  lungs  may  reach  the  twelfth  dorsal  or  even  the  second 
lumbar  vertebra.  Upon  auscultation,  expiration  is  found  greatly  length- 
ened so  that  it  is  to  inspiration  as  1  to  2  or  4,  the  converse  of  the  nor- 


EMPHYSEMA  513 

mal.  Vesicular  breathing  is  absent,  or  the  breathing  is  indeterminate; 
even  when  the  stethoscope  rises  and  falls  there  may  be  no  audible 
sound.  A -rubbing  sensation  may  result  from  muscular  contraction  or 
possibly  from  the  emphysema  vesicles.  Rales  result  from  bronchitis 
or  stasis;  a  pearly-colored  mucin  with  few  cells  may  be  evacuated 
after  much  coughing. 

2.  Cardiac  Insufficiency. — The  work  of  the  right  ventricle  is  in- 
creased because  the  imperfect  expiration  allows  neither  free  aspiration 
of  venous  blood  into  the  auricles  nor  adequate  filling  of  the  aorta,  and 
because  the  pulmonary  arterioles  are  in  part  occluded.  The  right 
ventricle,  therefore,  hypertrophies,  and  this  causes  the  accentuated 
second  pulmonic  tone;  hypertrophy  occurs  mostly  about  the  pul- 
monary conus  arteriosus.  The  diaphragm  is  low,  and  therefore  the 
hypertrophied  and  more  horizontal  heart  beats  in  the  epigastrium. 
Dilatation  soon  follows  and  is  accompanied,  in  advanced  cases,  by  tri- 
cuspid leakage,  nutmeg  liver,  congested  kidneys,  ascites,  oedema,  and 
other  signs  of  cardiac  insufficiency.  The  alteration  in  the  heart,  so 
marked  at  autopsy,  is  often  obscured  during  life,  for  the  lungs  cover  the 
heart  and  muffle  its  tones.  Functional  heart  murmurs  are  mostly 
systolic,  very  rarely  diastolic,  and  result  chiefly  from  degeneration  or 
relaxation  of  the  heart  muscle. 

The  clinical  course  is  long  and  often  covers  decades.  Patients 
may  acquire  emphysema  in  childhood  and  live  to  be  60  or  70  years  old. 

Diagnosis. — Developed  types  are  easily  recognized  by  the  barrel- 
chest,  its  hyperresonance,  the  low  borders  of  the  lung,  their  lack  of 
excursion,  the  obscuration  of  cardiac  dulness,  the  expiratory  dyspnoea, 
and  cardiac  stasis. 

Differentiation. — (a)  Acute  distention  of  the  lung  or  acute  emphy- 
sema, as  after  asthma  or  pertussis,  cannot  be  distinguished  by  one  ex- 
amination. It  is  seen  repeatedly  in  bronchial  stenosis  due  to  aortic 
aneurysm.  It  regresses  rapidly  even  after  months,  when  its  cause  is 
removed.  (6)  Vicarious  or  compensatory  emphysema  often  develops  in 
one  lung  when  contralateral  pleurisy  or  cirrhosis  of  the  lung  exists ;  it 
may  occur  on  the  same  side  with  the  lesion ;  marked  apical  emphysema 
almost  certainly  indicates  some  deeper  induration;  it  may  develop  in 
the  death  agony;  it  may  eventually  cause  wasting  of  the  lung,  (c) 
Emphysema  senile,  or  Jenner's  "small-lunged"  emphysema,  is  merely 
atrophy;  the  connective  tissue  wastes  and  the  alveoli  fuse,  but  the 
lungs  are  not  enlarged;  they  are  indeed  smaller,  the  diaphragm  stands 
higher,  the  cardiac  dulness  is  increased,  the  chest  flattened,  the  ribs 
oblique,  the  respiratory  muscles  wasted,  the  right  heart  is  not  hyper- 
trophied, and  respiratory  excursion  is  retained,  {d)  From  interalveolar 
interstitial  emphysema  the  first  differential  point  is  the  etiology;  (i)  it 
,  may  be  caused  by  trauma,  external  or  internal,  which  occurs  in  57  per 
cent  of  tracheotomies  (Money),  and  is  promoted  by  raising  the  deep 
fascia  from  the  trachea  during  the  operation  (Champneys);  it  is  es- 
pecially frequent  with  pneumothorax,  (ii)  It  may  result  from  foreign 
bodies,      (iii)  Ulceration  of  the  air  passages,  gangrene,  abscess,   or 

33 


514  DISEASES  OF  THE  RESPIRATORY  TRACT 

tuberculosis  and  less  often  gastric  ulcer  or  cancer  may  be  its  cause. 
Other  etiological  factors  are  (iv)  forced  entrance  of  air,  as  in  resuscita- 
tion of  the  new-born;  (v)  severe  coughing  efforts,  as  in  whooping 
cough;  (vi)  severe  pressure  efforts,  as  in  parturition;  and  (vii)  spasm 
of  the  glottis.  The  second  point  is  a  series  of  symptoms  which  are  not, 
however,  always  present,  as  creaking  in  the  mediastinum  and  some- 
times with  each  systole;  emphysema  and  crepitation  of  the  cervical 
cellular  tissue,  bulging  of  the  interspaces,  creaking  and  tympany  at  the 
edge  of  the  ribs  when  the  emphysema  is  under  the  costal  pleura;  ab- 
sence of  the  vesicular  murmur;  sometimes  pneumothorax;  and  obliter- 
ation of  the  heart  dulness,  dyspnoea  and  air  embolism.  It  is  usually 
fatal,  (e)  In  congenital  liypertrophy  of  the  lung  (pulmo  excessivus) 
the  lungs  are  very  voluminous,  but  their  excursion,  note,  auscultation, 
and  percussion  are  normal.  To  the  author  it  appears  to  be  especially 
common  among  Poles.  (/)  Pneumothorax  (q.  v.)  is  unilateral,  is 
usually  associated  with  fluid  in  the  pleura,  has  a  more  tympanitic 
note,  and  is  associated  with  succussion,  tinkling  rales  and  other  path- 
ognomonic signs. 

Prognosis. — Recovery  is  unusual  in  the  genuine  substantive  form, 
which  is  permanent.  Transient  forms  resulting  from  pertussis,  foreign 
bodies,  or  asthma,  often  or  usually  regress  completely.  Life,  even 
relative  comfort,  may  be  sustained  for  years  or  decades.  Much  depends 
on  associated  conditions,  as  frequent  severe  bronchitis,  chronic  nephri- 
tis, arteriosclerosis,  or  myocarditis.  Extreme  forms  impede  the  flow 
of  chyle  which,  with  dyspnoea  and  fatigue,  impairs  nutrition.  Severe 
complications  are,  failure  of  the  right  heart  upon  which  compensation 
devolves,  cyanosis,  gastric  disturbance,  diarrhoea,  hemorrhage  from 
the  lungs  or  bowels  (in  arteriosclerosis,  gout  or  infarction),  scanty 
urine,  and  anaemia  (in  the  aged). 

Death  usually  results  from  cardiac  failure  or  from  oedema  pul- 
monum.  It  may  occur  from  apoplexy,  pneumothorax,  haemoptysis, 
uraemia,  and  very  rarely  from  pulmonary  inflammation,  to  which 
subjects  of  emphysema  show  no  predisposition.  The  teaching  that 
tuberculosis  (Rokitansky)  or  valvular  disease  (Bouillaud)  exclude 
emphysema,  is  incorrect. 

Treatment. — (a)  Prophylaxis  concerns  chiefly  the  concomitant  or 
causal  bronchitis.  Severe  exercise  is  to  be  avoided,  (b)  Coincident 
gastric,  renal  or  gouty  disease  must  be  treated,  (c)  Climate  is  as  im- 
portant a  factor  as  it  is  in  chronic  bronchitis,  an  almost  inseparable 
associate  of  emphysema;  altitudes  are  expressly  to  be  avoided  as  they 
directly  promote  emphysema,  id)  Pneumotherapy  is  sometimes  bene- 
ficial. It  includes  inhalation  of  thinned  air,  or,  where  there  is  marked 
catarrh,  of  compressed  air.  Two  or  three  treatments  of  ten  minutes 
should  be  given  daily,  and  the  time  should  soon  be  extended  to  half  an 
hour,  (e)  Chronic  bronchitis  (q.  v.),  and  (/)  asthma  (q.  v.)  are  impor- 
tant considerations  in  treatment,  (g)  Rhythmic  compression  of  the 
chest,  three  or  four  times  daily,  should  be  practised  during  20  to  30 
expirations,      (h)   Cardiac   insufficiency  is  treated  as  in  valvular  or 


BRONCHOPNEUMONIA  515 

myocardial  heart  disease  {q.  v.),  and  strychnine,  venesection,  and  other 
measures  should  be  used.  (The  topic  is  discussed  briefly,  as  no  remedy 
nor  measure  can  restore  lost  elastic  tissue  nor  return  resilience  to 
damaged  contractile  fibers.) 


BRONCHOPNEUMONIA. 

This  affection,  partially  outlined  by  Sydenham  and  Gebhart,  was 
first  well  described  in  1840,  by  Rilliet  and  Barthez,  who  separated  it 
from  lobar  pneumonia  and  recognized  it  as  a  secondary  disease.  It 
might  be  well  classed  among  the  infections,  such  as  fibrinous  pneu- 
monia, except  that  unlike  the  latter  it  is  not  due  to  a  single  specific 
microorganism. 

Definition. — Bronchopneumonia  is  defined  with  difficulty;  (a) 
etiologically  it  is  due  to  various  microbes,  is  generally  secondary  to 
the  bronchiolitis  of  some  specific  infection,  as  measles  or  pertussis,  and 
occurs  chiefly  in  children;  (b)  pathologically  it  develops  about  the 
bronchioles  (bronchopneumonia)  and  in  a  few  lobules  (p.  lobularis,  p. 
insularis  or  nodosa)  rather  than  throughout  a  lobe,  its  exudate  is 
rather  catarrhal  (p.  catarrhalis)  than  fibrinous,  and  its  distribution  is 
usually  multiple  and  often  disseminated  (p.  disseminata);  (c)  clinic^ 
ally  it  is  identical  with  capillary  bronchitis,  which,  if  it  occurs  in  the 
first  years  of  life,  almost  never  spares  the  lung  tissue;  it  is  marked  by 
fever,  cough,  dyspnoea  and  cyanosis,  which  may  often  co-exist  with- 
out obvious  signs  of  hepatization. 

Etiology. — (a)  Some  cases,  especially  in  children  under  two  years, 
are  primary;  these  are  estimated  by  Holt  at  35  per  cent.,  by  others  at  a 
much  lower  figure;  (6)  most  cases  are  secondary  to  infections  affecting 
the  upper  air  passages.  In  279  cases  of  infantile  bronchopneumonia 
reported  by  Samuel  West,  32  per  cent,  followed  measles,  24  per  cent, 
pertussis,  16  per  cent,  diphtheria,  15  per  cent,  macrobronchitis,  7  per 
cent,  ileocolitis,  3  per  cent,  scarlatina,  2  per  cent,  influenza,  ^  per  cent, 
each  varicella  and  erysipelas,  (c)  Predisposing  causes  in  the  young  are 
poor  sanitation,  malnutrition,  syphilis,  tuberculosis  (scrofula),  and 
rickets.  Bronchopneumonia  causes  9  per  cent,  of  deaths  in  foundling 
asylums  (Miiller).  (d)  Age  is  an  etiological  factor.  Most  cases  are 
observed  in  children  two  or  three  years  old.  Seventy-five  per  cent,  of 
cases  of  pneumonia  in  children  under  five  years  of  age  are  lobular  (Holt). 
It  is  less  frequent  in  adults;  in  weak,  cachectic,  nephritic  and  aged  per- 
sons it  may  cause  death,  (e)  In  some  cases  microbes  may  act  directly  on 
the  lungs,  as  in  the  primary  cases  in  children,  in  the  influenza  of  adults, 
and  in  aspiration  or  inhalation  pneumonia.  "Schluck  pneumonic"  is 
prone  to  develop  in  diseases  in  which  the  laryngeal  sensibility  is  de- 
creased as  in  diphtheritic  pareses  or  bulbar  palsies;  in  ether  or  less 
often  chloroform  anaesthesia  in  which  the  germ-laden  saliva  is  drawn 
into  the  lungs;  in  comatose  states,  as  apoplexy,  or  uraemia;  in  menta.1 
diseases;  in  the  new-born;  in  cases  of  partial  drowning;  in  operations 


516  DISEASES  OF   THE  RESPIRATORY  TRACT 

on  the  throat,  as  tracheotomy  or  those  for  foreign  bodies  or  cancer  of 
the  larynx  or  oesophagus;  or  when  there  is  persistent  vomiting.  Smoke, 
vapors,  gases  and  dust  are  exceptional  causes.  (/)  It  is  probable  that 
infection  may  sometimes  occur  by  the  lymph  or  hlood  streams,  especially 
in  septic  affections. 

Bacteriology. — Bronchopneumonia  is  no  specific  bacteriological 
disease.  According  to  Netter,  in  adults  about  one-third  of  the  cases 
show  more  than  one  organism,  among  which  the  pneumococcus  ranks 
first  and  the  streptococcus  second ;  and  about  two-thirds  show  one  germ, 
of  which  the  pneumococcus  constitutes  39  per  cent.,  streptococcus  31 
per  cent.,  Friedlander's  bacillus  23  per  cent.,  and  the  staphylococcus  7 
per  cent. ;  in  children  mixed  infection  is  present  in  half  the  cases,  the 
streptococcus  predominating,  while  in  the  other  half  there  is  but  one 
organism,  the  pneumococcus  being  the  most  common.  Others,  as 
Deurck,  maintain  that  most  cases  show  mixed  infection.  Other  germs 
found  are  the  influenza,  typhoid,  tubercle  and  colon  bacilli,  Pfeiffer's 
Micrococcus  catarrhalis,  Micrococcus  tetragenus,  and  meningococcus. 
The  tubercle  bacillus  is  often  associated  with  the  pneumococcus. 

Pathology. — The  foci  of  consolidation  are  diffused  usually  in  the 
lower  and  sometimes  in  the  upper  lobes,  posteriorly.  They  vary  in 
size  from  that  of  a  pin  head  to  that  of  a  walnut,  or  may  be  larger;  many 
or  most  foci  lie  near  the  pleura,  through  which  they  may  often  be  seen 
and  felt;  the  pleura  is  often  granular  or  shghtly  fibrinous,  sometimes 
ecchymotic.  Foci  are  usually  bilateral.  On  section  the  consolidated 
nodes  appear  reddish-brown  and  later  yellowish  from  fatty  degenera- 
tion of  the  cells;  they  are  firm,  airless,  whence  they  sink  in  water,  and  on 
section  are  generally  smooth  and  glistening,  though  some  cases  of 
pneumococcus  infection  show  the  same  granulation  and  viscid  secretion 
which  are  present  in  genuine  fibrinous  pneumonia.  The  bronchioles 
supplying  the  consolidated  nodes  are  plugged  with  muco-pus,  so  that 
air  cannot  be  forced  through  them;  the  bronchioles  are  reddened, 
swollen,  sometimes  ecchymotic  or  dilated.  Many  parts  are  collapsed, 
which  some  consider  is  preliminary  to  consolidation,  but  though 
atelectasis  is  frequent  its  importance  has  been  overestimated.  In  for- 
tunately made  sections  a  dendritic  racemose  or  grape-like  arrangement 
may  be  seen  in  which  the  bronchioles  correspond  to  the  stems  and  the 
alveoli  to  the  leaves  or  grapes.  Microscopically  the  bronchioles  show 
dilated  vessels  and  leukocyte  emigration,  the  alveoli  show  epithelial 
desquamation  and  proliferation,  serous  exudation,  leukocyte  out- 
pouring, a  scattering  of  red  cells  and  but  little  fibrin  formation;  the 
alveolar  walls  show  much  interstitial  inflammation.  It  is  usually 
stated  that  no  fibrin  is  found,  but  this  is  a  mistake;  though  influenza 
pneumonia  is  strictly  cellular  (catarrhal),  aspiration,  pneumococcic  and 
other  forms  not  infrequently  show  a  fibrin  network,  though  decidedly 
less  than  is  the  case  in  lobar  types.  Near  the  foci  and  in  the  upper 
lobes  compensatory  emphysema  often  develops.  The  bronchial  lymph 
glands  are  hypersemic,  swollen  and  succulent.  Extension  occurs 
directly  from  alveolus  to  alveolus  or  along  the  peribronchial  connective 


BRONCHOPNEUMONIA  517 

tissue.  In  some  forms  numerous  lobular  foci  may  increase  in  size  and 
perhaps  fuse  so  that  the  greater  part  of  a  lobe  may  be  consolidated; 
this  form,  lyiown  as  the  pseudolobular,  is  often  due  to  the  pneumococ- 
cus,  is  often  seen  in  measles  and  diphtheria  and  may  clinically  present 
a  close  resemblance  to  lobar  pneumonia,  though  pathologically  areas 
of  collapsed,  dark  vascular,  or  sound  tissue  lie  between  the  broncho- 
pneumonic  patches. 

S3nnptoms. — The  clinical  picture  varies  considerably,  accordingly  as 
the  bronchopneumonia  is  primary  or  secondary.  In  the  primary  form, 
which  is  most  often  due  to  the  pneumococcus,  the  onset  is  brusque, 
with  chill,  convulsions,  vomiting,  or  pain  in  the  side.  The  fever 
rises  suddenly,  remains  high,  and  often  falls  by  crisis.  Capillary 
bronchitis  is  absent  and  the  consolidation  is  often  marked.  The  course 
is  short  and  the  death  rate  is  low.  In  adults  this  form  is  frequently 
unilateral.  The  inore  common  secondary  form  begins  insidiously, 
especially  if  it  follows  a  microbronchitis;  it  is  often  obscured  by  the 
disease  which  it  complicates.  The  fever  gradually  rises  to  103°  or  104° 
(if  fever  were  already  present),  and  is  generally  irregular  or  remittent, 
rising  with  the  formation  of  each  new  focus;  it  may  be  low  or  absent 
in  marantic  subjects.  There  may  be  no  physical  findings,  or  if  present 
they  are  frequently  indeterminate.  If  recovery  ensues,  lysis  is  the 
usual  solution.  Von  Ziemssen  held  that  fever  in  bronchitis  seldom 
exceeds  102°  and  that  higher  registrations  indicate  pneumonia. 

Subjective  and  General  Manifestations. — ^These  are  often  more 
obvious  than  the  objective  or  pulmonary  symptoms.  The  pulse  rises 
to  120  or  even  180  and  in  convalescence  is  more  tardy  in  reaching  nor- 
mal than  is  the  fever.  The  respiration  is  often  60  or  80,  the  expiration 
is  frequently  catchy  or  grunting,  and  the  respiration  ratio,  normally  1  to 
4,  becomes  1  to  3  or  2 ;  dyspnoea  develops  early,  and  with  it  restlessness 
and  irritability.  Cyanosis  develops  in  the  face  and  then  in  other  parts 
from  impaired  flow  of  the  blood  to  the  heart  which  is  due  to  continued 
coughing  and  to  stagnant  secretion.  The  cervical  veins  are  prominent. 
Pain  is  not  as  common  as  in  lobar  pneumonia.  The  cough  becomes 
dryer  and  more  distressing;  the  sputum  is  usually  swallowed  in  patients 
under  seven  years  of  age,  but  if  obtained  shows  nothing  characteristic, 
though  von  Niemeyer  found  that  it  sank  in  water  or  floated  under  the 
surface.    Meteorism  is  not  uncommon  in  severe  or  moribund  cases. 

Lung  Findings. — On  inspection,  irregular  excursion  is  sometimes 
seen.  The  accessory  muscles  of  the  nose,  neck,  chest,  and  abdomen  are 
in  full  play.  The  interspaces,  ribs,  sternum,  and  epigastrium  in  young 
plastic  chests,  retract  greatly  with  each  inspiration;  this  must  not  be 
confused  with  the  slight  physiological  retraction  observed  in  the  begin- 
ning of  inspiration.  Palpation  may  show  increased  fremitus  in  a  focus 
near  the  surface  and  measuring  2x5  cm.  Stagnant  secretion  in  the  air 
tubes  may  temporarily  suspend  fremitus.  Percussion  is  often  negative 
for  a  few  days  or  even  throughout  the  course,  as  it  is  ol)vious  that  deep, 
isolated  foci  cannot  produce  dulness.  In  the  thin,  infantile  thorax,  per- 
cussion must  be  made  lightly  and  special  importance  should  be  attached 


518  DISEASES  OF   THE  RESPIRATORY   TRACT 

to  palpatory  percussion.  Dulness  obtains  over  a  focus  having  an  area 
of  2  X  5  cm.  It  is  most  often  found  along  the  spine  over  the  lower  lobes, 
but  sometimes  also  over  the  scapular  spines.  Dulness  is  most  marked 
in  the  pseudolobular  (confluent)  forms.  Atelectasis  may  cause  dulness 
but  not  bronchial  breathing.  A  hyperresonant  note  in  front  indicates 
emphysema;  behind  it  shows  relaxation.  Auscultation  reveals  sub- 
crepitant  or  crepitant  rales;  they  are  often  heard  over  an  area  not 
exceeding  the  bell  of  the  stethoscope.  Bronchial  breathing  and  bron- 
chophony are  fairly  frequent,  and  occur  especially  when  the  child 
cries.     In  other  cases  the  breathing  may  be  rude  or  puerile. 

Special  types  have  been  considered  under  measles,  pertussis,  etc. 
Abt  (following  Holt,  Carmichael,  Ashby  and  Wright),  offers  the  follow- 
ing pathological  classification,  which  "undoubtedly  gives  the  clearest 
basis  for  an  understanding  of  the  physical  findings:  (a)  In  capillary 
bronchitis  there  is  no  sign  of  consolidation  in  any  part  of  the  lung.  Sib- 
ilant rales,  coarse  and  fine  crepitant  rales  are  distributed  over  one  or 
both  lungs.  The  sibilant  rales  are  due  to  congestion  and  swelling  of  the 
mucous  membrane  of  the  larger  and  smaller  tubes.  A  feeble  respira- 
tory murmur  indicates  areas  of  congestion.  (b)  In  disseminated 
bronchopneumonia,  which  is  characterized  by  small  areas  of  consolida- 
tion, percussion  usually  gives  negative  results,  though  sometimes  there 
is  very  slight  dulness.  The  vocal  fremitus  is  usually  not  altered.  As  a 
rule  the  consolidated  areas  are  situated  deeply  in  the  lung,  or  are  too 
small  to  cause  any  appreciable  difference  in  the  percussion  note.  Aus- 
cultation reveals  crepitant  rales  and  bronchovesicular  breathing  over 
the  consolidated  areas.  Vocal  and  crying  resonance  is  exaggerated, 
(c)  In  acute  generalized  bronchopneumonia,  the  percussion  note  is  dull 
over  a  large  area.  Even  an  entire  lobe  may  be  involved.  Palpation 
shows  an  increase  in  vocal  fremitus.  Auscultation  reveals  bronchial 
breathing,  and  fine  moist  rales  are  heard  over  the  dull  areas,  while  the 
rest  of  the  lung  shows  evidence  of  bronchitis. " 

Issues. —  Death  may  occur  from  carbonic  acid  narcosis,  irritability 
passing  into  apathy,  the  harassing  cough  becoming  less  marked  and 
causing  stagnation  of  bronchial  secretion  in  the  large  tubes  ("  suffoca- 
tive catarrh");  delirium  develops,  the  pupils  narrow,  and  Cheyne- 
Stokes  breathing  and  heart  failure  result.  Complete  resolution  is  the 
rule  in  cases  which  recover.  Delayed  resolution  with  remissions  and 
exacerbations  may  occur.  Complications  may  develop ;  (a)  pleurisy  is 
the  most  frequent;  (b)  gangrene;  (c)  abscess,  especially  in  aspiration 
and  influenza  forms;  (d)  pulmonary  induration;  (e)  bronchiectasis; 
(/)  tuberculosis,  which  is  less  often  a  sequel  than  a  previous  disease 
awakened  by  the  new  infection;  (g)  pericarditis,  endocarditis,  otitis, 
emphysema,  and  fibrinous  bronchitis  are  other  possible  complications. 

Diagnosis. — Reliance  on  physical  signs  alone  leads  to  many  errors 
and  a  diagnosis  is  often  determined  by  the  development  of  sudden  high 
fever  or  mild  fever  suddenly  rising  during  bronchitis,  by  dyspnoea, 
irregular  rapid  respiration,  cyanosis,  and  pain  in  the  chest.  In  very 
young  or  marantic  children  and  in  the  aged  the  onset  and  symptoms 


BROXCHOPNEUMOXIA  519 

may  be  very  atypical.  Lobar  pneumonia  (q.v.  variations  in  children) 
occurs  mostly  in  sound  children  over  three  years  of  age,  runs  a  shorter 
cyclical  typical  course,  ends  by  crisis,  is  unilateral  and  involves  the 
greater  part  of  one  or  more  lobes;  while  bronchopneumonia  occurs 
more  often  in  younger  weakly  children,  is  often  a  sequel  of  bronchioli- 
tis, runs  a  longer,  more  atypical,  unfavorable  and  relapsing  course,  re- 
solves by  lysis,  is  bilateral  and  is  less  marked  by  definite  pulmonary 
findings.  Tuberculosis  is  often  distinguished  only  by  the  course;  it 
invades  the  upper  lobes  more  than  does  bronchopneumonia,  and 
bacilli-laden  sputum  may  be  recovered  by  washing  the  stomach  or  by 
swabbing  the  throat  when  the  child  raises  mucus  after  coughing. 
Pleurisy  (q.v.)  is  diagnosticated  by  means  of  the  aspirating  needle. 

Course  and  Prognosis. — The  course  may  be  (a)  acute,  lasting  about 
a  week,  of  which  the  measles-pneumonia  is  the  prototype;  (b) 
subacute,  lasting  from  two  to  eight  weeks,  exemplified  by  the  pertus- 
sis-pneumonia, or  (c)  chronic,  covering  months,  as  in  tuberculous  bron- 
chopneumonia. 

The  prognosis  depends  on  the  patient's  social  situation,  previous 
history,  age,  the  disease  of  which  the  pneumonia  is  a  complication, 
and  the  extent  of  the  pneumonia.  The  outlook  in  general  is  serious, 
especially  in  secondary  forms,  among  which  measles  and  pertussis 
represent  the  more  serious  types;  in  the  very  young  it  is  almost  as 
fatal  as  infantile  diarrhoea;  aspiration  forms  are  very  serious,  as  are 
those  in  marantic  and  aged  subjects.  In  private  practice  the  death- 
rate  ranges  from  10  to  33  per  cent.,  in  hospitals  33  to  50  per  cent., 
and  in  asylums  even  higher  (50  to  100  per  cent.).  Early  cyanosis, 
dyspnoea  and  rapid  pulse  are  unfavorable  signs. 

Treatment. — 1.  Prophylaxis. — (a)  In  infections  which  produce  nasal 
or  pharyngeal  inflammation  the  nose  and  throat  should  be  frequently 
cleaned  with  mild  alkaline  antiseptics,  (b)  When  there  is  laryngeal  or 
bronchial  inflammation,  congestion  and  atelectasis  should  be  avoided 
by  frequent  and  regular  change  of  posture,  (c)  Deep  breathing  should 
be  encouraged  in  older  subjects,  or  enforced  in  the  young  by  affusions 
of  cold  water  on  the  neck  and  upper  thorax,  (d)  Exposure  should  be 
avoided,  especially  at  night  by  pinning  the  bedclothes  or  firmly  fasten- 
ing the  nightgown  to  the  foot  of  the  bed. 

2.  Therapy. — Actual  treatment  is  symptomatic,  as  the  varied  etiol- 
ogy precludes  specific  therapy,  (a)  The  patient  should  have  plenty  of 
fresh  air.  The  temperature  of  the  room  should  be  maintained  at  67° 
to  70°  with  constant  moderated  ventilation,  (b)  The  diet  should  be 
fluid,  diluted  or  predigested;  egg  albumin,  milk  and  plenty  of  water  are 
indicated.  At  the  onset  or  during  the  course  calomel  gr.  u,  every 
hour  for  five  or  six  doses  should  be  given,  followed  by  castor  oil,  particu- 
larly if  there  is  indigestion  or  tympany,  (c)  Expectorants,  as  ammonium 
carbonate,  tartar  emetic  or  ipecac,  should  not  be  given  generally,  as 
they  derange  digestion,  and  good  digestion  is  of  great  importance  to 
weak  as  well  as  to  strong  subjects.  Aromatic  spirits  of  ammonia,  tt^. 
V  to  XX,  every  three  or  four  hours,  is  least  deranging  and  is  a  diffusive 


520  DISEASES  OF  THE  RESPIRATORY   TRACT 

stimulant,  (d)  Pain  rarely  necessitates  the  use  of  opiates,  which  pro- 
mote stagnation  of  secretion;  dyspnoea,  pain,  restlessness,  cough, 
cyanosis,  and  rapid  pulse  may  be  relieved  by  paregoric,  which  is  prefera- 
ble to  Dover's  powder  or  morphine;  but  great  care  is  imperative  in  the 
use  of  any  opiate  in  young,  old,  or  weak  subjects,  (e)  Local  applica- 
tions, as  poultices  or  pneumonia  jackets  and  blisters,  are  useless.  (/) 
In  the  treatment  of  fever,  antipyretics,  aconite,  antimony  and  other 
cardiac  depressants  should  be  wholly  avoided.  Cool  applications  are 
equally  efficacious;  they  also  lessen  tympany  and  carbon  dioxide  nar- 
cosis, stimulate  the  heart  and  brain  centres,  and  deepen  the  respiration. 
A  cold  pack  should  be  applied  over  the  neck,  chest,  and  abdomen  and 
should  be  changed  frequently.  Cold  must  be  used  with  care  in  very 
young  and  in  marantic  subjects;  in  such  cases  a  warm  sponge  or  bath 
may  be  given,  during  which  cold  water  may  be  poured  on  the  neck  to 
stimulate  deep  breathing,  (g)  For  cardiac  stimulants,  whisky  and 
brandy  may  be  given  in  daily  doses  of  3ss  to  5iijj  very  well  diluted  in 
water  or  in  peptonized  milk.  Aromatic  spirits  of  ammonia,  digitalis, 
saline  infusions  or  enemata,  camphor  or  strychnine  (gr.  400  every  three 
or  four  hours  for  a  child  six  months  old)  may  be  used.  Hypodermics 
of  ether  may  cause  sloughing,  (h)  Respiratory  stimulants  include 
tr.  belladonna  (n^.i.  to  ii.  every  two  to  four  hours),  oxygen,  thoracic 
faradization  and  mechanical  compression  of  the  chest,  (i)  Emetics 
are  unreliable;  ipecac  and  similar  remedies  have  no  effect  when  there 
is  pronounced  carbon  dioxide  intoxication,  whence  it  has  been  recom- 
mended to  combine  them  with  coffee,  camphor,  or  cognac.  For  car- 
bon-dioxide intoxication  phlebotomy  should  seldom  be  practised.  (;) 
Inhalations  of  steam  (y.  Diphtheria  and  Croup)  may  be  beneficial; 
compound  tincture  of  benzoin  and  sodium  bicarbonate  are  often 
added  to  the  vaporizing  water,  {k)  During  convalescence  fresh  air  or 
a  sojourn  in  the  country  or  in  a  warm  climate  is  advisable. 

INDURATIVE  PNEUMONIA,  LUNG   CIRRHOSIS, 
FIBROID  PHTHISIS. 

Definition. — An  (almost  invariably)  secondary  overgrowth  of  the 
pulmonary  connective  tissue. 

Etiology.- — 1.  Diseases  of  the  Lung. — These  may  induce  local,  lobu- 
lar or  lobar,  unilateral  or  bilateral  fibrous  induration.  Local  indura- 
tion frequently  occurs  about  tumors,  parasites,  tubercles,  gummata, 
abscess,  gangrene,  trauma,  or  pneumokoniosis,  and  is  of  no  essential 
chncial  importance,  except  as  it  demarks  dangerous  foci  of  disease. 
Diffuse  induration  is  important,  though  decidedly  subordinate  to  the 
causal  disease,  (a)  Fibrinous  pneumonia  sometimes  (Charcot)  results 
in  lobar  induration;  Fraenkel  observed  it  seven  times  in  1,000  cases; 
it  occurs  notably  in  marantic  or  aged  subjects  and  results  from  delayed 
resolution  and  lack  of  regeneration  of  the  alveolar  epithelium;  the 
lung  becomes  airless  and  dense  from  development  of  fibrous  tissue 


INDURATIVE  PNEUMONIA,  LUNG  CIRRHOSIS,  FIBROID  PHTHISIS  521 

within  the  alveoh  whence  it  involves  contiguous  structures;  its  surface 
on  section  is  smooth,  and  the  connective  tissue  is  strikingly  translu- 
cent; slight  induration  may  be  noted  in  a  lobe  from  repeated  attacks  of 
pneumonia.  Subacute  induration  may  begin  within  two  or  three  weeks 
and  reach  considerable  development  in  one  or  two  months.  (6)  Bron- 
chopneumonia (Legendre  and  Bailly,  1844)  in  the  course  of  measles, 
pertussis,  or  influenza,  sometimes  leads  to  subacute  or  chronic  indura- 
tion, which  may  begin  from  an  alveolitis  or  peribronchitis,  (c)  Foreign 
bodies  and  aspiration  pneumonia;  (d)  chronic  tuberculosis;  and  (e) 
syphilis,  gangrene,  actinomycosis,  and  glanders  are  etiological  factors. 

2.  Bronchial  Affections. — (a)  Bronchiectasis,  which  was  noted  by 
Corrigan,  who  was  first  to  use  the  term  lung  cirrhosis;  (6)  bronchial 
stenosis,  as  by  aneurysm,  or  gumma;  and  (c)  pneumokoniosis ,  and 
putrid  and  chronic  bronchitis,  may  cause  indurative  pneumonia. 

3.  Pleural  Affections. — The  relation  of  pleurisy  to  lung  cirrhosis  is 
still  disputed;  some  consider  it  primary  to  lung  induration  and  others 
hold  it  secondary.  It  seems  established  that  primary  pleurisy  may 
sometimes  invade  and  cirrhose  the  lung;  this  is  the  "pleurogenous 
interstitial  pneumonia"  of  Charcot;  strands  of  connective  tissue  run 
into  the  lung  and  approach  and  fuse  toward  the  hilum. 

Other  causes  are  uncertain.  English  writers  mention  a  "fibroid 
tendency,"  which  is  probably  not  a  real  cause;  diabetes,  alcoholism 
and  malaria  are  also  referred  to  as  possible  etiological  factors. 

Pathology. — The  pathology  of  an  afl^ection  with  such  numerous 
causes  can  scarcely  be  described.  The  early  induration  is  reddish,  and 
the  older  connective  tissue  is  darker,  slate  colored  or  gray;  to  them 
Charcot  gave  the  names  of  induration  rouge  and  induration  grise, 
respectively.  The  new  connective  tissue  may  be  formed  in  the  bronchi, 
septi,  alveoli,  bloodvessels  or  pleura.  The  alveoli  nearly  always  show 
hyperplasia  of  the  connective  tissue.  The  lung  is  airless  and  dense; 
is  cut  with  difficulty  and  on  section  presents  either  a  granulated  or  a 
smooth  surface,  the  latter  in  cases  following  lobar  pneumonia  and 
sometimes  in  those  consecutive  to  gangrene  or  aspiration  pneumonia. 
The  volume  of  the  lung  is  decreased.  Its  shrinking  produces  changes 
in  the  mediastinum,  heart,  diaphragm  and  sound  lung,  which  will  be 
considered  under  Symptoms. 

Symptoms. — Incipient  or  localized  lesions  are  usually  undetected 
unless  they  are  observed  in  the  course  of  pneumonia  or  tuberculosis. 
Symptoms  may  be  inseparable  from  the  causal  affection  (tuberculosis, 
bronchiectasis)  or  may  follow  closely  upon  it  (pneumonia,  pleurisy). 
There  may  be  a  low  fever,  cough,  dyspnoea  on  exertion,  pain  in  the 
side,  rapid  pulse,  cyanosis,  anfemia,  malnutrition,  and  night  sweats. 
In  cases  where  the  original  malady  has  ended,  there  may  be  only 
slight  cough,  or  some  shortness  of  breath  on  exertion. 

Physical  findings  of  the  typical  chronic  case  are  as  follows:  (a) 
On  inspection  the  interspaces  are  found  narrowed  on  the  afl'ected  side, 
the  nipple  and  scapula  are  nearer  to  the  median  line,  the  shoulder  is 
lower,  the  spine  is  convex  toward  the  sound  side,  and  the  measurement 


522  DISEASES   OF    THE   RESPIRATORY    TRACT 

is  unilaterally  decreased.  In  left-sided  induration  the  lung  retracts 
from  the  heart,  leaving  its  pulsation  more  widely  exposed  and  dis- 
closing the  pulmonary  artery,  over  which  may  be  seen  and  felt  its 
systolic  filling  and  the  strong  diastolic  closure  of  the  pulmonary 
valves;  in  right-sided  induration  the  heart  beat  may  appear  to  the 
right  of  the  sternum  or  may  be  covered  up  by  the  compensatory 
emphysema  of  the  left  lung,  (b)  Palpation  corroborates  these  findings, 
and,  as  a  rule,  shows  increased  vocal  fremitus.  The  second  pulmonic 
tone  is  much  accentuated,  corresponding  to  the  hypertrophy  of  the 
right  ventricle  and  the  occasional  atheroma  of  the  artery,  (c)  Per- 
cussion elicits  dulness  below  and  sometimes  a  slightly  hyperresonant 
note  above  the  indurated  area;  the  apex  of  the  upper  lobe  is  on  a  lower 
level  and  the  diaphragm  stands  higher  (the  liver  rising  or  Traube's 
space  increasing);  there  is  no  respiratory  excursion,  (d)  Auscultation 
brings  out  the  absence  of  breath  sounds  below,  and  bronchial  breath- 
ing, and  subcrepitant,  crepitant,  and  bubbling  rales  above.  Additional 
signs  result  from  the  right  heart  hypertrophy  and  dilatation  and  from 
coincident  bronchiectasis,  or  cavity  formation  on  the  same  side,  and 
the  well  developed  compensatory  emphysema  on  the  opposite  and 
otherwise  healthy  side.    There  is  nearly  always  some  sputum. 

Diagnosis. — Diagnosis  is  more  easily  made  in  the  very  chronic  than 
in  the  subacute  forms;  subacute  post-influenzal  or  post-pneumonic 
induration  may  easily  suggest  tuberculosis,  or  interlobular  suppura- 
tion.    Slow-growing  tumors  of  the  lung  may  cause  confusion. 

Prognosis. — The  prognosis  varies  mth  the  etiology.  Ulcers  may 
form  from  arterial  occlusion  or  from  infected  bronchial  secretion, 
whence  the  frequency  of  lung  hemorrhage  (in  50  per  cent.)  and  its 
occasional  role  as  a  cause  of  death.  Amyloidosis  sometimes  results, 
but  death  is  usually  caused  by  right  heart  failure,  which  may  possibly 
occur  during  some  acute  intercurrent  disease. 

Treatment. — Therapy  is  unavailing,  though  life  may  be  prolonged 
for  decades  under  proper  hygiene.  Exercises  with  the  arms  may  check 
the  early  shrinking,  but  nothing  can  remove  an  established  induration. 
Warm  climates  at  the  sea  level  or  at  slight  elevation  are  beneficial. 
Some  writers  hold  that  turpentine  is  of  benefit  in  checking  induration. 


PNEUMOKONIOSIS. 

Zenker  employed  the  term  to  include  various  indurative  diseases  of 
the  lungs  due  to  "dust"  inhalation. 

Etiology  and  Pathology. — 1.  Anthracosis  is  due  to  inhalation  of 
carbon,  coal  dust,  soot,  charcoal  or  graphite,  and  is  known  as  "coal 
miner's  disease."  (a)  Moderate  amounts  of  carbon  inhaled  into  the 
trachea  and  bronchi  are  absorbed  by  the  leukocytes,  are  worked  up- 
ward by  the  ciliated  epithelial  cells  and  are  expectorated.  Individual 
tolerance  varies  greatly.  (&)  Larger  amounts  penetrate  the  bronchial 
mucosa  and  lodge  in  the  connective  tissue,  or  enter  the  lymph  stream 


PNEUMOKONIOSIS  523 

whence  they  reach  the  small  lymph  nodes  around  the  bloodvessels,  the 
bronchi,  the  pleura,  or  the  mediastinal  lymph  glands.  A  moderate 
amount  of  lung  pigmentation  occurs  in  all  city  inhabitants,  while  the 
lungs  of  countrymen  are  pink  and  devoid  of  soot  deposit.  It  is  possible 
that  the  lymph  nodes  may  later  throw  out  some  of  the  pigment  into  the 
bronchial  lumen,  (c)  Very  large  .amounts  may  reach  the  alveoli.  In 
these  cases  the  lungs  are  ink-black.  When  they  are,  as  it  were,  satura- 
ted, connective  tissue  proliferation  develops  (endoperialveolitis  nodosa 
and  endoperilymphangitis  fibrosa)  in  insular  foci;  this  is  sometimes 
called  fibrous  bronchopneumonic  induration  because  of  its  localization; 
it  occasionally  measures  5  x  15  cm.;  on  section  the  foci  are  hard  and 
exude  an  inky  fluid.  Diffuse  induration  is  common.  The  mediastinal 
lymph  glands  are  indurated,  and  the  process  often  extends  outside  the 
glands  (perilymphadenitis) ;  by  this  latter  process  the  glands  may 
become  adherent  to  and  rupture  into  the  pulmonary  veins,  whence  pig- 
ment-metastases  into  the  liver,  spleen,  kidneys,  and  mesenteric  glands 
are  not  infrequent.  Bronchial  perilymphadenitis  may  also  lead  to 
mediastinopericarditis,  to  stenosis  of  the  trachea,  bronchi,  oesophagus, 
cava,  vena  azygos,  and  pulmonary  artery,  to  oesophageal  diverticulum, 
to  fatal  hemorrhage  into  the  pericardium  or  into  the  bronchi  when 
the  aorta  is  also  eroded,  to  aspiration  pneumonia  by  intrabronchial 
rupture  or  to  vagus  or  recurrent  laryngeal  paralysis  by  pressure. 

2.  Siderosis  pulmonum  (Zenker)  is  a  very  similar  change,  due  to 
inhalation  of  mineral  dusts,  as  those  of  iron,  brass,  or  bronze;  there  are 
the  same  interstitial  deposit,  lung  induration,  bronchial  gland  cirrho- 
sis, and  metastases.  The  irritation  is  greater,  the  nodes  are  more  fre- 
quent and  the  induration  is  more  intense  than  in  anthracosis.  The  iron 
deposits  are  yellow  or  red  from  the  oxide,  or  black  from  the  phosphate. 
The  lungs  may  contain  1^  per  cent,  of  iron. 

3.  Chalicosis  pulmonum  (Peacock)  is  due  to  inhalation  of  alumina, 
quartz  or  sandstone,  and  is  known  as  "stone-cutter's  or  mill-stone- 
maker's  phthisis,"  "grinder's  rot"  or  "potter's  asthma."  Inhalation 
of  calcium  is  less  irritating  than  of  silica  or  quartz.  Of  all  forms,  the 
most  nodules  and  the  maximal  induration  occur  in  chalicosis. 

4.  Similar  changes  are  observed  from  inhalation  of  wool,  flax, 
cotton,  grain,  tobacco,  glass,  porcelain,  cocoa,  pepper,  cinnamon,  bone, 
and  horn.  Claisse  and  Jossue  place  special  stress  on  bacterial  coopera- 
tion. 

Ssnnptoms. — These  may  appear  only  after  many  years,  when  the 
symptoms  of  chronic  bronchitis ,  asthma,  emphysema,  and  finally  of  lung 
cirrhosis  appear.  The  sputum  contains  coal  dust,  soot,  charcoal  parti- 
cles, as  in  Traube's  celebrated  case,  and  yellow  oxide  or  dark  phosphate 
of  iron,  quartz,  and  silica.  Cavities  may  form  from  bronchiectasis, 
from  softening  of  the  nodose  indurations  or  from  tuberculous  complica- 
tions; in  some  cases  lung  stones,  set  free  by  ulceration,  may  be  raised. 
The  mediastinum  may  be  exposed  by  retraction  of  the  lungs,  due  to 
fibrous  mediastinitis.  Tuberculosis  is  common,  occurring,  according 
to  Phillip,  in  13  per  cent,  of  anthracosis  and  in  44  per  cent,  of  chalicosis. 


524  DISEASES   OF   THE  RESPIRATORY   TRACT 

Scissor-grinders  rarely  live  beyond  forty  years  of  age  and  those  em- 
ployed in  blasting  mines  usually  succumb  in  four  years. 

Treatment. — Treatment  is  largely  prophylactic  and  is  that  of  the 
concomitant  bronchitis  and  emphysema. 

ATELECTASIS. 

Atelectasis  is  a  congenital  or  acquired  "absence  of  air."  It  is  also 
called  apneumatosis. 

Congenital  Atelectasis. 

1.  The  congenital  atelectasis,  first  described  by  Joerg  (1834),  who 
differentiated  it  from  pneumonia,  is  the  persistence  of  the  normal  foetal 
condition  of  the  lungs;  it  develops  in  various  forms  of  dystokia,  and  in 
weakly  or  premature  infants. 

Etiology  and  Pathology. — This  variety  is  due  to  deficient  inspira- 
tory efforts  from  weak  muscles,  insufficient  stimulation  of  the  medulla 
centres,  and  aspiration  of  mucus  or  meconium.  The  base,  lower 
anterior  margin,  and  lingual  lobe  are  most  involved  and  the  distribution 
is  lobular.  The  color  of  the  lung  is  a  steel-blue,  and  if  the  subject 
lives,  the  atelectatic  portions  do  not  become  pigmented,  for  no  air 
enters  them.  The  airless  areas  are  superficial,  sunken,  lax,  do  not 
crepitate,  and  sink  when  put  in  water;  in  the  early  stage  the  part  can 
be  distended  by  inflation  of  the  bronchus  supplying  it  and  on  section 
exudes  a  serous  or  slightly  blood-stained  fluid.  Cylindrical  and  cystic 
bronchiectasis  may  result;  the  ductus  Botalli  and  foramen  ovale  are 
usually  patent,  the  right  heart  is  commonly  dilated  and  thrombosis  is 
frequent  in  the  brain  sinuses,  kidney,  and  right  heart. 

Symptoms. — ^The  new-born  who  have  atelectasis,  breathe  super- 
ficially and  cry  but  little.  Inspiration  is  marked  by  retraction  of  the 
epigastrium,  subclavicular  and  intercostal  spaces,  for  the  lungs  cannot 
follow  the  inspiratory  distention  of  the  thorax.  If  the  undistended 
area  measures  2  by  5  cm.  it  may  be  dull  and  increased  fremitus  with 
bronchial  breathing  may  be  detected,  but  more  often  the  breathing  is 
weak  or  entirely  absent.  Carbon  dioxide  narcosis  develops,  the  pulse 
becomes  small,  the  sensorium  becomes  dulled  and,  without  active 
intervention,  asphyxia  with  spasms  causes  death.  If  the  patient  lives, 
the  chest  is  peculiarly  deformed,  its  lower  parts  being  sunken,  so  as  to 
show  the  ribs.  Koestlin  describes  a  total  collapse  of  one  lung  in  a  man 
aged  twenty-two. 

Treatment. — Removal  of  meconium  and  mucus  by  swabbing  or 
aspiration  through  a  catheter,  Silvester's  artificial  respiration,  Schultz's 
swinging,  faradization,  and  warm  baths  with  cold  aft'usions  to  the  neck 
and  upper  chest  are  indicated. 


ACQUIRED  ATELECTASIS  525 


2.  Acquired  Atelectasis. 

Acquired  atelectasis  in  children  was  first  described  by  Legendre  and 
Bailly  (1844),  and  that  in  adults  by  Traube. 

Etiology. — It  may  be  due  to  marantic  causes,  to  obstruction  or 
compression;  the  lungs,  already  distended  and  ventilated,  collapse  and 
the  air  contained  is  absorbed,  (a)  The  marantic  form  occurs  in  indi- 
viduals reduced  by  typhoid,  infantile  diarrhoea  or  cachectic  conditions, 
and  by  lying  for  a  long  while  in  the  dorsal  decubitus.  (6)  Obstructive 
collapse  develops  most  frequently  in  capillary  bronchitis  (broncho- 
pneumonia), as  the  bronchioles  in  the  young  are  disproportionately 
narrow;  it  may  develop  in  all  conditions  which  promote  laryngeal, 
tracheal,  or  bronchial  stenosis.  These  forms  affect  the  posterior  parts 
particularly,  (c)  Compressive  apneumatosis  follows  compression  by 
cardiovascular  conditions  (aneurysm,  dilated  heart,  and  exudative 
pericarditis),  by  pulmonary  tumors,  pleural  exudates  or  pneumothorax, 
by  mediastinal  tumors  or  adenopathies  and  by  abdominal  distention 
(tumors,  ascites  or  meteorism).  The  part  of  the  lung  involved  de- 
pends on  the  direction  of  the  compression.  In  kyphoscoliosis  perma- 
nent compression  of  the  lung  frequently  leads  to  atelectasis,  and  if 
it  occurs  early  in  life,  to  hypoplasia. 

Pathology. — Pathologically  the  same  general  findings  obtain  as  in 
the  congenital  type.  The  lung  is  generally  darker,  red-brown  or  bluish. 
Bronchiectasis  may  develop  after  a  time.  In  the  congenital  and 
acquired  types,  hypersemia  may  cause  a  flesh-like  appearance  (carni- 
fication),  or  serous  transudation  may  cause  a  spleen-like  aspect  (splen- 
ization).  There  may  be  coincident  inflammation  or,  in  the  healthy 
parts,  vicarious  emphysema.  Long-standing  atelectasis  results  in  fatty 
degeneration  of  the  alveolar  epithelium  and  hyperplasia  of  the  inter- 
alveolar  and  interinfundibular  connective  tissue,  known  as  collapse 
induration. 

Symptoms. — Symptoms  are  easily  obscured  by  pleural  effusion,  and 
by  the  causal  bronchopneumonia,  with  whose  foci  it  may  be  confused. 
Inspiratory  retraction,  lessened  vesicular  breathing,  a  slightly  tym- 
panitic note  from  relaxation  of  the  collapsed  lung,  and  crepitant  rales 
are  common.  The  vocal  fremitus  is  seldom  increased,  and  bronchial 
breathing  is  uncommon,  unless  the  foci  are  both  large  and  superficial. 
Dilatation  of  the  right  heart  is  common.  In  recent  cases  the  'physical 
signs  disappear  after  a  few  hours  of  change  of  posture,  or  after  deep 
breathing  either  voluntary  or  induced  by  cold  affusions;  this,  with 
absence  of  fever,  pain,  and  cough,  serves  as  an  effectual  differentiation 
from  infarct,  pneumonia,  or  effusive  pleurisy.  After  one  has  slept 
for  some  hours  on  the  back,  a  few  crepitant  rales  may  be  heard  over 
the  lower  posterior  parts  for  three  or  four  inspirations;  this  is  quite 
physiological. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  vary 
according  to  the  cause.     Sudden  death  is  not  uncommon  in  persons 


526  DISEASES   OF   THE  RESPIRATORY   TRACT 

having  deformed  spines.  In  all  fevers,  as  typhoid,  and  in  all  respi- 
ratory inflammations,  the  posture  must  be  changed;  orders  to  this 
effect  should  be  written,  and  the  change  should  be  recorded  on  the 
history  sheet.  Cold  affusions  to  the  neck,  Brand's  hydrotherapy  and 
cardiac  stimulants  are  indicated. 


ABSCESS  OF  THE  LUNG. 

Suppuration  is  not  a  common  lesion,  but  may  occur  in  a  sound  or 
diseased  lung. 

Bacteriology. — The  staphylococcus  is  most  frequently  the  causative 
microorganism;  the  streptococcus,  pneumococcus,  pneumobacillus, 
influenza  bacillus,  colon  bacillus,  and  leptothrix  are  also  found. 

Etiology. — (a)  Lobar  pneumonia  causes  62  per  cent,  of  the  cases 
(Tuffler);  localization  in  an  upper  lobe,  alcoholism,  marasmus,  pneu- 
monia complicating  emphysema  and  lung  induration,  and  hemorrhagic 
types  are  the  predisposing  factors;  abscess  of  the  lung  is  somewhat 
analogous  to  the  necrosing  interstitial  pneumonia  in  cattle  and  horses. 

(b)  Lobular  pneumonia  may  suppurate,  especially  in  the  influenzal  type. 

(c)  Aspiration  pneumonia  is  causal  in  18  per  cent.  (Tuffler),  partic- 
ularly in  insane  or  delirious  persons;  foreign  bodies,  food,  saliva,  pus 
from  lesions  in  the  upper  respiratory  tract,  severe  vomiting,  oesophageal 
cancer  or  diverticulum  rupturing  into  a  bronchus,  are  its  usual  causes. 

(d)  Embolic  suppuratiofi  produces  17  per  cent,  of  the  cases,  (e) 
Trauma  is  an  etiological  factor.  (/)  Abscess  may  complicate  other 
pulmonary  or  bronchial  affections,  as  tuberculosis,  glanders,  actino- 
mycosis, echinococcus,  or  bronchiectasis,  (g)  Rupture  into  the  lung 
of  contiguous  foci  of  suppuration,  such  as  empyema,  suppurating  peri- 
bronchial glands,  subphrenic  abscess,  spinal  caries,  and  gastric  ulcer, 
is  the  cause  of  3  per  cent,  of  lung  abscesses.  Most  of  the  cases  occur 
in  middle-aged  males. 

Pathology. — The  cavity  varies  from  the  size  of  a  hazelnut  to  that 
of  an  orange;  in  rare  instances  it  may  occupy  an  entire  lobe  or  lung. 
The  abscess  is  usually  single,  except  in  the  embolic  form.  Its  shape 
is  irregular  and  it  is  sometimes  multilocular.  Its  inner  surface  is 
irregular  with  floccular  mural  shreds,  and  is  walled  with  pus-secreting 
granulations,  which  in  some  cases  may  fill  and  obliterate  the  cavity. 
Fibrous  tissue  develops  about  the  cavity,  and  in  chronic  abscess  be- 
comes dense  and  scar-like.  The  cavity  is  usually  near  the  lung's 
surface,  whence  the  frequency  of  complicating  pleurisy;  80  per  cent, 
of  lung  abscesses  are  in  a  lower  lobe  (Tuffler). 

Symptoms. — The  development  of  symptoms  varies  according  to 
the  causal  factor;  in  lobar  pneumonia  the  crisis  or  lysis  is  delayed, 
and  resolution  is  incomplete;  in  influenza  the  respiratory  symptoms 
and  fever  persist;  in  sepsis,  multiple  lung  involvement  perpetuates 
the  septic  process,  (a)  The  sputum  is  purulent,  creamy,  is  often 
offensive  or  rancid  without  putridity,  is  alkaline  and  may  measure  a 


ABSCESS   OF   THE   LUNG  527 

pint  to  a  quart  daily.  It  separates,  on  standing,  into  two  layers,  a 
granular  sediment  and  a  serous  upper  layer,  sometimes  with  frothy 
surface  if  J;he  coughing  is  intense.  In  metapneumonic  cases  the 
sputum  is  sometimes  grass-green.  The  sediment  almost  invariably 
reveals  shreds  of  lung  tissue  (Traube  and  Leyden),  and  yellowish- 
green  or  gray  flocculi;  these  are  absolutely  essential  to  diagnosis, 
and  consist  of  elastic  fibers  to  which  alveolar  epithelium  adheres. 
Hocmatoidin  crystals  or  platelets,  short  sheaths  of  fatty  crystals,  bac- 
teria (v.  s.),  and  in  chronic  cases  cholestearin  and  scar-like  connective 
tissue  are  also  found.  The  sputum  is  voided  periodically,  as  from 
cavities  of  other  causation;  "mouthful  expectoration"  is  the  rule,  (b) 
The  decubitus  varies  with  the  location  of  the  cavity;  for  instance,  the 
patient  assumes  the  erect  posture  if  the  cavity  is  in  a  lower  lobe,  to 
prevent  leaking  of  the  secretion  into  the  contiguous  air  passages,  (c) 
Sigjis  of  cavity  are  found  if  the  exulceration  is  large  and  superficial; 
80  per  cent,  of  them  occur  in  the  lower  lobes.  They  are  essentially 
those  of  tuberculous  or  bronchiectatic  cavities  (q.  v.)  and  vary  with  the 
stagnation  or  evacuation  of  the  pus;  thus  a  tympanitic  note,  bronchial 
or  amphoric  breathing,  and  increased  vocal  fremitus  are  found  when 
the  vomica  is  empty,  and  dulness,  weakened  breath  sounds  and  de- 
creased fremitus  are  present  when  it  is  full.  The  a;-rays  also  serve  to 
localize,  but  when  their  findings  and  the  physical  signs  differ  the  latter 
are  more  trustworthy,  (d)  Hectic  fever,  sweats,  rigors  and  leukocy- 
tosis occur  from  resorption. 

Diagnosis. — The  etiology  and  cavity  formation  are  often,  and  the 
sputum  is  always,  characteristic,  (a)  Abscess  breaking  into  the  lung 
from  the  spine,  or  from  the  subphrenic  or  pleural  spaces,  is  sudden, 
sometimes  suffocative  in  onset,  and  the  hsematoidin  crystals  and  shreds 
of  pulmonary  tissue  are  absent,  (b)  Gangrene  (v.  i.)  is  a  factor  in 
differentiation,  (c)  Tuberculosis  usually  occurs  in  an  upper  lobe; 
abscess  in  a  lower  one;  elastic  fibers  and  hoematoidin  crystals  are  more 
abundant  in  cases  of  abscess,  and  tubercle  bacilli  are  found  in  tuber- 
culosis, at  least  after  several  examinations,  (d)  In  cases  of  bron- 
chiectasis elastic  fibers  are  seldom  voided. 

Prognosis. — Spontaneous  recovery  may  follow  granulation  and 
cicatrization,  especially  in  lobar  pneumonia,  where  recovery  is  the 
rule.  In  influenzal  or  aspiration  pneumonia  or  in  sepsis,  the  out- 
look, is  far  less  favorable;  marasmus,  hectic  fever,  amyloidosis, 
lung  induration,  empyema,  pneumothorax  and  pericarditis  are  fre- 
quent issues. 

Treatment. — (a)  The  general  strength  should  be  maintained  by  giv- 
ing a  full  diet,  tonics,  and  alcohol.  (6)  Decomposition,  if  present, 
should  be  modified  as  in  bronchiectasis  or  gangrene,  bv  administra- 
tion  of  creosote  or  turpentine  internally,  (c)  Surgical  intervention  is 
indicated,  according  to  Fraenkel,  (i)  when  the  abscess  is  large,  shows 
no  tendency  toward  spontaneous  cure  and  the  contents  decompose; 
(ii)  when  rupture  into  the  pleura  occurs;  and  (iii)  when  the  abscess 
results  from  the  breaking  into  the  lung  of  a  contiguous  focus  of  sup- 


528  DISEASES   OF   THE  RESPIRATORY   TRACT 

puration.  Of  Korte's  12  operative  cases,  83  per  cent,  recovered;  in 
Garre's  96  cases,  80  per  cent.;  in  Tuffier's  series,  77  per  cent.;  in 
Freyhan's  acute  cases,  90  per  cent.;  and  in  his  chronic  cases  but  14 
per  cent. 

(G).  GANGRENE  OF  THE  LUNG. 

Definition. — A  necrosis  and  mortification  of  lung  tissue.  Gangrene, 
though  more  common  than  abscess,  is  an  infrequent  affection;  Eich- 
horst  found  gangrene  in  0.1  per  cent,  of  his  clinical  cases  and  Hensel 
in  1.6  per  cent,  of  his  autopsies. 

Bacteriology. — Some  physicians  maintain  that  certain  germs  pro- 
duce the  necrosis  and  other  germs  the  gangrene,  but  others  hold  that 
one  microorganism  may  produce  both  changes.  The  staphylococcus 
is  found  in  its  various  forms,  also  the  streptococcus,  colon  bacillus,  and 
pseudotubercle  bacillus  which  retains  its  stain  when  treated  with 
acids  like  the  bacilli  found  in  putrid  bronchitis  and  bronchiectasis;  the 
Bacillus  pyocyaneus,  and  the  Micrococcus  tetragenus  are  also  found; 
Hirschler  and  Terray  have  cultivated  a  micrococcus  which  liquefies 
gelatin  and  produces  skatol  and  indol,  and  therefore  causes  a  putrid 
odor  in  the  cultures.  Babes  described  bacilli  resembling  those  of 
malignant  oedema.  The  leptothrix,  oidium  albicans,  spirilla,  sarcinse 
and  monads  are  probably  of  but  secondary  importance. 

Etiology. — Decidedly  reduced  physiological  resistance,  e.g.,  from 
diabetes,  is  apparently  a  necessary  etiological  factor.  Lobar  pnevr- 
monia  may  terminate  in  gangrene  when,  as  in  abscess,  the  patient  is 
weakly,  diabetic,  addicted  to  alcohol  or  suffering  from  putrid  bron- 
chitis; its  frequency  is  not  great,  for  it  occurs  in  but  0.4  per  cent. 
(Fraenkel)  or  in  less  than  1  case  in  1,500  pneumonias  (Aufrecht); 
pneumonia  causes  23  per  cent,  of  lung  gangrene  (Coupland  and  Hen- 
sel). Lobular  'pneumonia  is  less  frequently  causal,  though  grippal 
pneumonias  may  terminate  in  gangrene  (7  per  cent,  in  Fraenkel's 
series).  In  Coupland  and  Hensel's  combined  cases,  14  per  cent,  were 
due  to  pulmonary  tuberculosis,  and  10  per  cent,  to  tumor  of  the  lung. 
Gangrene  may  complicate  lung  abscess  or  echinococcus.  Aspiration 
pneumonia  resulting  in  gangrene  occurs  particularly  in  insane,  deliri- 
ous, paralyzed,  or  emaciated  subjects;  foreign  bodies,  necrotic  dis- 
eases of  the  throat  or  bronchi,  laryngeal  perichondritis,  bronchiectasis, 
putrid  bronchitis,  and  bronchial  stenosis  promote  gangrene.  Embolic 
gangrene,  a  cause  of  19  per  cent,  of  lung  gangrene,  may  result  from 
suppurative  gangrenous  lesions  in  peripheral  parts,  as  in  or  about  the 
appendix,  uterus,  or  extremities.  Rupture  into  the  lung,  as  of  oesoph- 
ageal cancer  or  diverticulum,  putrid  pleurisy,  subphrenic  abscess,  or 
gastric  ulcer  may  cause  gangrene.  Trauma  is  an  occasional  promot- 
ing factor.  Gangrene  usually  occurs  within  the  second  to  fourth  de- 
cades of  life  and  chiefly  in  males. 

Pathology. — Genuine  gangrene  must  not  be  confused  with  soften- 
ing of  the  lung,  which  is  due  to  regurgitation  of  the  gastric  juice  into 


GANGRENE  OF   THE  LUNG  529 

the  lung  during  the  death  agony  or  after  death.  In  rare  cases,  too,  a 
non-putrid  pneumomalacia,  analogous  to  myomalacia  cordis,  is  ob- 
served. Lung  gangrene,  according  to  Hensel,  occurs  in  the  right 
lung  in  45  per  cent.,  in  the  left  in  37  per  cent.,  and  in  both  lungs  in 
18  per  cent,  of  the  cases.  Laennec,  who  first  described  pulmonary 
gangrene,  distinguished  two  types,  the  circumscribed  and  the  diffuse,  (a) 
Circumscribed  gangrene  occurs  chiefly  in  the  lower  lobes  and  toward 
the  surface,  rarely  in  the  interior  and  oftener  on  the  right  than  on  the 
left  side.  The  focus  may  attain  the  size  of  an  orange.  Laennec  dis- 
tinguishes three  stages,  (i)  The  formation  of  a  yellow,  green  or 
brown  slough,  which  may  be  expectorated  entire;  (ii)  liquefaction,  or 
moist  gangrene;  and  (iii)  formation  of  a  cavity  which  is  irregular  in 
shape,  has  ragged  walls,  and  contains  a  stinking  liquid  resembling  the 
sputum  of  gangrene  {v.  i.).  The  cavity  may  be  limited  by  granulations 
and  later  by  connective  tissue,  or  may  gradually  extend,  corroding  more 
and  more  lung  tissue.  Extension  may  also  result  from  aspiration  of  the 
septic  matter  from  the  bronchi  into  other  lung  areas.  Recovery  may 
follow  localization,  organization  of  granulations,  and  contraction  of 
connective  tissue.  Microscopically  there  is  (i)  an  inner  zone  of  offen- 
sive fluid  or  necrotic  tissue,  bacteria  and  emigrated  leukocytes;  (ii) 
outside  of  this  is  a  zone  of  granulations,  beyond  which  is  (iii)  congested 
or  oedematous  lung.  (6)  The  rarer  diffuse  gangrene  has  no  demarka- 
tion,  and  a  large  area,  an  entire  lobe,  or  even  the  whole  lung  may  be 
macerated,  stinking  and  discolored.  The  diffuse  form  occurs  moi:e 
often  in  the  upper  lobes,  and  in  the  right  more  frequently  than  in  the 
left  side.  In  both  forms  the  sputum  irritates  and  injects  the  bronchial 
mucosa,  the  bronchial  glands  are  usually  tumefied  and  degeneration  or 
metastasis  may  occur  in  various  viscera. 

Sjuiptoms.— L  The  sputum  is  characteristic;  its  presence  is  almost 
absolutely  essential  to  a  diagnosis,  and  it  is  absent  only  when  the  putrid 
focus  has  no  bronchial  connection.  Its  odor  is  extremely  offensive, 
faecal,  stinking,  garlicky,  or  sometimes  sweetish.  This  odor  is  less 
marked  in  diabetic  gangrene;  it  is  most  offensive  at  the  moment  of 
evacuation,  and  on  standing  may  gradually  lessen.  The  sputum, 
which  is  voided  periodically,  and  sometimes  in  mouthfuls,  is  usually 
abundant  (a  pint  to  a  quart),  is  alkaline,  and  on  standing  separates 
into  three  layers,  an  upper  layer  of  foam,  a  middle  one  of  green  or 
gray  serum,  and  a  lower  one  of  green  or  brownish  granular  sediment. 
In  the  sediment  various  important  structures  are  found;  there  are 
flocGuli  of  lung  tissue,  which  are  seen  best  against  a  dark  background,, 
and  which  vary  in  size  from  small  particles  to  pieces  as  large  as  the 
thumb  and  show  alveolar  arrangement;  elastic  fibers  are  not  nearly 
as  common  as  they  are  in  abscess  of  the  lung,  unless  the  process  is 
very  acute,  for  a  trypsin-hke  ferment  rapidly  digests  the  fibers;  Dit- 
trich's  plugs  are  usually  found,  consisting  of  detritus  and  bacteria, 
and  emitting  a  most  foetid  odor  (described  under  Putrid  Bronchitis 
AND  Bronchiectasis);  long  fatty  needles  (Virchow),  lung  pigment,  pus 
cells,  red  corpuscles,  haematoidin,  bacteria,  infusoria,  triple  phosphates, 

34 


530  DISEASES   OF   THE  RESPIRATORY   TRACT 

leucin,  tyrosin,  formic  and  other  allied  acids,  phenol,  indol,  skatol, 
ammonia  and  sulphuretted  hydrogen  are  also  found, 

2.  Chest  findings. — Besides  the  findings  of  bronchitis  caused  by 
the  offensive  sputum,  signs  of  infiltration  or  cavity  formation  are  ob- 
tained if  the  focus  is  superficial  and  measures  two  and  a  half  inches. 
In  the  common  circumscribed  form  the  signs  of  cavity  are  identical 
with  those  in  tuberculosis,  bronchiectasis  or  abscess,  i.  e.,  a,  tympanitic 
note,  increased  vocal  fremitus,  bronchial  or  amphoric  breathing,  and 
metallic  rales  are  obtained  when  the  cavity  is  empty,  or  dulness,  de- 
creased fremitus  and  weak  breathing,  when  it  is  full.  In  the  rare 
dijfiLse  form  there  are  signs  of  infiltration  as  in  pneumonia,  which 
signs  are  also  found  in  the  initial  stage  of  the  circumscribed  gangrene. 
Pulsation  of  the  gangrenous  lung  is  very  rare.  The  a:-rays  are  often 
valuable  in  detecting  the  localization  of  the  gangrene.  The  patient 
lies  so  that  the  cavity  is  dependent,  in  order  to  avoid  constant  trickling 
of  the  ca^dty  secretion  into  the  bronchi,  i.  e.,  on  his  back  when  it  is 
posterior,  or  on  his  face  when  it  is  anterior  or  in  an  upper  lobe. 

3.  General  symptoms  result  from  the  causal  disease  or  from  sepsis. 
Remittent  fever,  chills,  sweats,  prostration,  emaciation,  pallor,  rapid 
bounding  pulse,  anorexia,  vomiting,  diarrhoea,  leukocytosis,  albumin- 
uria and  in  severe  cases  a  profound  typhoid  state  mark  the  degree 
of  intoxication. 

4.  Complications  may  dominate  the  clinical  picture,  (a)  Pleurisy 
(in  12  per  cent.),  usually  purulent  or  putrid,  may  be  one  of  the  chief 
symptoms,  and  operation  may  evacuate  most  offensive  fluid  with  large 
fragments  of  necrotic  lung.  (6)  Hsemoptysis  is  seldom  fatal  though 
frequently  profuse,  and  the  blood  raised  may  be  dark  brown,  (c) 
Pyopneumothorax,  or  (d)  rupture  into  the  thoracic  wall,  oesophagus, 
aorta,  mediastinum,  pericardium,  or  peritoneum  may  occur,  (e)  There 
may  be  metastatic  deposits  in  the  brain,  liver,  joints,  or  muscles.  (/) 
Clubbed  fingers  occasionally  result  from  septic  absorption,  (g)  Amy- 
loid degeneration  of  the  liver,  spleen  and  kidneys  sometimes  results 
from  chronic  gangrene. 

Course  and  Prognosis. — The  course  may  be  acute,  subacute  or 
chronic;  in  general  it  is  more  rapid  in  diffuse  (usually  fatal  within  a 
week),  and  more  chronic  in  circumscribed  forms  (weeks  to  even  three 
months).  The  prognosis  depends  on  the  etiology,  the  physical  strength 
of  the  patient,  the  degree  of  absorption,  localization  and  surgical 
accessibility  (v.  Therapy). 

Diagnosis. — Exploratory  puncture  is  dangerous,  for  it  favors  dif- 
fusion, (a)  In  fcetor  ex  ore  the  breath  is  foetid  but  the  sputum, 
if  any,  shows  no  characteristic  findings  of  gangrene,  (b)  In  putrid 
bronchitis  the  sputum  shows  Dittrich's  plugs  and  foetor,  but  no  fatty 
crystals,  elastic  fibers,  nor  pulmonary  tissue,  (c)  In  abscess  elastic 
fibers  and  pus  are  more  abundant,  the  fatty  crystals  are  oftener  in 
sheaths  than  in  long  needles,  and  hsematoidin  crystals  are  more  com- 
mon; bronchial  plugs  or  foetor  are  absent,  (d)  In  bronchiectasis  elastic 
fibers  are  very  rare  and  lung  tissue  has  never  been  found,     (e)  In 


TUMORS   OF   THE  LUNG  531 

tuberculosis  coincidence  of  the  two  affections  and  the  pseudotubercle 
bacillus  (v.  Tuberculosis)  may  alone  cause  confusion. 

Treatment. — 1.  Surgical. — Expectant  treatment  results  in  a  mor- 
tality of  53  per  cent.  (Eichhorst)  to  80  per  cent.  (Lenhartz).  In  15 
personal  cases  (a  small  number),  10  (66  per  cent.)  recovered  under 
medical  treatment.  With  operative  treatment  Tuffier  gives  the  death- 
rate  in  72  cases  as  40  per  cent.,  and  Freyhans  in  26  cases,  30  per  cent.; 
Garrd  in  122  cases  records  66  per  cent,  of  recoveries  and  34  per  cent, 
of  fatalities.  The  indications  for  treatment  are  (a)  the  vital  indication 
when  acute  gangrene  assumes  the  foudroyant  type,  or  (6)  when,  in 
chronic  forms,  there  is  no  tendency  toward  spontaneous  healing.  Bull 
reports  recovery  even  in  multiple  gangrene.  Accurate  localization  by 
physical  findings  or  by  the  x-rays,  is  of  course  conditional  and  was 
possible  in  65  per  cent,  of  Tuffier's  series  of  74  cases. 

2.  Expectant  Treatment.— This  is  indicated  in  deep-seated  gan- 
grene, in  hopeless  metastases  as  those  of  the  brain,  or  in  apparent 
demarkation.  The  patient  should  be  kept  on  his  back  to  avoid 
leakage  into  sound  bronchi.  The  diet  should  be  sufficient  to  support 
the  strength  and  should  include  full  alcoholic  stimulation.  Carbolic 
acid,  balsam  of  Peru  or  creosote  may  be  given  internally.  Turpentine 
is  most  efficacious  when  there  is  a  complicating  hemorrhage  (Skoda). 

TUMORS  OF  THE  LUNG. 
1.  Carcinoma. 

Cancer  of  the  lung  may  be  primary  or  more  often  secondary  to 
that  of  the  mamma,  or  of  the  digestive  or  genital  organs.  It  occurs  in 
0.17  per  cent,  of  autopsies  or  in  1.8  per  cent,  of  cancer  autopsies 
(Paessler,  quoted  by  Fraenkel).  Most  primary  cases  develop  between 
forty  and  sixty  years  of  age.  In  primary  forms  the  sexes  are  equally 
involved  though  Paessler  found  73  per  cent,  in  males;  the  secondary 
forms  are  frequent  in  women. 

Etiology. — Trauma  is  an  uncertain  factor.  Cancer  usually  develops 
in  the  bronchi,  in  which  previous  ulceration,  syphilis  or  adherent  and 
rupturing  lymph  glands  are  predisposing  factors.  Carcinoma  probably 
may  develop  from  the  bronchial  mucous  glands  or  even  from  the  alveo- 
lar epithelium.  Histologically  the  cylindrical  type  is  by  far  the  most 
frequent,  though  medullary,  scirrhous  and  other  forms  may  be  encoun- 
tered. Cancer  usually  begins  at  the  hilum,  and  may  extend  toward 
the  pleura,  either  by  contiguity  along  the  bronchi  or  by  the  lymph 
spaces.  The  upper  lobes  are  more  often  involved  than  the  lower  ones, 
and  the  right  twice  as  frequently  as  the  left.  The  disease  is  generally 
unilateral.  In  85  per  cent,  of  cases  metastases  occur  in  the  liver, 
bones,  brain,  mediastinum,  testes,  and  kidney.  Secondary  cancer 
is  generally  bilateral;  the  lungs  are  strewn  with  miliary  nodules 
resembling  miliary  tuberculosis,  or  present  numbers  of  larger  nod- 


532  DISEASES  OF   THE  RESPIRATORY   TRACT 

ules.     Calcification    and    ossification    may   occur   in    tumors    of    the 
lung. 

Symptoms. — When  there  is  a  primary  accessible  tumor  in  another 
part  of  the  body,  the  appearance  of  cyanosis,  dyspnoea,  blood-stained 
sputum,  and  signs  of  lung  infiltration  or  of  cavity,  facilitates  a  diag- 
nosis of  lung  metastasis.  When  there  is  a  hidden  primary  focus  or 
a  primary  lung  tumor,  diagnosis  is  often  for  a  long  time  difficult  or 
impossible. 

1.  Early  General  Symptoms. — These  are  usually  ambiguous;  they 
are  suggestive  of  tuberculosis,  pleurisy,  or  bronchitis,  all  of  which  may 
indeed  complicate  neoplasm.  Thoracic  oppression,  asthmatic  attacks, 
stridor  and  dyspnoea  result  from  pressure  on  the  trachea  and  vagus 
or  wide  substitution  of  tumor  for  lung  tissue.  Cyanosis,  dyspnoea, 
rapid  breathing,  fever,  emaciation  and  sweats  may  suggest  miliary 
tuberculosis ;  this  resemblance  may  also  be  noted  at  autopsy  in  miliary 
carcinosis.  Fever  is,  however,  not  common.  Actual  pain  is  usually 
pleuritic.     Cough  is  common. 

2.  Sputum. — The  sputum  in  over  50  per  cent,  of  cases  is  rather 
characteristic,  though  it  may  show  similar  changes  in  tuberculosis  and 
other  affections.  Altered  blood  gives  it  a  reddish-brown  color.  It 
may  resemble  raspberry  jelly  in  hue  and  in  consistency;  it  is  some- 
times grass-green  or  prune-juice  in  color.  Occasionally  macroscopic 
and  microscopic  bits  of  cancer  tissue,  in  characteristic  nest-like  arrange- 
ment, are  seen. 

3.  Physical  Signs. — (a)  Inspection:  the  patient  usually  lies  on 
the  affected  side  to  give  freer  play  to  the  sound  lung.  Marked 
ectasia  may  result;  sometimes  the  diseased  side  is  shrunken  from 
complicating  lung  cirrhosis  or  atelectasis.  Unilateral  retraction  with 
other  signs  indicates  bronchial  stenosis,  (b)  Palpation  elicits  increased 
fremitus  if  the  tumor  grows  into  the  bronchial  lumen  or  compresses  it 
from  without,  (c)  Percussion  gives  an  irregular  dulness,  increasing 
to  absolute  flatness,  in  outlining  which  the  finger  perceives  greatly 
increased  resistance;  it  most  often  occurs  over  an  upper  lobe  or  under 
the  sternum,  {d)  ^wscw/to^fon  varies  with  the  patency  of  the  bronchus, 
giving  bronchial  breathing  when  it  is  open  and  weak  or  absent  breathing 
when  occluded. 

4.  Compression  Symptoms. — Besides  the  early  dyspnoea  and  cough 
{v.  s.),  (a)  the  heart  is  often  luxated  or  its  yielding  auricles  are 
crowded.  (6)  The  venous  trunks  suffer  compression  with  frequent 
cyanosis  and  oedema  of  the  face,  neck  and  arms  and  with  dilatation 
of  other  veins  of  the  thorax,  due  to  formation  of  a  collateral  circula- 
tion, (c)  There  is  compression  of  the  vagus,  with  rapid  or  slow  heart, 
and  recurrent  laryngeal  compression  with  phonic  changes,  {d) 
Dysphagia,  (e)  intercostal  neuralgia  and  brachial  neuralgia  or  par- 
alysis, and  (/)  tracheal  or  bronchial  stenosis  are  other  symptoms  of 
compression. 

5.  Metastasis. — This  occurs  in  85  per  cent,  of  cases;  there  may  also 
be  extension,  by  contiguity,  to  the  axillary  or  cervical  glands. 


SARCOMA   AND  LYMPHOSARCOMA  533 

6.  Complications. — These  include  haemoptysis  from  necrosis  and 
cavity  formation;  gangrene  and  bronchiectasis;  and  pleurisy,  which 
is  usually  serous;  hemorrhagic  effusions  occurred  in  12  per  cent,  of 
Moutard  Martin's  200  cases;  the  fluid  may  resemble  venous  blood; 
adipose  or  chyliform  effusions  are  rare;  hydropic,  fatty  and  granular 
cells  may  be  obtained  by  puncture,  and  Hellendall  advises  aspiration 
for  flocculi  of  tumor  tissue,  with  the  syringe  and  needle  partly  filled, 
with  salt  solution,  before  aspiration.  Carcinomatous  nodes  may  de- 
velop at  the  site  of  puncture,  though  hard  nodules  at  the  site  of  tapping 
not  infrequently  occur  after  puncture  of  simple  pleuritis  and  ascites. 

2.  Sarcoma  and  Lymphosarcoma. 

Sarcoma  and  lymphosarcoma  may  be  primary  or  secondary,  and  are 
more  frequent  than  cancer.  They  probably  begin  chiefly  in  the  lymph 
nodes  of  the  bronchi,  and  oftener  on  the  left  than  on  the  right  side. 
Extension  in  all  directions  occurs  along  the  peribronchial  tissues  from 
the  hilum.  A  primary  very  malignant  lymphosarcoma  develops  in  the 
lungs  of  miners  in  the  cobalt  mines  of  Saxony;  it  causes  75  per  cent, 
of  the  deaths  among  them ;  secondary  sarcomata  in  the  liver  are  com- 
mon. Ulceration  is  less  common  than  in  cancer,  but  the  symptoms 
are,  in  the  main,  identical.  Sarcomatous  tissue  is  occasionally  voided 
in  the  sputum  or  aspirated  by  the  exploring  needle.  The  diagnosis  of 
malignant  lung  tumors  must  be  made  chiefly  from  aneurysm  {q.  v.) 
and  pleurisy  {q.  v.).  The  rc-rays  may  be  of  some  value.  There  are 
three  main  clinical  groups,  (a)  in  which  a  neoplasm,  perhaps  its  exact 
type,  can  be  diagnosticated;  (6)  in  which  some  growth  is  present  but 
differentiation  from  aneurysm  is  uncertain;  and  (c)  in  which  the  dis- 
ease entirely  escapes  detection  or  is  only  suspected. 

Prognosis. — Death  generally  occurs  in  less  than  a  year  with  cachexia 
or  suffocation,  but  it  may  result  in  a  few  weeks  after  the  first  symptoms 
appear. 

Other  Tumors  of  the  Lung. 

Other  tumors,  as  fibroma,  lipoma,  osteoma,  or  enchondroma  are  of 
solely  anatomical  interest. 

Treatment. — The  treatment  of  tumors  of  the  lung  is  only  palliative. 
Morphine  must  be  used  when  the  dyspnoea  and  cough  are  extreme. 
The  a;-rays  offer  little  encouragement.  Arsenic  seems  to  help  when 
given  in  full  doses. 


534  DISEASES  OF   THE  RESPIRATORY   TRACT 

CIRCULATORY  AFFECTIONS  OF  THE  LUNG. 
1.  Acute  Congestion. 

As  a  secondary  lesion  acute  hypersemia  commonly  occurs  with 
acute  tuberculosis,  pneumonia,  influenza,  effusive  pleurisy,  perhaps 
rheumatism,  with  inhalation  of  hot  vapors  or  air,  or  with  cardiac  strain; 
when  extensive  lesions  occur  in  the  lungs  the  obstructed  blood  may 
seek  other  parts  of  the  lungs  and  possibly  produce  collateral  congestion, 
though  this  is  justly  disputed.  French  writers  describe  an  acute 
'primary  congestion  to  which  they  give  the  name  of  Woillez  (Maladie 
de  Woillez),  though  it  was  previously  described  by  Dechambre,  Legen- 
dre,  Bailly  and  Fournet.  Its  status  as  an  independent  lesion  is  doubt- 
ful; some  cases  are  apparently  larval  or  abortive  pneumonia  which 
occurs  in  any  large  epidemic.  According  to  Carriere  it  is  due  to  atten- 
uated pneumococci,  which  he  has  demonstrated  by  puncture  of  the 
lung.  Cold,  exposure,  alcohoHsm,  and  violent  exertion  are  alleged 
causes.  It  develops  like  pneumonia,  with  chill,  fever  of  101°  to  103°, 
pain  in  the  side,  dyspnoea,  cough,  and  a  sputum  which  is  at  first  scanty 
and  later  is  more  abundant  and  viscid  but  not  blood-stained.  Physical 
examination  is  said  to  elicit  somewhat  impaired  resonance,  weak  or 
occasionally  bronchial  breathing,  rales  which  are  coarser  than  in  pneu- 
monia and  at  times  a  pleural  rub.  All  these  symptoms  and  signs 
strongly  suggest  atypical  fibrinous  pneumonia.  Venesection  and  vaso- 
dilator remedies,  as  aconite  or  veratrum,  are  said  to  be  of  benefit. 

2.  Passive  Congestion;   Hypostasis. 

In  broken  compensation,  particularly  in  mitral  stenosis,  the  lungs  are 
distended,  heavy,  indurated,  pigmented,  and  on  section  are  brownish- 
red;  this  is  brown  induration  {induratio  pulmonum  fusca).  Histologic- 
ally the  capillaries  are  turgid,  the  connective  tissue  is  increased,  the 
lungs  are  tinged  with  altered  blood  pigment,  and  the  sputum  contains 
the  so-called  heart  cells  (See  Symptoms  of  Valvular  Disease.)  The 
breathing  is  sometimes  puerile  and  the  lung  voluminous. 

Hypostasis  is  a  species  of  passive  congestion  which  results  from 
weak  heart,  as  in  typhoid  and  other  fevers,  in  old  age,  cachexise,  mar- 
asmus, in  opium  and  other  narcoses,  or  in  apoplectic  and  other  comas. 
Even  under  these  conditions  it  rarely  occurs  if  the  patient's  position 
is  changed  every  few  hours.  The  lung  is  dark  red,  engorged  with 
blood  and  serum,  and  may  also  show  aspiration  pneumonia  and 
atelectasis ;  the  latter  conditions  are  often  incorrectly  called  hypostatic 
pneumonia.  On  physical  examination,  there  is  moderate  dulness  over 
the  lower  lobes  posteriorly;  in  apoplexy  this  may  occur  only  on  the 
paralyzed  side;  the  breathing  is  more  often  weak   than    bronchial, 


INFARCT;  EMBOLISM  535 

and  moist  (sometimes  crepitant)  rales  are  heard.    Fever  is  no  part  of 
hypostasis. 

Treatmeiit. — Treatment  of  passive  congestion  is  that  of  the  funda- 
mental lesion;  phlebotomy,  cardiac  stimulation  or  even  aspiration  of 
the  right  ventricle  in  broken  compensation  and  in  hypostasis,  frequent 
change  of  posture,  and  cardiants,  are  indicated. 


3.  Infarct;  Embolism. 

Etiology. — Embolism  was  first  observed  by  Laennec;  Virchow, 
Cohnheim  and  Litten  established  its  pathology.  The  most  frequent 
source  of  lung  embolism  is  ia)  fibrinous  coagula  from  the  right  heart, 
the  frequency  and  mechanism  of  which  have  been  discussed  under 
Acute  and  Chronic  Endocarditis  (mitral  stenosis)  and  Septicemia. 
Clots  may  also  reach  the  lung  from  peripheral  or  peri-uterine  throm- 
boses, and  are  either  simple  {i.  e.,  non-suppurative,  marantic)  or 
inflammatory  and  septic.  Rarer  causes  are  (6)  tumor  or  hepatic  tissue, 
(c)  fat  embolism  after  fractures,  and  liver  injury,  id)  air  embolism  or 
{e)  parasites  (echinococcus  cysts). 

Pathology  of  Infarction. — The  embolus  may  obstruct  a  main  branch 
of  the  pulmonary  artery,  straddle  one  of  its  secondary  bifurcations, 
or  lodge  in  a  smaller  vessel.  Not  every  embolism  produces  an  infarct, 
for  instantaneous  death  may  occur,  the  occlusion  may  be  incomplete, 
or  collateral  circulation  may  be  possible.  Occlusion  of  an  end  vessel 
results  in  the  hemorrhagic  infarct,  which  is  often  wedge-shaped 
with  its  base  toward  the  pleura,  is  dark  at  first  and  later  lighter,  is 
airless,  on  section  projects  above  the  cut  surface,  often  measures 
2  to  6  cm.,  and  is  attended  by  extravasation  of  blood  into  the  lung 
cells  and  sustentacular  tissue,  though  the  lung  is  not  torn.  This  is 
known  as  a  fibrinous  or  simple  infarct.  If  the  embolus  contains  pus 
or  putrefactive  microorganisms,  it  develops  into  abscess  or  gangrene. 
Infarcts  occur  oftener  in  the  lower  than  the  upper  lobes  and  more 
frequently  on  the  right  than  on  the  left  side.  They  are  often  multiple. 
Small  infarcts  may  be  wholly  absorbed,  but  the  larger  ones  leave  pig- 
mented cicatrices. 

Sjmaptoms. — (a)  Infarction  of  the  main  pulmonary  trunk  may  re- 
sult in  immediate  death,  as  sudden  death  from  sitting  up  after  child- 
birth. In  other  cases  death  occurs  in  a  short  time  from  cerebral 
anaemia  attended  by  convulsions,  dyspnoea,  and  cardiac  failure.  The 
infarct  may  cover  the  greater  part  of  the  lobe  involved ;  if  the  patient 
lives  for  some  time,  a  sudden  systolic  murmur  may  develop  over  the 
pulmonary  artery  (Litten).  (b)  Infarction  of  a  smaller  vessel  is  often 
ushered  in  with  chill,  vomiting,  dyspnoea,  cyanosis  and  fever,  even 
with  bland  embolism.  The  sputum  contains  dark  blood  and  there  is  a 
"stitch  in  the  side"  from  pleural  participation.  Physical  examination 
frequently  elicits  a  pleural  rub  and  later,  in  some  cases,  slight  dulness, 
especially  behind,  between  the  spine  and  scapular  line;   crepitant  rales 


536  DISEASES   OF   THE  RESPIRATORY   TRACT 

and  bronchial  breathing  are  frequently  present.     Pyogenic  or  putrid 
clots  cause  abscess,  gangrene,  empyema,  or  pneumothorax. 

Diagnosis. — Diagnosis  is  often  at  best  a  probability  diagnosis. 
Sudden  cardiac  failure  is  very  difficult  to  differentiate  from  an  embolic 
occlusion  of  a  main  pulmonary  trunk,  especially  when  death  occurs 
without  haemoptysis.  The  etiology,  the  sudden  onset  and  circum- 
scribed chest  signs  are  of  diagnostic  importance.  Treatment  lies 
solely  in  cardiac  stimulation. 

4.  (Edema  of  the  Lungs. 

Etiology. — In  the  etiology  of  this  secondary,  common,  frequently 
terminal  or  agonal  affection,  three  iTnportant  causes  stand  in  the  fore- 
ground, viz. ,  heart,  kidney  and  lung  disease.  (Edema  consists  of  the 
pouring  out  into  the  air  cells  and  interstitial  tissue  of  a  serous  trans- 
udate. A  precise  classification  of  the  mechanism  of  pulmonary 
oedema  is  difficult:— (a)  Stasis  due  to  weakened  heart  is  probably  its 
most  frequent  mechanism.  Cohnheim  and  Welch  demonstrated  ex- 
perimentally that  it  may  result  from  failure  of  the  left  ventricle  whereas 
there  is  continued  activity  of  the  right  ventricle;  this  may  be  com- 
mon in  the  death  agony,  but  the  explanation  is  not  entirely  satisfactory, 
as  cases  of  pulmonary  oedema  occur  in  which  the  pulse  (and  therefore 
the  action  of  the  left  ventricle)  is  strong;  however,  general  cardiac 
anasarca  may  occur  when  the  radial  pulse  is  apparently  sufficiently 
strong,  though  it  is  known  that  the  heart  must  be  weak.  Grossmann 
advances  the  theory  that  there  is  a  spasm  of  the  left  ventricle.  Weak 
heart  may  result  from  any  disease  of  the  endo-,  myo-,  or  pericardium. 
Sahli  explains  certain  cases  by  (b)  paralysis  of  the  'pulmonary  vessels. 
Under  either  (a)  or  (6)  nephritic  oedema  or  the  toxic  oedemas,  such  as 
those  from  the  iodides,  ether,  pilocarpine  or  muscarin,  may  be  in- 
cluded, (c)  Inflammatory  oedema,  such  as  that  around  a  fibrinous 
pneumonia  and  numerous  other  pulmonary  diseases,  cannot  be  strictly 
brought  under  oedema,  for  it  is  an  exudation,  not  a  transudation. 
However,  in  this  form  the  pulse  is  usually  strong,  and  there  is  often 
fever,  {d)  Angioneurotic  oedema  is  sometimes  described.  It  is  also 
possible  that  (e)  occult  changes  in  the  blood  and  bloodvessels  are  causal 
factors.  These  varied  mechanisms,  though  generally  stated  to  be 
most  common  in  cardiac,  renal,  and  pulmonary  lesions,  may  also  oper- 
ate in  cachexia,  ansemia,  cerebral  disease,  old  age,  and  innumerable 
other  conditions. 

Pathology. — Pathologically  oedema  may  be  circumscribed  or  oftener 
diffuse.  The  lungs  are  large,  heavy  and  spongy;  they  pit,  and  on 
section,  especially  of  the  bases,  a  frothy,  serosanguineous  fluid  exudes. 

S3nnptoms. — Symptoms  usually  come  on  precipitately,  with  hurried 
breathing,  dyspnoea,  cyanosis  and  carbon  dioxide  intoxication.  The 
sputum  is  copious,  foamy,  serous,  somewhat  resembling  soapsuds,  or 
at  times  is  tinged  with  blood;  it  is  rich  in  albumin  and  poor  in  mucus 


HAEMOPTYSIS  537 

and  cells.  The  huhhling  breathing  indicates  serum  in  the  alveoli. 
The  second  pulmonic  sound  is  accentuated,  the  pulse  is  weak,  the  lung 
note  is  slightly  tympanitic  from  relaxation,  and  coarse  and  fine  rales 
are  heard  everywhere.  If  the  lower  lobes  are  filled,  the  physical  signs 
may  closely  resemble  those  of  consolidation,  i.  e.,  there  may  be  in- 
creased fremitus,  bronchial  breathing  and  dulness.  The  diagnosis 
is  determined  from  the  sputum  and  lung  findings. 

Treatment. — Treatment  may  be  beneficial  in  some  cases,  though  too 
often  oedema  is  the  death  agony  itself,  (a)  Prophylaxis  concerns  the 
causal  disease,  for  example,  cardiac  weakness,  or  anasarca,  in  cases 
of  nephritis,  {h)  Rapidly  acting,  diffusive  stimulants  are  urgently 
indicated  hypodermatically,  as  camphor,  ether,  strophanthus  and 
strychnine,  and  coffee  or  champagne  by  mouth,  (c)  Morphine  vnth 
atropine  is  at  times  almost  specific,  (d)  Venesection  relieves  the  right 
heart  and  therefore  the  lungs,  (e)  Stimulating  expectorants,  as  senega 
and  rapid  purgation  by  crotin  oil,  irj^iij,  on  the  tongue,  are  sometimes 
of  value.  The  author  has  obtained  no  results  from  the  acetate  of 
lead,  which  is  recommended  by  Traube  in  doses  of  gr.  ss  to  i  every 
hour  or  two,  and  by  Nothnagei  in  a  single  dose  of  gr.  x  to  xx. 


5.  Haemoptysis. 

Haemoptysis  or  haemoptoe  refers  to  "spitting  of  blood,"  while  pro- 
fuse hemorrhage  is  known  as  pneumorrhagia. 

Etiology. — (a)  Laryngeal  ulceration  or  inflammation;  (b)  tracheal 
ulceration  or  aneurysm  bursting  into  the  trachea;  (c)  severe  inflam- 
mation or  ulceration  of  the  bronchi,  stasis  from  cardiac  disease, 
bronchiectasis,  putrid  and  fibrinous  bronchitis,  rupture  into  the  air 
passages  of  aneurysm  or  anthracotic  lymph  glands,  and  thermal, 
chemical  or  mechanical  irritation  are  etiological  factors;  haemoptysis 
may  also  occur  in  the  acute  exanthemata,  in  such  affections  of  the 
blood  as  haemophiha,  scurvy,  purpura  haemorrhagica,  and  leukaemia, 
and  in  gout,  renal  disease  and  cholaemia;  haemoptysis  occurring  as 
vicarious  menstruation  was  mentioned  by  Hippocrates,  and  though 
rare,  is  an  established  variety;  vicarious  haemoptysis  after  ovariotomy 
or  suppression  of  hemorrhoidal  bleeding  is  still  more  uncommon  and 
its  existence  has  been  regarded  with  just  scepticism,  (d)  Lung  disease 
is  the  most  important  etiological  factor,  and  the  chief  lesion  is  (i)  tuber- 
culosis, iq.v.),  which  causes  80  to  90  percent,  of  cases  of  blood-spitting. 
It  is  commonest  between  the  fifteenth  and  thirtieth  years,  and  very 
rarely  occurs  under  six  years  of  age,  as  children  seldom  develop  cavi- 
ties. As  stated  under  tuberculosis,  it  occurs  as  capillary  or  profuse 
hemorrhage.  It  was  noted  long  ago  that  haemoptysis  sometimes  occurs 
rather  epidemically  among  tuberculous  cases;  in  such  an  outbreak, 
Flick,  Ravanell  and  Erwin  found  the  pneumococcus  in  the  sputum, 
(ii)  Infarcts  are  usually  characterized  by  haemoptysis,  (iii)  Pneu- 
monia, abscess  and  gangrene;    (iv)  tumors;    (v)  parasites  of  the  lung, 


538  DISEASES   OF   THE  RESPIRATORY   TRACT 

echinococcus,  filiaria,  gregarina,  distoma  and  actinomycosis;  and  (vi) 
syphilis  and  leprosy,  are  more  uncommon  causes,  (e)  Haemoptysis 
nervosa  is  most  rare,  though  authentic  cases  have  occurred  in  cerebral 
traumatism,  hysteria  (where  it  has  caused  death),  epilepsy  and  in 
some  other  neuroses.  (/)  A  toxic  haemoptoe  may  occur  from  mercury 
or  iodide,  but  it  is  very  rare. 

Symptoms. — Symptoms  may  follow  those  of  the  causal  disease,  as 
tuberculosis,  mitral  stenosis,  or  aneurysm,  or  they  may  develop  in 
apparent  health.  Haemoptysis  is  in  itself  only  a  symptom.  Blood 
poured  out  into  a  cavity  or  into  the  lung  substance  is  not  always 
voided,  especially  in  very  weak  or  moribund  persons.  Prodromes  are 
unusual ;  without  other  warning,  a  salty  taste  in  the  mouth,  substernal 
warmth,  a  sense  of  something  rising  from  the  chest,  and  coughing,  are 
followed  at  once  by  a  few  spoonfuls  or  more  of  blood.  At  times  a 
previously  mucous  sputum  may  be  accidentally  noted  to  be  blood- 
stained. The  blood  varies  in  amount  from  the  merest  stain  to  5  quarts 
(Laennec);  it  may  appear  but  once  or  may  recur  several  times.  It 
is  generally  bright  red  and  well  mixed  with  air;  the  formation  of 
rouleaux  is  uncommon.  If  the  blood  has  clotted  in  the  lung  or  air 
passages,  the  clot,  too,  is  mixed  with  air  and  perhaps  with  mucus. 
Casts  of  the  bronchioles  may  be  voided.  If  there  is  gangrene  or  abscess, 
the  blood  may  be  brown  or  buff-colored  and  the  red  cells  may  be 
disintegrated.  Brown  heemosiderin  granules,  or,  if  the  blood  has 
remained  in  the  clot  two  weeks,  hsematin  crystals  may  occur.  Asthma 
crystals  are  occasionally  seen. 

Physical  findings,  other  than  those  of  the  fundamental  condition, 
are  frequently  lacking;  if  the  blood  obstructs  a  fairly  large  bronchus, 
there  may  be  bronchial  breathing,  bronchophony,  increased  fremitus, 
and  dulness  if  the  affected  area  measure  2  by  5  cm.  In  the  bronchioles, 
blood  gives  rise  to  small  rales,  in  the  bronchi  to  coarser  rales. 

Complications. — Fever,  aside  from  the  causal  disease,  may  result 
from  resorption  (ferment  fever).  Urobilin  icterus,  functional  heart 
murmur,  relaxation  of  the  right  heart,  albuminuria  and  pufl&ness  of 
the  ankles  are  possible  but  not  conspicuous  compHcations. 

Diagnosis. — Examination  of  the  nose,  gums,  throat  and  larynx 
readily  excludes  hemorrhage  which  may  simulate  hsemoptoe.  It  is 
often  difficult  to  distinguish  at  the  time  of  bleeding  between  arterial 
and  capillary  or  between  bronchial  and  pulmonary  bleeding,  but  the 
question  may  be  decided  by  the  history,  by  later  physical  examination 
and  by  the  clinical  evolution. 

H^MATEMESIS . VS . HAEMOPTYSIS . 

(a)  The  blood  is  acid   (unless  a  very         Is  alkaline 
large  amount  is  voided). 

(6)  The  patient  nearly  always  recognizing  whether  it  is  vomited  or  coughed  up. 
(Blood  from  the  lung   is  very  rarely     .^^  (Haemoptysis,  very  rarely,  causes  con- 
swallowed  and  then  vomited.)  sensual  vomiting.) 


HEMOPTYSIS  539 

(c)  Is  often  dark  (though  large  amounts         Nearly    always    bright     (though    when 

of  bright  red  blood  may  be  vom-  stagnating  in  a  cavity  it  may  become 

ited,  as  in  ulcer).  dark  or  buff), 

(d)  Is  mixed  with  food,  HCI,  ferments,       Mixed  with  air,  which  is  also  found  in 

etc.  the  clots.    (Not  infrequently  tubercle 

bacilli,  heart  cells,  etc.,  are  found.) 

(e)  In  10  to  15  per  cent,  of  cases  blood         Is  very  rarely  in  stools. 

is  in  the  stools. 

Prognosis  and  Course. — The  duration  is  variable,  but  spontaneous 
cessation  is  the  rule.  The  immediate  prognosis  is  good,  as  early 
death  from  hemorrhage  is  rare,  except  in  cases  of  profuse  pneumor- 
rhagia,  resulting,  for  instance,  from  aneurysmal  rupture,  and  even 
here  the  patient  may  live  year.s  after  the  aneurysm  has  broken  into 
the  lung  substance.  Drowning  or  suffocation  of  the  patient  in  his 
own  blood  is  rare.  The  final  outcome  depends  on  the  etiology.  In 
Ware's  386  cases,  16  per  cent,  recovered. 

Treatment. — Prevention. — In  tuberculosis  {q.  v.)  the  patient  should 
be  kept  quiet,  the  cough  should  be  suppressed  and  exertion  and  vocal 
efforts  should  be  avoided;  in  heart  disease  and  marantic  thrombosis, 
rest  is  indicated  to  obviate  detachment  of  the  thrombi. 

Therapy. — Absolute  'physical  and  mental  quiet  should  be  enforced 
when  haemoptysis  occurs.  No  movement  should  be  allowed ;  coughing 
should  be  suppressed  by  hypodermatic  injections  of  morphine,  which 
also  allay  the  attendant  mental  excitement  (opiates  are  not  to  be 
employed  in  cases  of  very  large  hemorrhages,  for  bronchial  occlusion 
may  result).  The  patient  should  be  assured  of  a  favorable  outcome; 
no  physical  examination  should  be  made  except  auscultation  of  the 
chest  in  front,  and  this  should  be  done  only  if  necessary,  for  immediate 
treatment  takes  precedence  of  diagnosis ;  if  rales  indicate  which  side 
the  hemorrhage  is  on,  the  patient  should  lie  on  that  side  to  prevent 
aspiration  into  the  contralateral  bronchus. 

Arterial  pressure  should  he  reduced  by  administration  of  aconite  or 
veratrum,  which  lessen  tension  in  both  the  pulmonary  and  arterial 
circulation.  A  liquid,  simple,  spare  diet  should  be  given.  Alcohol, 
coffee,  tea,  strychnine,  and  digitalis  should  be  interdicted.  Even  if 
the  patient  collapses  cardiants  should  be  avoided,  for  syncope  is 
nature's  readiest  haemostatic;  the  old  custom  of  venesection  in  this 
way  promoted  thrombosis.  Cardiac  excitement  is  lessened  by  placing 
a  large  ice-bag  over  the  precordium.  Active  purgation  by  croton  oil 
is  very  beneficial. 

Haemostatics  are  not  proven  to  control  the  lesser  blood  circuit, 
which  appears  to  be  rather  independent  of  drugs  which  operate  on 
the  arterial  circuit.  Ergot,  if  anything,  rather  raises  the  blood  pressure 
in  the  lungs  and  should  therefore  seldom  be  given.  Calcium  chloride 
gr.  V  to  X,  and  common  salt  on  the  tongue  are  of  some  value  (salt 
acts  reflexly,  by  way  of  the  vagus,  on  the  pulmonary  vessels).  Gelatin 
(2  per  cent.)  may  be  used  in  urgent  cases  and  the  beneficial  effects  of 
turpentine  have  long  been  known.    Nature,  as  a  rule,  effects  the  cure; 


540  DISEASES  OF   THE  RESPIRATORY   TRACT 

drugs  do  not,  though  opiates  reinforce  nature.  Hippocrates  employed 
ligature  of  the  extremities,  i.  e.,  binding  tightly  for  a  few  minutes 
the  vessels  of  the  groin  and  axilla,  in  order  to  lessen  the  return  flow  of 
blood  toward  the  point  of  hemorrhage.  Artificial  pneumothorax,  to 
compress  the  bleeding  lung,  has  been  advocated  in  cases  of  desperate, 
profuse  and  persistent  haemoptysis. 


PARASITES  OF  THE  LUNG. 
Echinococcus  of  the  Lung. 

Man  may  become  infected  with  tha  tinea  echinococcus  from  dogs 
by  their  licking  their  master's  hands  or  from  faeces  contaminating 
human  food,  especially  vegetables.  The  unilocular  form  is  much 
more  common  than  the  multilocular.  Infection  occurs  either  (a) 
primarily,  the  embryo  skipping  the  liver,  or  (6)  much  more  often 
secondarily,  by  metastasis  or  breaking  through  the  diaphragm  from 
the  liver.  According  to  Neisser's  figures  from  900  cases,  50  per  cent, 
occurs  in  the  liver,  9  per  cent,  in  the  kidneys,  8  per  cent,  in  the  cran- 
ium and  7  per  cent,  in  the  lungs.  The  small  miliary  white  cysts  may 
grow  to  the  size  of  an  adult's  head.  They  may  calcify,  indurate,  sup- 
purate, putrify  or  rupture  into  contiguous  parts  (See  Animal 
Parasites), 

Symptoms. — Many  cases  produce  no  symptoms  and  are  unex- 
pected findings  at  the  post  mortem,  Dieulafoy  described  three  clinical 
stages: — (a)  the  initial,  (6)  the  tumor  stage  and  (c)  the  suppurative 
or  rupture  stage,  (a)  The  initial  stage  often  has  no  symptoms,  but 
may  be  marked  by  scanty  capillary  haemoptysis,  cough,  emaciation 
and  possibly  fever,  all  of  which  may  closely  simulate  incipient  phthisis. 
(b)  In  the  tumor  stage,  there  is  bronchial  (or  weak)  breathing,  increased 
fremitus  and  circumscribed  dulness,  which  occurs  in  the  lower  lobes 
and  twice  as  frequently  on  the  right  side  as  on  the  left;  it  sometimes 
causes  bulging  of  the  chest  wall.  There  is  a  sharp  transition  between 
it  and  the  note  of  the  sound  contiguous  lung.  Dislocation  of  the  heart, 
compression  of  the  lung  and  other  luxations  may  occur.  The  x-rays 
often  confirm  the  physical  signs.  The  dulness  curves  upward,  but 
is  quite  different  from  the  curve  of  pleuritic  effusion  which  is  concave 
upward.  Tumor  of  the  lung  gives  a  larger,  harder  flatness.  Puncture 
(v.  i.)  reveals  a  clear,  aseptic  fluid  of  1,009-15  specific  gravity  with 
little  or  no  albumin,  very  rich  in  sodium  chloride  and  the  characteristic 
succinic  acid;  the  inosite  is  of  no  practical  importance;  the  booklets 
are  pathognomonic,  (c)  In  the  stage  of  suppuration  or  rupture,  as 
in  liver  echinococcus,  rupture  may  occur  into  the  pleura  (in  which 
primary  disease  is  25  times  as  rare),  Pneumothorax  may  result.  Far 
oftener  rupture  into  a  bronchus  occurs,  with  pain,  dyspnoea,  collapse, 
and  sudden  "mouthful"  expectoration  of  pus,  small  vesicles,  lamel- 
lated  cyst  wall  and  booklets.    At  the  time  of  rupture  a  curious  urticaria 


DISTOMA   OF   THE  LUNG  541 

develops  (Finsen)  which  is  probably  toxic  as  the  fluid  from  echino- 
coccus  cysts  produces  it  when  inoculated  into  animals.  Profuse 
hsemoptoe  js  common.  If  it  comes  from  the  liver,  the  sputum  is  ochre- 
yellow  from  undissolved  bilirubin,  even  when  there  is  no  direct  con- 
nection with  the  bile  vessels;  cholestearin  is  often  present.  The 
vesicles  or  cyst  wall  may  cause  suffocation.  Rupture  may  also  occur 
into  the  pericardium,  stomach,  or  peritoneum.  In  this  stage  hectic 
fever  is  usual. 

Diagnosis. ^ — Diagnosis  is  determined  only  from  the  sputum,  or  from 
puncture  which  has  decided  dangers,  as  sudden,  probably  toxic  death 
is  a  common  sequel. 

Prognosis. — The  course  varies  much.  A  cyst  in  two  or  three  months 
becomes  as  large  as  a  hazelnut,  and  in  five  months  as  large  as  an 
orange  (Dieulafoy).  Death  may  result  from  suffocation,  hemorrhage, 
gangrene,  hectic  fever  or  toxaemia  from  rupture  or  puncture. 

Treatment. — If  puncture  is  made,  and  is  followed  by  severe  symp- 
toms, the  case  should  be  instantly  operated.  There  is  no  medical 
treatment.  Without  surgical  intervention  57  per  cent.  (Hearn)  to  66 
per  cent.  (Davaine)  die.  Tuffier  and  Garre  report  but  10  per  cent, 
mortality  with  operation. 


Distoma  of  the  Lung. 

This  affection  was  first  described  by  Baelz  in  Japan,  Formosa  and 
Corea.  The  worm  is  plump,  wide,  egg-shaped,  measures  8  to  10  x  4 
to  6  mm.,  is  brownish  red  and  is  provided  with  two  small  suckers. 
Its  eggs  are  oval,  brown  and  measure  0.08  to  0.1  x  0.05  mm.  Little 
is  known  of  its  origin.  It  is  found  in  the  bronchi  and  in  the  infarcts 
and  cavities  which  it  produces.  The  cavities  contain  red  disks,  a 
mucoid  substance  and  shreds  of  lung  tissue,  and  are  surrounded  by 
fibrous  tissue.  The  parasite  is  also  found  in  the  liver,  diaphragm, 
mesentery  and  brain.  The  course  of  the  disease  is  chronic,  though 
most  cases  terminate  favorably;  it  is  marked  by  (a)  bronchitic  symp- 
toms, (6)  haemoptysis  and  (c)  a  viscid  clear  sputum  in  which  minute 
brownish-red  dots,  the  distoma  eggs,  are  seen.  In  exceptional  cases 
death  results  from  emaciation,  exhausting  haemoptysis  or  brain  em- 
bolism. 

Tuberculosis,  syphilis,  and  actinomycosis  of  the  lung  are  described 
under  Infections. 


542  DISEASES  OF   THE  RESPIRATORY   TRACT 

DISEASES  OF  THE  PLEUEA. 

(A).  PLEURISY. 

Definition. — Pleurisy  is  an  inflammation  of  the  pleura,  rarely  pri- 
mary but  usually  secondary  to  tuberculosis  or  other  lung  disease,  general 
infections,  septiceemic  affections  and  various  diseases  in  contiguous 
tissues  or  organs. 

Pleurisy  constitutes  about  3  per  cent,  of  internal  maladies  and  is 
the  most  common  of  all  post  mortem  findings  (in  over  50  per  cent.). 
It  is  susceptible  of  division  into  infinite  varieties,  acute,  subacute  or 
chronic  according  to  its  course,  dry  or  effusive  according  to  its  con- 
sistence, primary  or  secondary  as  to  its  cause,  diffuse  or  circumscribed 
as  to  its  distribution  and  serofibrinous,  hemorrhagic  or  suppurative 
as  to  its  nature.  Any  such  classification  is  more  or  less  artificial, 
whence  it  seems  preferable  to  describe  first  all  its  symptoms  and  group 
special  types  later. 

Etiology. — 1.  Tuberculosis. — So-called  primary,  spontaneous  or 
cryptogenetic  pleurisies  are  often  tuberculous  (Barrs,  Netter,  Lemoine, 
Vaillard,  Coston  and  Dubville).  Landouzy  considers  that  98  per  cent, 
of  all  pleurisies  are  tuberculous  and  that  60  per  cent,  of  all  cases  of 
phthisis  pass  through  the  so-called  pleuritis  a  frigore;  Netter  holds 
that  70  to  80  per  cent.,  and  Ashoff  that  nearly  all  "primary"  cases, 
are  tuberculous.  Thirty-two  per  cent,  of  Osier's  cases  were  tubercu- 
lous, 32.6  per  cent,  of  Bowditch's  and  40  per  cent,  of  Hedges  cases. 
Le  Damay  in  55  "primary"  pleurisies  proved  by  inoculation  that  92 
per  cent,  were  tuberculous.  Trauma  favors  development  of  tuber- 
culous pleurisy.  The  causal  lesion  may  be  recognized  at  autopsy  in 
calcified  bronchial  glands  or  in  small  lung  foci.  Tuberculous  pleurisy 
is  often  bilateral.  Non-tuberculous  pleurisy,  by  causing  adhesions, 
may  sometimes  favor  the  development  of  pulmonary  tuberculosis. 
Its  special  relations  will  be  discussed  later. 

2.  Diseases  of  the  Lung  Substance. — Such  diseases  as  pneumonia, 
abscess,  gangrene,  infarcts,  tuberculosis,  tumors,  pneumothorax,  echin- 
ococcus,  tertiary  syphilis,  and  actinomycosis  are  etiological  factors; 
according  to  Koplik,  95  per  cent,  of  pleurisies  in  children  follow  pneu- 
monia. It  is  less  frequent  in  diseases  involving  the  bronchi,  as  in 
grippe  or  measles. 

3.  Acute  Infections. — Rheumatism,  sepsis,  puerperal  fever,  endo- 
and  pericarditis,  variola,  scarlatina,  measles,  diphtheria  and  other 
acute  infections  may  result  in  pleurisy.  It  develops  in  about  2  per 
cent,  of  typhoid  cases;  it  may  develop  in  secondary  syphilis  without 
lung  lesions  (Chantemesse  and  Widal),  probably  from  toxaemia. 

4.  Diseases  of  Adjacent  Organs. — (a)  Intrathoracic  affections,  in- 
volving the  ribs,  spine,  oesophagus,  mediastinum,  lymph  glands,  dia- 
phragm, and  pericardium;   (6)  abdominal  affections,  as  of  the  stomach, 


PLEURISY  543 

spleen,  or  liver  (abscess, tumor, or  cirrhosis  [in  16  per  cent.]),  subphrenic 
abscess,  suppurative  or  tuberculous  peritonitis  (in  25  per  cent.),  peri- 
nephritic  abscess,  abdominal  malignancy,  etc.,  may  promote  pleurisy; 
pleural  infection  may  occur  by  direct  local  invasion  or  by  the  lymph 
and  blood  streams;  in  neglected  appendicitis,  hepatic  and  diaphrag- 
matic invasion  occurs,  followed  by  pleural  infection. 

5.  Tumors. — Echinococcus  and  endothelioma  (Wagner  and  Fraen- 
kel)  are  the  most  important  types.  According  to  Neelsen,  endotheli- 
oma is  an  infectious  process,  a  lymphangitis  proliferans  (Schwenniger) 
or  according  to  Schottelius  it  is  a  lymphangitis  carcinomatosa.  The 
pleura  swells  and  develops  callosities  or  adhesions.  Carcinoma,  sar- 
coma, ecchondroma,  and  rarely  lipoma  are  also  factors;  pleural  neo- 
plasms are  far  more  frequently  secondary  than  primary. 

6.  Altered  Conditions  of  the  Blood  (Dyscrasiae). — Gout,  nephritis, 
scurvy,  and  tertiary  syphilis  are  often  causative  of  pleurisy;  these 
conditions  frequently  produce  bilateral  pleurisy  and  result  possibly 
from  chemical  products  or  from  reduced  physiological  resistance, 
which  predisposes  toward  various  infections. 

7.  Terminal  Infections. — Various  forms  of  sepsis  are  often  fatal  to 
subjects  of  chronic  disease  of  the  heart,  liver  and  kidneys;  bilateral 
pleurisy  is  frequent. 

8.  Age,  Sex,  Localization. — Age:  most  cases  occur  between  the 
twentieth  and  fiftieth  year,  but  no  person  is  exempt,  from  intra-uterine 
life  to  extreme  old  age.  Sex:  Eichhorst  observed,  pleurisy  in  3  per 
cent,  of  all  his  male  and  2  per  cent,  of  all  his  female  cases,  and  found 
the  following  localization:  right-sided  in  54  per  cent.,  left-sided  in  42 
per  cent.,  and  bilateral  in  4  per  cent.  Cases  following  nervous  disease, 
cold  or  exposure,  venous  thrombosis,  or  trauma  can  usually  be  brought 
within  the  above  given  classification. 

Bacteriology. — The  etiological  classification  above  given  does  not 
correspond  to  the  bacteriological  division.  Suppurative  pleurisy  may 
result  from  the  streptococcus,  pneumococcus,  tubercle  bacillus,  or 
less  often  from  the  staphylococcus,  or  typhoid  or  colon  bacilli;  serous 
pleurisy  may  be  due  to  the  tubercle  bacillus  or  to  the  pyogenic  organ- 
isms. The  frequently  negative  cultural  results  have  favored  the 
hypotheses  that  chemical  products,  such  as  retained  urinary  substances 
in  uraemia  or  tuberculin  in  phthisis,  may  of  themselves  produce 
pleurisy,  or  that  bacteria  produce  pleurisy  and  then  die.  It  must  be 
remembered  that  cultures  are  usually  made,  not  from  the  pleura 
directly,  but  from  the  fluid  effused  from  it.  The  organisms  found  are 
most  frequently  the  pneumococcus,  tubercle  bacillus  and  streptococcus, 
less  often  the  staphylococcus,  pneumobacillus  of  Friedlander,  typhoid, 
colon,  influenza  (in  two  cases  only)  and  diphtheria  bacillus,  gonococcus, 
ray  fungus,  glanders  bacillus.  Micrococcus  tetragenus,  and  Micrococcus 
pyogenes  tenuis,  (a)  Purulent  pleurisy  (empyema)  is  most  often  due 
to  the  streptococcus  in  adults  and  to  the  pneumococcus  in  children. 
About  10  per  cent,  of  empyema  is  tuberculous;  empyema  giving 
no  results  culturally  or  by  inoculation  is  usually  tuberculous  and  may 


544  DISEASES   OF   THE  RESPIRATORY   TRACT 

be  regarded  as  a  cold  abscess  of  the  pleura  (Kelsch  and  Vaillard). 
The  staphylococcus,  Micrococcus  tetragenus  and  pyogenes  tenuis, 
pneumobacillus,  typhoid  and  colon  bacilli  are  infrequent  factors.  (&) 
Serous  pleurisy  is  usually  tuberculous,  as  shown  by  the  constantly 
increasing  percentage  of  cases  in  which  inoculations  are  successful. 
It  was  formerly  stated  that  tubercle  bacilli  are  not  frequently  found, 
and  that,  when  found,  their  presence  suggests  a  direct  communication 
with  a  tuberculous  focus  in  the  lung  or  lymph  glands;  negative  results 
are  due  either  to  an  insufficient  amount  of  fluid  (less  than  10  to  20 
c.c.)  being  inoculated,  or  to  the  effusion  being  due  to  toxins  rather 
than  to  the  microorganisms  themselves.  Eichhorst  found  tubercle 
bacilli  by  direct  examinations  in  but  15  per  cent,  of  serous  pleurisies, 
though  his  inoculations  were  positive  in  62  per  cent.  Jousset  recom- 
mended that  the  fluid  be  allowed  to  coagulate  and  the  clot  digested 
with  pepsin,  centrifuged  and  then  stained;  his  method  is  termed 
inoscopy.  (c)  Most  cases  of  so-called  primary  pleurisy  which  are  non- 
tuberculous  are  due  to  Fraenkel's  pneumococcus.  (d)  Meta-  and  para- 
pneumonic pleurisy  is  most  frequently  due  to  the  pneumococcus,  but 
also  to  the  streptococcus  and  staphylococcus,  even  when  no  pus  is 
formed,  although  mixed  infections  have  a  tendency  to  suppuration. 

Symptomatology. — Physical  findings  are  absolutely  essential  for 
diagnosis  and  all  subjective  symptoms  are  ambiguous  or  may  be 
wholly  absent.  In  the  main,  all  types  have  much  the  same  signs  which 
differ  more  quantitatively  than  qualitatively;  serous  pleurisy  nearly 
always  shows  friction,  and  fibrinous  pleurisy  is  almost  always  accom- 
panied by  some  exudation. 

Inspection. — (a)  Inspiratory  retraction  of  the  intercostal  spaces  may 
result  from  imperfect  ingress  of  air,  from  pain  or  from  adhesions. 
Epigastric  retraction  during  inspiration  is  due  to  contraction  of  the 
diaphragm.  (6)  The  patient  often  lies  at  first  (during  the  dry  stage) 
on  the  sound  side  to  avoid  pain  from  pressure  on  the  inflamed  surfaces; 
later  (during  the  exudative  stage)  he  lies  on  the  diseased  side  in  order 
to  allow,  for  mechanical  reasons,  a  freer  expansion  of  the  sound  lung, 
especially  when  the  exudate  is  large.  Traube  believed  that  continued 
lying  on  the  diseased  side  aggravated  pain  by  congesting  the  pleural 
and  subpleural  veins.  The  patient  may  sit  up  for  breath,  or  assume 
the  diagonal  decubitus  (Andral).  (c)  Ectasia  (distention)  of  the 
affected  side  occurs  especially  in  children,  and  is  determined  by  men- 
suration and  inspection.  The  interspaces  are  obliterated,  the  costal 
arch  is  immobile  during  respiration,  the  skin  glistening,  the  spine 
curved  toward  the  diseased  side,  the  shoulder  higher  and  the  nipple 
and  scapula  are  further  from  the  median  line.  The  right  chest  is 
normally  one  or  two  centimeters  larger  than  the  left;  again,  the  sound 
side  usually  measures  three  centimeters  more  than  its  normal  dimen- 
sions (or  more  than  the  diseased  side)  on  account  of  compensatory 
emphysema  (Gerhardt  and  Kerlias).  In  some  cases  of  very  large 
effusions  the  writer  has  observed  an  apparent  retraction  of  the  dis- 
eased side,      (d)   Respiratory   movement  of   the   affected  side  is  de- 


PLEURISY  545 

creased  or  absent  in  both  dry  and  exudative  pleurisy.  Respiration  is 
reflexly  decreased  on  the  diseased  side,  and  at  times  occurs  somewhat 
later  than  on  the  sound  side,  i.  e.,  the  breathing  lags  on  the  diseased 
side.  The  frequency  of  respiration  is  increased  from  lung  compres- 
sion, pain,  heart  luxation,  the  low  diaphragm,  fever  or  oedema  and 
paresis  of  the  intercostal  muscles.  Pain  alone  may  reflexly  decrease 
the  respiratory  expansion,  and  variation  on  the  same  side  may  occur, 
there  being  more  movement  above  and  less  below,  (e)  The  a:-rays 
often,  but  not  always,  show  a  dark  shadow.  (/)  Inspection  also  reveals 
cyanosis,  oedema  of  the  chest  wall  (in  suppurative  pleurisy  and  oc- 
casionally in  other  forms),  dislocation  of  the  apex  beat,  substernal 
pulsation,  venous  pulsation;  (g)  absence  of  Litten's  phenov^enon 
and  (h)  rarely  pulsation  of  the  effusion,  (i)  C.  L.  Greene  describes  a 
rhythmic  lateral  displacement  of  the  heart  peculiar  to  pleurisy:  "  Such 
movement  is  most  marked  in  medium-sized  effusions.  The  heart 
approaches  the  affected  side  in  inspiration  and  moves  outward  in 
expiration.  The  extent  of  movement  is  variable,  but  often  amounts 
to  two  inches.  It  may  be  measured  by  fluoroscopic  examination, 
auscultatory  percussion,  or,  in  the  case  of  right-sided  effusions,  by 
simple  deep  percussion  of  the  free  cardiac  border,  or  in  some  instances 
by  mere  inspection  of  the  apex  beat.  Deep  breathing,  and  especially 
forced  expiration,  are  essential  to  the  success  of  the  maneuver,  and  to 
obtain  this  morphine  must  sometimes  be  administered.  Marked 
rhythmic  lateral  movement  has  not  been  found  by  the  writer  in  pneu- 
monia, tuberculous  infiltrations  of  the  lung,  malignant  disease  of  the 
pleura  or  lung,  or  in  subdiaphragmatic  abscess," 

Palpation. — Palpation  confirms  the  findings  of  inspection,  (a)  An 
up  and  down  (less  often  horizontal)  friction  rub  is  felt;  it  increases 
on  pressure,  which  also  increases  the  pain  and  tenderness,  and  it  is 
the  more  readily  distinguished  the  coarser  the  rub  and  the  more  capable 
the  chest  wall  of  vibration.  It  is  usually  absent  in  obese  individuals. 
The  friction  develops  before  the  effusion,  is  often  present  with  it,  and 
after  it  is  absorbed.  The  rub  is  due  to  roughening  of  the  pleura, 
which  loses  its  glistening  appearance  and  looks  like  glass  upon  which 
one  has  breathed  (Klebs);  the  two  raw  pleural  surfaces  scrape  on 
each  other.  It  may  be  very  transient,  lasting  a  few  hours  or  days,  or 
even  disappearing  when  the  patient  takes  a  deep  breath;  or  it  may 
last  for  months,  or  even  years.  (6)  Pressure  on  a  tender  interspace 
during  deep  inspiration  may  cause  a  sudden  contraction  of  the  upper 
part  of  the  rectus  muscle  on  the  side  of  lesion  (Schmidt),  (c)  Vocal 
fremitus,  normally  greater  on  the  right  than  on  the  left  side,  varies 
according  to  the  level  at  which  it  is  tested,  (i)  Above  the  effusion  it 
is  normal,  (ii)  Near  the  spine,  over  the  compressed  and  relaxed 
lung  it  is  increased,  (iii)  Below,  it  is  weak  or  absent,  from  exudation 
of  thick  fibrin  or  fluid,  though  less  change  is  observed  in  dry  pleurisy 
than  in  the  effusive  form.  Irregular  findings  are  due  to  the  presence 
of  adhesions  bringing  the  lung  closer  in  some  places  than  in  others 
to  the  chest  wall.    The  condition  of  the  lung  and  the  bronchial  secre- 

35 


546  DISEASES   OF   THE  RESPIRATORY   TRACT 

tion  are  important  in  diagnosis,  whence  before  testing,  the  patient 
should  cough  and  take  a  few  deep  breaths.  The  results  are  irregular 
in  cases  of  loculated  effusion,  (d)  By  tapping  with  the  finger  tips 
the  increased  resistance  is  clearly  palpated,  (e)  (Edema  of  the  chest 
wall  on  the  diseased  side  may  be  inflammatory  (in  serous  as  well  as 
in  purulent  pleurisy),  or  mechanical  and  more  intense  from  pressure 
on  the  azygos  or  hemiazygos  veins.  (/)  Fluctuation  is  rarely  palpable, 
and  only  in  cases  of  great  effusion.  It  is  elicited  by  pressing  the 
fingers  of  one  hand  upward  toward  the  diaphragm  mth  the  fingers  of 
the  other  hand  in  the  interspaces,  (g)  Palpation  also  determines  the 
dislocated  apex  beat,  the  dislocated  liver  or  spleen,  the  bulging  of  the 
diaphragm  and  sometimes  a  furrow  between  the  diaphragm  and  liver 
(Stokes). 

Percussion. — Percussion  is  negative  in  dry  pleurisy,  except  when 
there  is  a  very  thick  fibrinous  exudate,  which  may  cause  dulness 
and  weak  breathing;  after  an  effusion  has  resorbed,  the  plastic  lymph 
which  is  left  may  cause  dulness.  When  there  is  effusion  (a)  dulness 
is  found  between  the  fifth  and  eighth  ribs  in  the  left  axilla  or  on  the 
right  side  over  the  liver  and  posteriorly.  Dulness  may  also  result  from 
old  adhesions,  atelectasis  of  the  lung,  great  fibrin  formation  in  the 
pleura,  or  a  very  thick  chest  wall.  As  in  pneumothorax,  distention  of 
the  lungs  and  calcification  of  the  ribs  may  somewhat  obscure  the  dul- 
ness of  an  effusion.  In  doubtful  cases  the  apparently  sound  side 
should  be  percussed  first.  According  to  Ferber's  experiments  on  the 
cadaver,  thirteen  ounces  (400  c.c.)  of  fluid  are  necessary  in  the  adult 
for  recognition  and  four  ounces  (120  c.c.)  in  children;  post  mortem 
experiments,  however,  do  not  exactly  fulfill  the  conditions  obtaining 
during  life.  The  effusion  must  be  one  inch  (2  c.c.)  thick  to  produce 
dulness.  Sometimes,  however,  even  six  to  seven  ounces  (200  c.c.) 
which  produce  a  dulness  two  fingers  in  height,  may  be  recognized. 
In  some  doubtful  cases  smaller  amounts  may  be  detected,  as  proven 
by  puncture,  especially  in  persons  ha^dng  thin  thoracic  walls,  as  in 
children  and  women.  Light  percussion  is  necessary  when  the  effusions 
are  small,  lest  other  normal  parts  be  brought  into  vibration.  Before 
percussion  the  patient  should  breathe  deeply  several  times  to  eliminate 
partial  collapse  of  the  lung  and  impaired  ingress  of  air  from  accumu- 
lated bronchial  secretion.  Percussion  is  absolutely  essential  to  diag- 
nosis. Not  merely  the  audible  dulness  should  be  regarded,  but  also 
the  palpable  sense  of  resistance,  on  light  percussion.  The  dulness  is 
marked,  and  usually  amounts  to  distinct  flatness.  In  larger  effusions, 
the  flatness  is  at  first  located  posteriorly,  and  is  noticed  to  increase 
along  the  spine  and  also  laterally  in  the  axilla.  In  massive  exudates, 
flatness  may  reach  from  the  lower  limit  of  the  pleura  to  above  the 
clavicles. 

The  dulness  is  usually  highest  posteriorly,  but  adhesions  may  cause 
an  opposite  condition.  The  line  of  dulness  is  not  even,  but  describes 
a  parabolic  curve  (courbe  de  Damoiseau),  due  according  to  Ger- 
hardt  to  the  uneven  thickness  of  the  chest  wall  or  according  to  Eich- 


PLEURISY  547 

horst  to  irregular  adhesions.  If  the  fluid  should  effuse  while  the 
patient  is  in  bed,  the  highest  level  of  dulness  would  be  in  the  axillary 
line;  if  it  should  effuse  when  he  is  out  of  bed,  the  upper  level  would 
be  horizontal.  Dulness  is  found  one  to  two  centimeters  higher  than 
the  upper  level  of  the  fluid,  due  to  plastic  exudate,  (b)  Right-sided 
effusions  merge  with  the  liver  dulness,  but  the  lower  limit  of  left- 
sided  effusions  can  usually  be  determined,  because  they  invade  Traube's 
semilunar  space.  This  "half  moon"  space  lies  between  the  fifth  and 
sixth  costal  cartilages  above,  and  tenth  rib  below,  representing  the 
supplementary  pleural  space,  and  is  designated  as  the  "half-moon" 
space  because  of  the  curve  at  its  upper  portion,  produced  by  the  apex 
of  the  heart;  its  tympanitic  note  is  decreased  or  replaced  l3y  flatness 
in  left-sided  effusions  (without  adhesions).  Dulness  here  may  not  be 
confused  with  that  of  the  spleen,  for  there  is  no  respiratory  excursion 
in  pleurisy,  and  the  dulness  lies  more  toward  the  heart  than  toward 
the  splenic  region.  Scybala,  or  food  in  the  stomach  or  bowels,  may 
also  impinge  on  Traube's  space,  (c)  Respiratory  excursion  is  absent 
in  effusions  of  any  size,  (d)  The  change  of  the  upper  line  of  dulness 
with  change  of  position  has  been  emphasized  by  Gerhardt,  Rosen- 
bach,  Da  Costa,  and  by  most  writers.  It  is  usually  stated  that  change 
of  position  causes  variation  in  the  level  of  the  effusion,  and  that  the 
level  changes  in  55  per  cent.,  changes  very  little  in  30  per  cent.,  and 
none  in  15  per  cent,  of  cases.  According  to  personal  experience,  it  is 
difficult  to  detect  on  account  of  the  adhesions  which  are  usually  present 
at  the  level  of  the  fluid.  The  line  of  dulness  does  not  change  rapidly 
on  mere  change  of  posture ;  the  patient  must  lie  some  hours  in  another 
posture  before  any  alteration  of  the  upper  level  occurs,  (e)  A  vertical 
strip  of  tympany  along  the  spine,  often  measuring  three  centimeters 
wide,  may  be  detected  when  there  is  a  large  exudate ;  it  is  due  to  com- 
pression of  the  lung.  Tympany  in  the  lower  part  of  the  left  chest  may 
result  from  gaseous  distention  of  the  stomach  and  intestines.  (/) 
Tympany  is  observed  over  an  upper  lobe  from  compression  or  relax- 
ation of  the  lung.  It  was  first  observed  by  Avenbrugger  and  Skoda, 
and  is  usually  called  the  Skodaic  note.  Rosenbach  explains  it  by  ten- 
sion of  the  intercostal  muscles  during  inspiration,  (g)  "  Cracked-pot" 
resonance  occasionally  appears  on  short  forcible  percussion  over  the 
upper  lobe,  and  results  from  sudden  expulsion  of  air  through  the  rima 
glottidis.  (h)  William's  tracheal  note  is  observed  on  the  left  more  than 
on  the  right  side,  and  chiefly  when  the  entire  side  is  dull.  It  is  obtained 
most  clearly  in  the  first  and  second  interspaces,  and  is  due  to  trans- 
mission of  percussion  vibration  from  the  fluid  to  the  trachea,  giving 
a  tympanitic  note.  A  change  of  pitch  with  opening  and  closing  of  the 
mouth,  like  that  observed  by  Wintrich,  in  lung  cavities,  may  some- 
times occur,  (i)  Grocco's  sign  is  a  small  triangular  dulness  on  the 
sound  side  along  the  vertebrae,  due  to  compression  of  the  healthy  side 
or  to  dislocation  of  the  aorta  and  mediastinum  by  large  exudates,  (j) 
There  may  be  dislocation  of  other  organs.  There  is  no  direct  parallel- 
ism between  the  amount   of  exudate  and  the  amount  of  luxation, 


548  DISEASES   OF  THE  RESPIRATORY   TRACT 

which,  of  course,  is  absent  if  the  organs  are  adherent.  The  heart  is 
usually  dislocated  in  toto  and  but  seldom  suffers  torsion  or  change  of 
the  direction  of  its  axis.  The  right  ventricle  may  be  seen  to  pulsate  to 
the  right  of  the  sternum,  even  as  far  as  the  line  of  the  right  nipple, 
when  the  effusion  is  left-sided.  In  right-sided  effusions  the  apex  is 
pushed  to  the  left  and  downward,  for  the  diaphragm  is  lower.  The 
liver  is  less  easily  displaced  than  the  heart,  but  in  right-sided  effusions 
is  pushed  down  and  the  left  lobe  tipped  somewhat  upward,  though  both 
lobes  may  be  dislocated  downward  in  very  extensive  pleurisies  (Traube 
and  Fraentzel).  In  left-sided  effusions  the  spleen  is  dislocated  down- 
ward and  forward,  undergoes  some  torsion,  and  may  stand  perpendicu- 
lar to  the  costal  arch. 

Auscultation. — This  is  most  important  in  dry  or  effusive  pleurisy, 
(a)  The  friction  rub  (see  Palpation)  may  be  hard  or  soft,  is  super- 
ficial (i.e.,  close  to  the  ear),  and  resembles  the  sound  made  by 
scratching  the  finger  upon  the  ear,  or  the  crunching  of  snow  under 
the  shoe;  it  often  develops  in  the  first  twelve  hours.  It  is  most  fre- 
quent during  inspiration,  but  is  also  very  often  detected  in  expira- 
tion; it  seldom  occurs  during  expiration  alone.  Inflammation  of  one 
leaf  of  the  pleura  is  sufficient  for  its  production.  It  may  disappear 
after  several  long  breaths  which  smooth  the  pleural  roughening.  The 
interrupted  rub  is  due  to  pleural  irregularities.  It  may  be  increased 
by  pressure  and  is  subject  to  no  law  as  to  its  duration.  Wintrich 
heard  a  pleural  rub  which  lasted  more  than  four  years  and  Gerhardt 
heard  one  lasting  six  years.  It  is  heard  most  frequently  over  the 
anterolateral  portion  of  the  chest,  and  is  detected  more  clearly  with 
the  stethoscope  than  with  the  naked  ear,  but  may  sometimes  be  heard 
at  a  distance  of  several  feet  as  in  a  case  seen  by  the  writer  with  Dr.  H. 
M.  Richter.  If  it  is  apical,  it  is  probably  due  to  tuberculosis.  It  may 
also  be  present  in  miliary  tuberculosis  (v.  Jiirgensen)  and  in  tumors 
of  the  lungs  or  pleura  without  actual  pleurisy.  It  usually  becomes 
less  clear  when  exudation  develops,  and  its  reappearance  may  indi- 
cate the  beginning  of  absorption,  or  the  extension  of  the  process  at 
the  level  of  the  fluid.  (6)  The  breath  sounds  are  modified  not  only 
by  the  effusion,  but  also  by  the  condition  of  the  lung,  the  strength  of 
breathing  and  the  conditions  of  conduction  existing  in  the  pleura  and 
thoracic  walls.  In  general,  and  especially  in  men  and  children,  the 
respiratory  sounds  are  weakened,  even  in  fibrinous  pleurisy,  from 
repressed  breathing,  and  perhaps  from  pain  alone;  cog-wheel  breath- 
ing is  common.  In  moderate  effusions  three  zones  are  observed:  (i) 
Absence  of  breathing  in  the  lower  parts  from  compression  of  the  lung 
by  the  exudate,  which  lessens  the  conduction  of  the  vesicular  sounds; 
(ii)  Bronchial  breathing  in  the  middle  zone  from  moderate  collapse  of 
the  alveoli  of  the  lung,  with  fair  conduction  through  the  bronchi, 
(iii)  An  upper  zone  of  sharp  or  exaggerated  vesicular  breathing.  In 
larger  effusions  the  lower  zone  extends  higher  and  bronchial  breath- 
ing may  be  heard  near  the  clavicle  or  between  the  scapula  and  spine. 
In  the  largest  effusions  the  breathing  is  indistinct  everywhere,  with 


PLEURISY  549 

areas  of  metallic  bronchial  breathing  when  the  lung  is  wholly  col- 
lapsed. Amphoric  breathing  results  in  exceptional  cases,  (c)  The 
voice  sounds  are  not  heard  over  the  fluid  or  over  very  thick,  plastic 
exudate.  They  may  persist  in  various  places,  when  islets  of  the  lung 
are  adherent  to  the  chest  wall,  (d) Bronchial  breathing  and  increased 
fremitus  may  be  present,  especially  in  children  with  empyema,  under 
the  following  conditions :  if  the  chest  wall  is  not  the  seat  of  oedema,  if 
the  bronchi  are  patent,  if  there  is  no  great  fibrin  deposit  on  the  pleura, 
and  if  the  lungs  are  retracted  but  not  absolutely  compressed.  The 
bronchial  breathing  may  sometimes  be  as  intense  as  in  pneumonia 
or  tumor.  In  adults  increased  fremitus  may  be  observed  between 
the  spine  and  scapula  where  the  lung  is  compressed,  (e)  Bronchoph- 
ony depends  upon  the  same  conditions  as  bronchial  breathing, 
viz.,  patent  bronchi,  moderate  retraction  of  the  lung  and  conditions 
favoring  good  conduction  of  sound.  (/)  JEgophony,  which  is  an  exag- 
gerated bronchophony,  was  described  by  Laennec;  it  is  found  chiefly 
in  middle-sized  eflfusions,  usually  at  the  level  of  the  fluid.  It  occurs 
less  often  in  large  cavities  and  in  infiltrations  of  the  lung.  In  large 
effusions  it  is  rare,  the  compression  being  too  great.  It  is  caused  by 
the  voice  sounds  passing  through  the  compressed  smaller  bronchi  to 
the  chest  wall;  it  may  be  present  when  the  exudate  is  increasing  or 
decreasing  at  a  given  point,  (g)  Baccelli's  symptom  is  the  "whispering 
voice,"  which  is  heard  on  the  diseased  side;  Baccelli  thought  that  it  was 
observed  more  often  in  serous  effusions,  but  it  also  occurs  in  other  forms 
of  pleurisy,  in  chronic  induration  of  the  lungs,  pneumonia,  hydro- 
thorax  and  cavities,  (h)  A  wide  propagation  of  the  Aear^  tone*  is  indic- 
ative of  consolidation,  rather  than  of  effusion,  but  if  consolidation  is 
excluded,  the  hearing  of  the  heart  tones  more  widely  than  normal  sug- 
gests dislocation  of  the  heart  by  an  effusion.  Murmurs,  which  result 
from  bending  of  the  large  vessels  by  dislocation  of  the  heart  may  be 
heard,  as  well  as  accidental  murmurs  resulting  from  a  weakened  heart, 
from  toxaemia  or  from  high  temperature. 

Diagnostic  Puncture. — This  determines:  (a)  the  existence  of  pleu- 
risy, excluding  pneumonia,  hypostasis,  tumor,  or  atelectasis;  (b) 
the  character  of  the  fluid;  and  (c)  the  prognosis.  It  is  indicated  in 
all  doubtful  cases.  Puncture  with  aspiration  is  also  an  important 
therapeutic  measure.  Negative  results  from  puncture  may  result 
from  a  thick  fibrin  deposit  and  thick  exudate,  from  failure  to  reach  an 
encapsulated  effusion,  as  in  interlobar  pleurisy,  and  from  the  membrane 
being  pushed  in  before  the  needle  so  that  the  fluid  is  not  reached.  In 
negative  or  dry  taps  after  withdrawal  of  the  needle,  examination  should 
be  made  to  see  that  no  plug  of  fibrin  or  cells  has  collected  in  the 
needle.  If  a  plug  is  obtained  it  should  be  emptied  upon  a  glass  slide  and 
examined  under  the  microscope.  Care  should  be  taken  that  no  car- 
bolic acid  or  alcohol  remain  in  the  syringe  or  needle,  which,  by  coagu- 
lating the  serum,  may  cause  some  dry  punctures.  The  puncture  should 
be  made  with  a  large  needle.  Positive  residts:  when  the  needle  is  intro- 
duced, resistance  may  be  felt,  which  is  due  to  a  callous  pleurisy  or  an 


550  DISEASES   OF   THE  RESPIRATORY   TRACT 

indurated  lung.  Often  after  introducing  the  needle,  the  point  may  be 
felt  to  be  freely  movable  as  in  a  cavity.  Sometimes  the  results  differ 
according  to  the  level  of  the  puncture;  serum  may  in  rare  cases  be 
obtained  from  a  high  puncture  and  a  cellular  deposit  from  a  lower 
one;  this  results  from  the  cells  settling  to  the  bottom.  Again,  punc- 
ture in  different  localities  may  show  serum  in  one,  and  hemorrhage  or 
pus  in  other  sacs.  Bacteriological  examinations  made  with  10-20  c.  c.  of 
the  serum  give  frequent  results,  and  60  to  90  per  cent,  of  the  serous 
cases  are  proven  tuberculous  on  inoculation.  The  special  chemical, 
bacteriological,  cellular  and  other  characteristics  will  be  discussed 
under  individual  forms. 

Sjnnptoms. — Symptoms  may  be  absent  (latent  pleurisy);  if  present 
they  are  not  distinctive  and  there  is  no  fixed  relation  between  the  symp- 
toms and  physical  findings,  (a)  The  temperature  is  variable.  Its  rise 
is  usually  gradual  and  a  rigor,  as  in  pneumonia,  rarely  occurs.  For 
weeks  there  may  be  no  temperature,  even  in  purulent  exudates, 
especially  in  marantic,  diabetic  and  ansemic  subjects  and  in  terminal 
infections.  When  present  it  may  be  continuous,  but  more  frequently 
subcontinuous  or  remittent.  The  average  elevation  is  101°  to  102°. 
Temperature  is  no  positive  index  as  to  the  character  of  the  fluid. 
Exacerbations  of  temperature  are  important  prognostically,  especially 
when  the  appetite  is  poor  and  no  change  occurs  in  the  physical 
findings.  Recovery  is  not  to  be  expected  until  the  temperature  has 
been  normal  for  some  time.  A  sudden  rise  and  fall,  like  a  crisis,  is 
exceptionally  observed  just  before  resorption,  (b)  Thepulseis  increased; 
it  is  sometimes  small  and  is  occasionally  of  the  paradoxical  type  or 
unequal  in  the  two  radial  vessels,  (c)  Dyspnoea  is  seldom  a  part  of 
pleurisy,  for  effusions  may  attain  enormous  proportions  without  respir- 
atory difficulty,  particularly  when  they  are  gradual  in  development. 
Dyspnoea  is  usually  referable  to  coincident  bronchitis,  pneumonia, 
lung  congestion  (Potain),  pericarditis,  arteriosclerosis,  nephritis  or  to 
bilateral  pleuritis.  (d)  Pain  is  usually  an  initial  symptom.  It  is  in  no 
way  proportional  to  the  physical  findings.  It  may  be  absent  when  aus- 
cultation shows  a  marked  rub.  Its  character  is  usually  dull,  tearing, 
stabbing  and  sometimes  very  severe;  it  may  be  crampy  or  colicky. 
The  pain  is  usually  pleural  (Cruivelhier)  but  may  be  neuralgic  or  due 
to  neurotic  or  muscular  causes.  Pain  is  present  in  the  diseased  side, 
well  doviai  over  the  ribs,  over  the  liver,  epigastrium  or  low  in  the  back, 
and  sometimes  may  radiate  to  the  sound  side  (Laennec  and  Gerhardt), 
into  the  arm  or  spine,  or  into  the  abdomen,  especially  in  children,  in 
which  case  it  may  simulate  appendicitis,  (e)  Coughing,  an  early  and 
frequent  symptom,  results  from  accidental  bronchitis  or  more  often 
from  pleural  irritation.  It  may  occur  after  change  of  posture  or  after 
tapping.  It  is  usually  unproductive.  (/)  Other  symptoms  are  anorexia, 
vomiting,  headache,  difficult  swallowing  due  to  involvement  of  the 
foramen  oesophageum  (Ferber)  and  marked  sweating  (the  sweats  of 
pleurisy  rank  next  in  importance  after  those  of  sepsis  and  rheumatism.) 
The  urine  is  scanty  but  increases  during  resorption,  when  peptonuria 


PLEURISY  551 

and  transient  albuminuria  are  often  found  (Courmont  and  Nicola). 
The  skin  may  be  pale  and  cachectic  from  purulent  accumulations,  red 
from  high  temperature,  cyanotic  from  poor  oxygenation  or  suddenly 
pallid  from  hemorrhage  into  the  pleura  when  there  is  also  a  sudden 
increase  of  fluid.  Emaciation  is  common  in  chronic  pleurisy  of  the 
tuberculous  or  purulent  type. 

Special  Forms. — I.  Character  of  the  Inflammation. — In  790  cases 
Eichhorst  found  serous  pleurisy  in  81  per  cent.,  fibrinous  in  12  per  cent., 
purulent  in  5  per  cent.,  ichorous  and  hemorrhagic,  each  in  1  per  cent. 

1.  Serous  pleurisy  is  the  prototype  of  pleural  inflammation.  As 
stated,  most  cases  are  tuberculous.  The  fluid  is  lemon-colored.  Its 
specific  gravity  ranges  between  1,015  to  1,023,  which  Mehu  con- 
siders characteristic  of  inflammation.  Albumin  is  present,  and 
amounts  to  3  to  7  per  cent.;  sugar  is  frequently  present;  glycogen, 
urea,  uric  acid,  and  bile  are  inconstant  constituents.  The  fluid  clots 
after  puncture.  All  varieties  of  pleurisy,  serous  and  otherwise,  con- 
tain white  blood  cells,  red  blood  cells  and  endothelial  cells;  the  cells 
may  show  some  fatty  degeneration. 

Cytodiagnosis.—M^uch.  emphasis  has  been  placed  on  the  character  of 
the  leukocytes  found  in  tuberculous  pleuritis;  Widal  and  Renault 
(1900)  especially  insisted — and  later  writers  confirmed  the  statement — 
that  lymphocytes  are  characteristic  of  primary  pleural  tuberculosis  and 
afford  early  diagnostic  data,  long  before  the  results  of  inoculation  are 
available;  the  fluid  must  be  examined  before  it  coagulates;  in  other 
pleurisies  the  polymorphonuclears  prevail;  in  other  words, the  "lymph- 
ocytic formula"  indicates  tuberculosis,  the  "polymorphonuclear 
formula"  indicates  pyogenic  infection  or  pleurisy  secondary  to  well- 
developed  phthisis,  and  the  "endothelial  formula"  indicates  irritation, 
transudation  or  malignancy.  The  tuberculous  nature  of  pleurisy  is 
established  by  inoculation  tests,  which  are  positive  in  50  to  66  and  94 
percent.,  by  apical  involvement  or  that  of  other  serous  membranes,  by 
the  finding  of  tuberculosis  in  cases  of  sudden  death  in  the  course  of 
pleurisy  (Lendouzy,  Dujardin,  Beaumetz,  Dieulafoy,  Kelsch,  Binet), 
and  by  the  fact  that  25  to  33  per  cent,  of  cases  later  become  obviously 
tuberculous.  It  is  well  to  suspect,  at  least,  the  tuberculous  nature  of 
all  so-called  rheumatic  pleurisies  (pleuritis  a  frigore),  though  cold  may 
sometimes  produce  pleurisy  in  both  man  and  beast.  The  sputum 
and  lungs  should  be  carefully  watched  in  such  cases  for  some  time 
(See  Prognosis).  For  the  tuberculin  test  and  Marmorek's  modifica- 
tion of  it  see  Diagnosis  of  Tuberculosis.  The  leukocytes  are 
not  increased  in  the  blood  count. 

2.  Fibrinous  pleurisy  usually  shows  some  fluid,  serous  or  purulent, 
if  systematic  punctures  are  made. 

3.  Purulent  or  suppurative  pleurisy  (empyema)  usually  begins  as  a 
serous  exudate  which  soon  becomes  opaque  and  purulent.  The  sterile 
tuberculous  form  has  been  discussed  (v.  s.  Bacteriology),  The  most 
frequent  types  are  (a)  the  streptococcic  form,  which  is  observed  chiefly 
in  adults,  in  which  the  fluid  is  thin  and  separates  on  standing  into  an 


5S2'  DISEASES   OF   THE  RESPIRATORY   TRACT 

upper  serous  layer  and  a  lower  denser  layer,  in  which  fibrin 
formation  is  slight;  and  (6)  the  pneumococcic  form,  which  is  more 
common  in  children,  in  which  the  fluid  is  more  homogeneous  and  viscid, 
like  the  "laudable"  pus  of  the  early  writers,  in  which  the  fibrin  and 
membrane  formation  is  abundant,  and  the  odor  peculiar;  it  is 
more  often  accompanied  by  endocarditis,  pericarditis  and  meningitis, 
and  is  more  often  febrile  and  more  susceptible  of  spontaneous  recovery 
than  the  streptococcic  form.  Over  80  per  cent,  of  juvenile  empyemas 
are  pneumococcic.  The  fact  that  the  pneumococcus  has  far  less  pyo- 
genic properties  in  the  lung  than  in  the  pleura,  has  excited  frequent 
comment.  Microscopically,  various  bacteria  are  present  (v.  Bacteri- 
ology), polymorphonuclear  and  often  fatty  white  cells,  and  sometimes 
cholestearin  and  Charcot-Leyden  crystals.  The  distention  of  the  chest 
may  be  enormous;  Krause  reported  22  pounds  of  pus  in  one  case. 
Leukocytosis  and  hectic  fever  are  mentioned  under  symptoms. 

Empyema  pulsans  (Walshe)  is  not  frequent;  95  per  cent,  of  all 
pulsating  effusions  are  purulent,  while  but  5  per  cent,  are  serothorax; 
93  per  cent,  are  left-sided.  A  pulsating  tumor  as  large  as  the  fist  may 
be  noticed,  which  usually,  but  not  always  decreases  during  inspiration, 
or  the  effusion  may  simply  pulsate  behind  the  ribs;  in  either  case  the 
pulsation  may  be  expansile.  The  pulsating  tumor  is  usually  between 
the  second  and  fourth  ribs,  anteriorly,  but  may  be  seen  lower  on  the 
side  or  even  well  below  in  the  back.  Pulsation  is  not,  as  some  consider 
it,  a  sign  of  necrosis  of  the  pleura;  it  has  been  attributed,  though  with- 
out satisfactory  reason,  to  such  causes  as  coincident  pneumothorax 
(Fereol),  atelectasis  of  the  lung  (Comby),  or  adhesions  and  paresis  of 
the  intercostal  muscles  (Traube,  Keppler).  The  most  apparent  con- 
ditions for  pulsation  in  an  empyema,  are  considerable  cardiac  energy, 
massive  exudation  and  paresis  of  the  intercostal  muscles.  Empyema 
pulsans  may  be  confused  with  aneurysm,  which  latter  is  much  slower 
in  its  evolution,  is  much  oftener  located  above  and  to  the  right,  and  has 
its  own  signs,  murmur,  and  thrill;  it  may  be  confused  with  pulsating 
abscess,  gangrene  or  tumor  of  the  lung  and  pulsating  pneumonia.  The 
pulsation  ceases  after  aspiration.  Aneurysm  may  co-exist  with  pleurisy. 
Expansile  pulsation  of  the  chest  wall  has  been  observed  twice  without 
exudation,  aneurysm  or  any  organic  change  (Lafleur  and  Edwards). 

Empyema  may  rupture  externally,  empyema  necessitatis.  Rupture 
is  usually  along  the  sternum  or  lower  ribs.  Gravitating  abscesses  may 
result,  as  pulsating  tumors  in  the  groin  and  loin,  which  may  be  con- 
fused with  aneurysm  or  spinal  caries.  Rupture  into  the  lung  may 
cause  suffocation  during  sleep;  according  to  Netter,  25  per  cent,  of 
post-pneumonic  empyemas  rupture  into  the  bronchi.  Fistulse,  hectic 
fever  and  amyloidosis  are  frequent  sequelfe.  Hippocrates  knew  of  the 
^' mouth  full"  expectoration  and  also  the  fact,  later  described  by 
Traube,  that  pus  may  penetrate  the  lung  like  a  sponge  without  per- 
foration or  pneumothorax.  Unverricht  thinks,  however,  that  perfora- 
tion into  the  lung  without  pneumothorax  is  probably  caused  by  a  small 
opening  which  allows  the  escape  of  fluid  into  the  lung  but  does  not  allow 


PLEURISY  553 

the  escape  of  air  into  the  pleura,  because  of  the  higher  tension  in  the 
exudate.  Halhn  (1905)  found  114  cases  of  bilateral  empyema  recorded 
in  the  hterature;  67  per  cent,  occurred  in  males  and  90  per  cent,  in 
young  persons  under  fifteen  years  old;  the  mortality  was  30  per  cent. 

4.  Putrid  pleurisy  is  usually  associated  with  gangrene  of  the  lung, 
pneumothorax,  oesophageal  carcinoma,  appendicular  abscess  and 
kindred  lesions.  The  fluid  is  extremely  foetid;  fat,  leucin,  tyrosin, 
cholestearin  and  sometimes  hsematoidin  crystals  are  found;  the  colon 
bacillus  and  other  gasogenic  bacteria  are  frequently  present. 

5.  Hemorrhagic  pleurisy  is  usually  serofibrinous,  and  the  exudate 
is  tinged  with  blood.  Five  to  six  thousand  red  cells  per  c.mm.  are  neces- 
sary to  produce  a  reddish  tinge.  Its  character  is  seldom  suspected  be- 
fore puncture,  (a)  Most  cases  are  tuberculous.  Dieulafoy  speaks  of  these 
cases  as  having  "  haemoptysis  into  their  pleurae. "  After  puncture,  more 
fluid  is  frequently  formed,  but  recovery  is  possible,  (b)  Some  cases  are 
cancerous;  Moutard-Martin  has  found  hemorrhagic  pleurisy  in  but  12 
per  cent,  of  pulmonopleural  cancer;  pain,  dyspnoea,  luxation  and 
rapid  pulse  are  frequent  symptoms;  the  fluid  is  dark  red,  contains 
little  fibrin,  and  is  usually  formed  rapidly;  a  case  of  Desnos  was 
punctured  30  times  in  six  months,  (c)  Some  cases  occur  in  liver  cirrho- 
sis (of  which  Laennec  published  the  first  case  in  1826),  in  nephritis,  and 
in  hemorrhagic  fevers  or  exanthemata;  profuse  hemorrhage  into  the 
pleura  was  called  pleural  hsematoma  by  Wintrich  and  pachypleuritis 
hemorrhagica  by  Chouppe  from  its  resemblance  to  hemorrhagic  pachy- 
meningitis. 

6.  Chyliform  pleurisy  occurs  chiefly  in  pleural  neoplasms  or  in 
tuberculosis;  the  fluid  is  milky,  contains  fatty  droplets,  fatty  cells  and 
albuminous  detritus  in  suspension;  cholestearin  and  lecithin  may  be 
found  (v.  i.  Chylothorax).    The  exudate  is  sometimes  colloid. 

In  multilocular  exudation,  in  which  one  pocket  contains  pus,  another 
serum,  a  third  hemorrhagic  fluid, etc.,  Galliard  speaks  of  polymorphous 
pleurisy. 

II.  Location  of  the  Exudate. — 1.  Pleuritis  diaphragmatica  pro- 
duces much  subjective  disturbance.  Radiating  pain  is  often  experi- 
enced, which  may  resemble  that  of  angina  pectoris  (Andral).  Pain 
and  tenderness  in  the  epigastrium  and  between  the  tenth  rib  and  the 
xiphoid,  is  pathognomonic,  according  to  Gueaneau  de  Mussy. 

Schmidt's  respiratory  abdominal  reflex,  an  inspiratory  spasm  of  the 
upper  part  of  the  rectus  muscle,  is  rather  indicative  of  phrenic  involve- 
ment. Dysphagia  from  inflammation  of  the  foramen  oesophageum 
may  result.  If  left-sided,  vomiting  and  singultus  may  be  noted,  and 
if  right-sided,  icterus  is  not  uncommon.  Cough  may  occur  spontan- 
eously or  on  pressure.  Pressure  in  the  lower  interspaces  near  the  spine 
elicits  tenderness;  tenderness  over  the  cervical  portion  of  the  phrenic 
nerve  may  be  noted,  together  with  reflected  pain  along  the  mammillary 
branches  of  the  cervical  nerves  to  the  shoulder.  Dyspnoea  is  usually 
great,  the  temperature  is  generally  normal,  the  lower  chest  moves  but 
little,  the  respiratory  murmur  is  very  weak,  and  friction  may  be  heard 


554  DISEASES   OF   THE  RESPIRATORY   TRACT 

over  the  liver  or  in  the  "half -moon"  space  of  Traube.  If  there  is  no 
exudate,  the  diaphragm  may  remain  high.  Fluid  may  accumulate 
between  the  diaphragm  and  lung  without  reaching  the  chest  wall,  and 
therefore  without  causing  dulness.  Fibrinous  is  more  common  than 
serous  effusion. 

2.  Interlobar  pleurisy  is  difficult  to  diagnosticate,  as  there  is  little 
surface  dulness.  The  amount  of  exudate  may  vary  from  a  few  c.  c.  up 
to  400.  It  occurs  most  frequently  after  lobar  pneumonia  or  in  tubercu- 
losis. Previous  pleurisy  may  favor  its  development  by  marked  adhe- 
sions obliterating  the  general  pleural  space.  As  Laennec  noted,  it  is 
almost  always  suppurative.  Its  early  diagnosis  is  uncertain,  for  the 
fever,  rales,  cough  and  dyspnoea  are  suggestive  of  a  lesion  of  the  lung; 
later  a  zonular  dulness  is  found  conforming  to  an  interlobar  fissure; 
the  dulness  is  bounded  above  and  below  by  a  normal  or  somewhat 
over-resonant  note.  The  heart  may  be  pushed  to  the  right,  when  there 
is  left-sided  localization,  but  the  liver  is  not  luxated  in  right-sided 
localization.  The  symptoms  may  resemble  those  of  lung  abscess  from 
which  during  life  differentiation  is  sometimes  impossible.  Interlobar 
pleuritis  may  be  shown  clearly  by  the  x-rays.  Large  effusions  may 
break  internally,  and  pus  is  then  suddenly  detected  in  the  sputum. 
Haemoptysis  may  occur.  Puncture  is  attended  with  some  danger,  as 
the  lung  may  be  infected  by  the  needle,  during  its  withdrawal. 
Spontaneous  recovery  is  infrequent.  The  outlines  of  the  lobes  are 
shown  in  Figs.  33,  34  and  35. 

3.  Mediastinal  pleurisy,  described  by  Laennec  and  Andral,  is  most 
often  tuberculous  or  pneumococcic,  and  more  frequently  purulent  than 
serous.  The  symptoms  of  lung  compression  are  less  distinctive  than 
are  those  of  compression  of  the  mediastinal  tissues.  There  may  be 
wheezing,  dyspnoea,  dysphagia,  fever,  intrathoracic  oppression  or 
pain,  a  pertussis-like  cough,  enlarged  thoracic  veins  from  azygos  com- 
pression, deviation  of  the  larynx  or  trachea,  and  dulness  between  the 
scapula  and  spine;  the  a;-rays  picture  may  be  suggestive.  The  sudden 
onset  and  febrile  course  differentiate  it  from  aneurysm,  tumor,  and 
adenopathies.    The  outlook  is  unfavorable,  without  operation. 

4.  Peri-  (para-)  pleuritis  (Wunderlich,  Bartels,  Billroth)  is  an 
inflammation  outside  of  the  parietal  pleura,  and  is  usually  purulent. 
Some  cases  follow  glanders,  but  most  of  them  are  due  to  actinomycosis. 
Fistulse  and  the  evacuation  of  the  characteristic  sulphur  granules  are 
common.  The  symptoms  are  more  local  and  irregular  than  those 
of  pleurisy;  fluctuation  is  more  frequent;  heart  dislocation  and  lung 
compression  are  rare;  the  respiratory  excursion  is  free,  and  on  heavy 
percussion  lung  resonance  may  be  elicited  beneath  the  dulness. 
Metastatic  inflammation,  perforation  and  burrowing  are  common. 

III.  Pleurisy  in  Children. — In  children  pleurisy  is  attended  by  more 
general  symptoms,  higher  temperature,  higher  pulse  and  more  rapid 
respiration  rate.  Bronchial  breathing  is  more  frequent,  there  is  less 
dulness,  less  luxation,  and  less  friction.  It  often  follows  pneumonia, 
where,  in  the  majority  of  cases,  the  empyema  is  more  benign.    Tuber- 


PLEURISY 


555 


culosis  is  less  frequently  causative  in  children  than  in  adults.  Accord- 
ing to  Lemoine,  metapneumonic  pleurisy  is  distinguished  from  the 
parapneunionic  type,  by  its  slower  course. 


Fig.  33. 


Fig.  34. 


Fig.  35. 


Cuts  from  Dieulafoy,  showing:     Fig.  33,  the  posterior  surface  of  the  lungs  and  their  interlobar 
fassures;  Fig.  34,  the  lateral  aspect  of  the  left  lung;  and  Fig.  35,  that  of  the  right  lung. 

^  Course. — The  course  of  uncompHcated  pleurisy  averages  three  to 
six  weeks;  acute  cases  last  two,  sub-acute  three  to  eight,  and  chronic 
eight  or  more  weeks.  No  general  rule  can  be  laid  down,  and  the  onset, 
whether  mild  or  stormy,  is  no  index  of  the  issue.  No  cycle  is  seen  in  any 
form  of  pleurisy.  Pleuritis  acutissima,  with  high  fever,  typhoid  sym- 
toms  and  early  death  is  fortunately  rare.  Friction  along  the  lowest 
limits  of  the  pleura  and  in  front  rarely  attends  great  effusions  and 
therefore  (after  the  exclusion  of  tuberculosis,  carcinoma  or  pyaemia) 


556  DISEASES   OF   THE  RESPIRATORY   TRACT 

the  prognosis  is  relatively  good.  In  the  average  case  dry  pleurisy  pre- 
cedes and  succeeds  exudation.  Recurrence  and  exacerbations  render 
the  prognosis  unfavorable.  Death  frequently  follows  from  exhaustion 
and  gradual  cardiac  failure.  Partial  absorption  with  persistence  of 
temperature  or  with  dyspnoea  is  indicative  of  tuberculous  pleurisy. 
Rheumatic  pleurisies  heal  more  readily  than  tuberculous.  The  author 
has  seen  recovery  of  secondary  carcinomatous  pleurisy. 

Issue. — 1.  Resorption. — Resorption  may  occur  and  even  purulent 
(pneumococcic)  pleurisy  may,  in  exceptional  cases,  be  absorbed  in  part 
without  operation  or  rupture,  leaving  inspissated  caseous  accumu- 
lations. Serous  pleurisies  may  be  absorbed  after  three  to  six  months, 
during  which  time  persistent  friction  is  common  over  the  lower  part  of 
the  chest. 

2.  Adhesions. — The  thickness  of  pleural  adhesions  is  more  important 
than  their  extent.  Universal  obliteration  of  the  pleura  by  thin  adhesions 
is  often  of  no  consequence.  Retraction  of  the  lung,  compensatory 
emphysema,  pain,  thoracic  oppression,  obliteration  of  the  comple- 
mentary pleural  space,  dulness,  decreased  vocal  fremitus  and  breathing, 
failure  of  Litten's  phenomenon,  decreased  respiratory  excursion  and 
stagnation  of  bronchial  secretion  may  occur  when  the  adhesions  are 
thick.  If  there  is  exudate  around  the  heart,  the  apex  beat  may  in- 
crease during  the  inspiration;  this  also  occurs  in  bronchial  catarrh 
(Eichhorst).  Failure  of  the  right  heart  and  stasis  may  ensue,  though 
most  extensive  adhesions  sometimes  exist  without  cardiac  embarrass- 
ment. Peritonitis,  mediastinitis,  induration  aiid  obliterative  peri- 
carditis may  complicate  the  case.  In  some  instances  the  pleura 
calcifies  or  ossifies,  leaving  a  deposit  measuring  three  cm.  or  more  in 
thickness. 

3.  Sudden  Death. — Fatal  syncope  may  result  after  exertion,  after 
coughing  or  after  the  efforts  of  urination  or  defecation.  Sudden  death 
may  occur  from  paralysis  of  the  left  ventricle,  from  cardiac  thrombosis, 
pulmonary  oedema,  bending  of  the  aorta,  compression  of  the  cava  at 
the  diaphragm,  and  rarely  from  pulmonary  embolism  caused  by  venous 
thrombosis.  Rupture  of  fluid  into  the  lung  or  bronchi,  which  may 
drown  the  patient  during  sleep,  and  death  from  hemorrhage  into  the 
effusion,  from  pneumothorax,  or  from  brain  embolism  are  even  rarer. 

4.  Retractio  Thoracis. ^Retraction  is  characterized  by  increased 
resistance,  decreased  fremitus,  decreased  circumference  of  the  affected 
side  and  often  by  bronchiectasis.  The  percussion  note  is  dull  and  the 
breathing  is  usually  decreased,  but  sometimes  is  bronchial.  The  causa- 
tive factors  are  atmospheric  pressure,  contraction  of  the  pleural  scars, 
extension  of  the  inflammation  into  the  lungs,  and  pleurogenous  (inter- 
stitial) pneumonia,  which  is  also  known  as  pleuritis  deformans,  and 
which  sometimes  divides  the  lung  up  into  lobes  or  islets.  Retraction 
is  generally  a  slow  process  but  the  writer  has  seen  marked  deformity 
develop  in  three  weeks. 

5.  Changes  in  Other  Organs. — When  retraction  occurs,  other  organs 
may  be  dislocated.     The  liver  may  be  higher  when  the  right  side  is 


PLEURISY  557 

involved,  and  in  left-sided  retraction  the  lung  may  shrink  away  from 
the  heart,  the  spleen  and  the  heart  may  lie  higher  and  Traube's  space 
may  be  increased.  Organs  displaced  by  exudate  may  in  rare  cases 
remain  luxated  after  the  exudate  is  absorbed.  Pleural  callosities  may 
produce  recurrent  laryngeal  paralysis  which  may  also  follow  the  pres- 
sure of  a  fluid  exudate  or  enlargement  of  the  glands.  Other  compli- 
cations are  acute  and  chronic  infiltration  in  the  lung;  inflammation  and 
degeneration  in  the  chest  muscles;  extension  to  other  serous  surfaces; 
septicopysemia;  stasis  in  the  liver,  stomach,  extremities,  etc.;  hem- 
orrhages into  the  skin;  chronic  nephritis;  amyloid  degeneration  and 
pulmonary,  glandular,  genito-urinary  or  miliary  tuberculosis.  Scag- 
liari,  quoted  by  Eichhorst,  reports  forty-seven  cases  of  paralysis  of  the 
arm,  probably  due  to  brachial  neuritis. 

Diagnosis. — The  physical  findings  only  are  final;  symptoms  are 
most  unreliable.  Diagnosis  of  the  malady  is  the  first  step,  and  the 
second  is  the  determination  of,  its  cause. 

Differentiation. — 1.  The  diagnosis  of  pleuritis  sicca  is  established 
only  by  feeling  or  hearing  the  friction  rub.  (a)  It  must  be  distinguished 
from  rales.  The  crepitant  rale  is  largely  inspiratory,  and  is  heard  as  a 
number  of  small  rales  at  the  end  of  inspiration.  Bronchitic  rales  or 
rhonchi  are  continuous.  Coughing  and  deep  inspiration  alter  or  re- 
move rales  but  the  pleural  rub  is  increased  by  pressure  and  deep  in- 
spiration, and  is  less  extensive.  It  may  disappear  after  a  number  of 
deep  inspirations,  because  this  makes  the  two  surfaces  temporarily 
smooth,  (b)  It  must  be  differentiated  from  sacculated  breathing  and 
from  the  physiological,  bilateral  cracking  in  the  chest  muscles  on  deep 
breathing,  (c)  Distinction  is  necessary  from  intercostal  neuralgia, 
which  is  intermittent,  occurs  in  typical  attacks  and  is  limited  to  the 
interspaces;  Valleix's  points  are  usually  but  not  always  present; they 
exist  at  the  angle  of  the  ribs,  in  the  middle  of  the  axilla  and  anteriorly, 
and  correspond  to  the  points  of  exit  of  the  posterior,  lateral  and  an- 
terior perforating  branches  of  the  intercostal  nerves.  Intercostal 
neuralgia  is  increased  less  on  deep  breathing  than  is  pleuritic  pain. 
(d)  Pleuritis  sicca  must  be  differentiated  from  caries  of  the  ribs,  in  which 
pain  is  localized  directly  over  one  rib  and  not  between  the  ribs,  (e) 
It  must  be  distinguished  from  rheumatism  of  the  thoracic  muscles. 
This  may  be  very  difficult,  for  both  affections  may  induce  pain  on 
breathing,  tenderness  and  disturbed  breathing;  there  may  be  a  history 
of  cold  or  exposure,  or  of  repeated  attacks.  There  is  usually  no  fever 
or  cough.  Faradization  decreases  the  pain,  and  movement  increases 
it  more  than  is  the  case  in  pleurisy.  (/)  The  rub  in  pericarditis  (q.  v.) 
is  more  distinctly  cardiac,  and  depends  upon  the  cardiac  movements. 
In  pleurisy  along  the  border  of  the  heart,  on  holding  the  breath  the 
pleuritic  rub.  is  heard  near  or  over  the  heart,  and  decreases  after 
five  or  six  heart  beats.  On  very  deep  inspiration  the  pleural  rub 
ceases  and  the  pericardial  rub  is  increased.  Dift'erentiation  is  most 
difficult  when  there  is  pleurisy  over  the  lingual  lobe  and  left  border 
of  the  heart,  though  pericarditis  most  commonly  produces  a  rub  at 


558  DISEASES   OF   THE   RESPIRATORY    TRACT 

the  base  of  the  heart,  especially  over  the   conus  pulmonalis  arter- 
iosus. 

2.  Pleuritis  humida  (pleuritis  effusiva)  must  be  distinguished  (a) 
from  infiltration  of  the  lung  substance  (see  table  in  Diagnosis 
OF  Pneumonia).  The  fremitus  is  decreased  in  pleurisy,  increased 
in  consolidation;  if  a  bronchial  plug  decreases  the  fremitus  in 
consolidation,  it  can  usually  be  dislodged  by  coughing.  In  con- 
solidation the  dulness  often  corresponds  to  one  lobe;  the  pleuritic 
dulness  increases  downward,  though  the  upper  border  of  dulness 
in  pneumonia  is  also  sometimes  irregular.  Only  when  pneumonia 
involves  an  entire  lung  is  there  any  luxation  of  the  heart,  or  in- 
volvement (in  left-sided  pneumonia)  of  Traube's  space.  In  con- 
solidation there  is  a  close  topographical  parallelism  between  the 
intensity  of  the  bronchial  breathing  and  the  degree  of  dulness.  When 
there  is  very  slight  bronchial  breathing,  pleurisy  is  probably  not  present 
although  it  may  exist  in  some  cases.  The  sputum,  the  length  of  the 
clinical  course,  dislocation  of  the  heart,  liver,  and  spleen,  the  infre- 
quency  of  chills,  the  ectasia  shown  by  the  cyrtometer  and  the  solution 
by  lysis,  are  indicative  of  pleurisy.  iEgophony  occurs  more  frequently 
in  pleurisy  along  the  upper  border  of  the  fluid,  but  is  usually  transitory. 
Exploratory  puncture  is  the  final  test  and  also  determines  the  nature  of 
the  fluid.  The  presence  of  blood,  carcinoma  cells,  streptococci,  pneu- 
mococci,  tubercle  bacilli,  etc.,  are  of  diagnostic  value,  (b)  It  must  be 
differentiated  from  tumors  of  the  lung,  which  produce  cachexia,  nar- 
rowing of  the  chest  behind  on  one  side,  and  the  characteristic  exudate; 
this  is  often  brown  (Fraenkel)  and  sometimes  chyliform,  and  contains 
fat  globules  (Quincke)  and  degenerated  large  cells  which  may  show 
mitoses ;  the  glands  above  the  clavicle  may  be  enlarged  as  well  as  those 
in  the  mediastinum,  which  produce  recurrent  laryngeal  paralysis. 
Tumor  particles  are  rarely  obtained  by  puncture  or  in  the  sputum,  and 
are  only  found  in  carcinoma,  for  sarcoma  rarely  ulcerates.  When 
tumors  of  the  lung  are  suspected,  a  trocar  rather  than  a  needle  should 
be  used.  There  is  more  resistance  to  puncture  in  tumor  than  in 
pleuritis.  Unverricht  observed  the  development  of  carcinoma  at  the 
seat  of  puncture.  In  tumors  there  is  less  displacement,  less  invasion  of 
Traube's  space  and  less  widening  of  the  chest  than  in  pleurisy,  and  the 
breathing  is  often  bronchial,  the  flatness  is  intense  and  the  fremitus  is 
increased,  (c)  Hydrothorax  (q.v.),  which  is  usually  described  as 
bilateral,  may  nevertheless  be  unilateral,  especially  in  disease  of  the 
liver,  kidneys  and  heart,  where  right-sided  hydrothorax  is  observed. 
Unilateral  hydrothorax  is  sometimes  caused  by  obliteration  of  the 
other  pleural  cavity  by  adhesions.  The  fluid  readily  shifts  its  level 
on  change  of  posture,  which  does  not  occur  in  pleurisy.  Salicylic  acid, 
iodine  and  potassium  iodide  are  said  to  pass  readily  into  transudates, 
and  but  slowly  and  in  small  amounts  into  exudates  (Rosenbach  and 
Pohl),  though  this  claim  has  been  disproven  by  Weintraub,  Leuch  and 
Feldmann.  (The  iodine  is  detected  by  adding  nitric  acid  and  shaking 
with  chloroform,  which  becomes  red  colored.)     In  hydrothorax,  the 


PLEURISY  559 

specific  gravity  is  below  1,014,  the  albumin  is  less  than  3  per  cent,  and 
the  sediment  shows  few  white  cells  and  some  endothelial  cells,  which 
are  not  pathognomonic  of  hydrothorax,  as  has  been  claimed.  Bac- 
teriologicaf  tests  are  negative,  (d)  The  presence  of  hcemothorax  is 
determined  only  by  puncture. 

3.  Circumscribed  pleurisy  in  some  instances  requires  differentiation, 
(a)  It  differs  from  'pericarditis  in  that  it  shows  a  more  irregular  outline, 
the  apex  beat  is  not  altered  and  there  is  no  cardiac  insufiiciency  or 
pericarditic  friction.  (6)  It  may  be  distinguished  from  lung  cavities, 
which  show  dulness  when  full  of  secretion  and  resonance  when  the 
secretion  is  voided;  the  fluid  obtained  by  puncture  (which  is  made 
under  a  wrong  diagnosis)  has  a  higher  specific  gravity  and  a  larger  per- 
centage of  fat  than  that  of  pleurisy,  (c)  Differentiation  from  splenic 
tumors  is  determined  by  respiratory  excursion  and  palpation  of  the 
lower  edge  of  the  spleen,  {d)  Liver  enlargements  rarely  occur  solely 
upward,  save  in  echinococcus  and  in  abscess  of  the  convexity;  these 
are  prone  to  occur  anteriorly,  and  pleurisy  is  more  frequently  detected 
posteriorly.  In  tumors  of  the  liver  there  is  usually  respiratory  excursion 
which  is  absent  in  pleurisy.  In  rare  instances  of  very  large  right-sided 
pleurisy  there  is  a  furrow  between  the  costal  arch  and  the  liver  down- 
ward (Stokes),  (e)  It  should  be  differentiated  from  subphrenic  abscess 
(v.  Localized  Peritonitis),  which  may  be  intraperitoneal  (as  from 
liver  abscess)  or  extraperitoneal  (e.  g.,  perinephritic).  The  liver  stands 
higher  in  the  chest  because  of  the  paretic  diaphragm.  There  may  be  a 
history  or  physical  signs  of  previous  disease  of  an  abdominal  organ. 
The  needle,  when  thrust  toward  the  abscess,  reaches  the  pus  only  when 
thrust  deep  in  the  lower  interspaces.  The  pus  has  frequently  a 
faecal  odor.  The  manometer  shows  increased  pressure  during  in- 
spiration and  decreased  pressure  during  expiration,  the  converse  of  the 
findings  in  pleural  effusion.  (/)  It  must  be  distinguished  from  abscess 
of  the  liver.  Pleurisy,  either  serous  or  suppurative,  may  complicate 
abscess  of  the  liver.  Differentiation  is  easy  when  abscess  of  the  con- 
vexity is  located  forward;  when  it  is  situated  posteriorly,  aspiration 
alone  will  distinguish  it;  the  pus  shows  liver  cells,  amoebae,  choles- 
tearin,  and  bile. 

Prognosis. — The  iminediate  mortality  is  about  5  per  cent.,  though  a 
prognosis  cannot  be  made  in  the  first  week  or  two.  (a)  The  etiology 
is  an  important  factor.  (6)  The  nature  of  the  -fluid  is  of  prognostic 
import.  Fibrinous  pleurisy  (except  when  it  occurs  at  the  apex  of  the 
lung)  is  the  most  favorable  type.  Prince  Ludwig  Ferdinand  considers 
the  prognosis  in  the  effusive  forms  as  follows:  (i)  most  favorable  in 
metapneumonic  serous  or  purulent  pleurisy;  (ii)  next  most  favorable 
in  serous  pleurisy  due  to  the  staphylococcus,  (iii)  less  favorable  in 
staphylococcus  empyema,  (iv)  least  favorable  in  tuberculous,  foetid 
or  putrid  forms.  The  prognosis  is  usually  poor  in  hemorrhagic,  chyli- 
form,  peracute  and  bilateral  (generally  hemorrhagic  or  purulent) 
effusions.  It  is  more  favorable  in  effusions  which  are  relatively  rich  in 
solid  constituents  (Mehu  and  Bernheim);    effusions  containing  little 


560  DISEASES  OF   THE  RESPIRATORY   TRACT 

solids  are  apt  to  recur.  When  the  freezing  point  of  the  exudate  is  found 
by  cryoscopy  to  be  below  that  of  the  blood,  spontaneous  absorption  is 
unlikely  to  occur  (Rothschild).  From  a  study  of  116  cases  of  effusive 
pleurisy,  Courmont  (1906)  concludes  that  the  mortality  is  25  per  cent, 
in  effusions  which  have  an  agglutinating  power  for  the  tubercle  bacil- 
lus, and  75  per  cent,  in  effusions  which  have  not.  Since  the  time  of 
Hippocrates,  the  belief  has  prevailed  that  right-sided  are  less  favorable 
than  left-sided  effusions,  (c)  The  persistence  of  temperature  and 
sweats,  anaemia,  recurrences,  and  external  rupture  are  unfavorable. 
(d)  Sudden  death  is  more  frequent  than  it  is  usually  believed  to  be. 
The  author  saw  three  cases  in  one  year. 

Opinions  vary  as  to  the  ultimate  prognosis.  Eighty-seven  per  cent, 
of  cases  become  tuberculous  in  one  to  two  years  (Fiedler);  33  per 
cent  die  in  five  years  (Bars);  66  per  cent,  are  curable  (Osier);  15  per 
cent,  die  of  tuberculosis,  90  per  cent,  are  in  good  health  after  two  to 
five  years  and  80  per  cent,  are  healthy  after  five  years  (Cabot). 

Treatment. — Etiological  treatment  can  be  applied  only  to  the  rheu- 
matic and  syphilitic  forms. 

Treatment  of  fibrinous  pleurisy,  which  remains  fibrinous,  or  in  the 
fibrinous  or  first  stage  of  exudative  pleurisy.  Pain  is  the  main  indi- 
cation; morphine  may  be  given  in  severe  cases,  especially  when 
coughing  is  severe;  the  ice-bag,  poultices,  blisters,  cups  and  hot  fomen- 
tations give  little  relief  when  the  pain  is  acute;  blisters  may  eventually 
cause  as  much  pain  and  discomfort  as  the  disease  itself;  the  pleura 
should  be  splinted  by  three  or  four  strips  of  adhesive  plaster  two  inches 
wide,  overlapping  the  median  line  before  and  behind  by  about  three 
inches,  and  running  around  the  chest  horizontally  and  obliquely;  these 
should  be  applied  with  considerable  pressure  during  expiration  that  the 
lung  in  its  lower  part  and  the  pleural  surfaces  may  be  well  immobilized; 
zinc  oxide  adhesive  plaster  is  least  irritating  to  the  skin.  Personal 
experience  with  the  early  use  of  salicylates,  which  are  advocated  by 
Aufrecht  and  Fiedler,  has  not  been  satisfactory.  The  patient  should 
be  kept  in  bed.  The  use  of  leeches  sometimes  relieves  the  pleural  con- 
gestion. 

In  serous  pleurisy,  the  patient  should  be  kept  in  bed,  and  the  cough 
and  fever  should  be  treated  expectantly.  Laxatives  are  given  "solely  to 
obviate  straining  at  stool,  which  may  induce  cardiac  weakness;  pur- 
gatives do  not  reduce  the  amount  of  the  effusion.  If  at  the  end  of  the 
second  week  the  effusion  shows  no  sign  of  being  absorbed,  various 
measures  are  indicated;  Schroth's  treatment  consists  in  limiting  the 
amount  of  fluid  ingested  to  about  one  quart  (1000  c.c.)  daily,  but  it  has 
few  adherents,  as  the  method  gives  no  results  and  exudation  is  an 
active,  not  a  passive  process;  tincture  of  iodine  may  be  applied,  but  is 
seldom  beneficial,  and  when  old  is  distinctly  a  local  irritant;  potassium 
iodide,  digitalis,  drastics  to  produce  copious  evacuations,  pilocarpine 
(combined  with  cognac  to  support  the  heart), cotton  jackets  and  sweats 
are  often  given.  Of  late  a  salt-free  diet  (dechlorination)  is  advised,  as 
in  nephritis  (q.  v.).    The  author  cannot  agree  that  any  of  these  meas- 


PLEURISY  561 

ures  are  helpful  and  believes  pilocarpine  is  always  dangerous.  Trans- 
udates may  be  removed  in  this  way  but  not  exudates. 

Aspiration, — Trousseau's  indications  were  (a)  the  vital  indication 
(when  life  is  threatened,  because  of  large  exudates) ;  (6)  moderate 
effusions  with  slow  resorption,  and  (c)  persistent  or  residual  exudates. 
The  author  believes  that  early  'puncture  (thoracocentesis)  and  aspira- 
tion are  indicated  in  every  case,  where  two  quarts  or  more  (2,000  or 
2,500  c.c.)  of  fluid  are  effused,  whether  the  temperature  is  still  high  or 
not,  and  whether  pressure  symptoms  or  dyspnoea  are  present  or  not. 
This  amount  of  effusion  causes  dislocation  of  the  heart,  liver  or  spleen, 
compression  of  the  lung,  or  ectasia,  as  shown  by  the  cyrtometer;  intra- 
thoracic pressure  may  cause  sudden  death,  sometimes  without  any 
warning  symptoms  of  cardiac  insufficiency.  Early  puncture  does  not 
irritate  the  pleura  nor  favor  recurrence  or  suppuration.  Early  and 
repeated  puncture  obviates  compression  of  the  lung  and  atelectasis  as 
well  as  compression  and  torsion  of  the  large  arteries.  Aspiration  was 
first  advocated  by  Wyman  and  Bowditch  of  Boston  more  than  50 
years  ago. 

Method  of  Aspiration. — After  the  usual  surgical  antisepsis,  a  small 
trocar  or  large  aspirating  needle  is  introduced,  which  has  an  elbow 
connecting  with  a  rubber  tube,  to  siphon  the  fluid  to  a  vessel  below,  or 
connecting  with  a  bottle  which  can  be  exhausted  by  a  pump.  There  is 
no  absolute  rule  as  to  the  site  of  puncture.  This  must  be  governed 
solely  by  the  physical  signs;  for  instance,  adhesions  which  hold  the 
lung  to  the  surface  vitiate  any  set  law;  fluid  is  usually  obtained  most 
advantageously  between  the  scapular  and  post-axillary  lines  and  low 
down  in  the  chest.  The  trocar  should  be  introduced  suddenly,  to 
avoid  bending  of  the  spine  which  narrows  the  interspaces;  it  should  be 
introduced  perpendicularly  to  the  chest  wall  and  not  obliquely,  in  order 
to  avoid  injuring  the  intercostal  artery,  as  a  result  of  which  the  author 
once  saw  fatal  hsematoma  and  haemothorax.  Whisky  and  hypo- 
dermics should  be  at  hand,  because  of  the  possibility  of  syncope.  The 
use  of  the  pump  is  necessary  in  but  10  per  cent,  of  cases,  for  the  fluid 
can  usually  be  siphoned  readily;  a  tube  is  attached  to  the  needle  or 
trocar,  filled  with  boric  acid  solution,  clamped  with  an  artery 
forceps  and  undamped,  when  it  is  placed  in  a  basin  containing  the 
same  solution  and  at  a  somewhat  lower  level  than  the  seat  of 
puncture.  The  fluid,  if  pumped,  should  be  withdrawn  gradually; 
caution  is  necessary  lest  air  be  pumped  the  wrong  way,  i.  e.,  into  the 
pleura.  The  amount  removed  need  not  be  great,  as  moderate  relief  of 
intrapleural  tension  often  promotes  absorption.  The  amount  to  be 
withdrawn  is  estimated  somewhat  arbitrarily  at  one  quart  (1,000  c.  c, 
Naunyn  and  Dieulafoy), or  three  pints  (1,500  or  1,600  c.c,  Fraenkel  and 
Bowditch).  Complete  or  nearly  complete  evacuation  may  cause  the 
accidents  enumerated  below  and  is  thought  by  Litten  to  induce  miliary 
tuberculosis.  Aspiration  should  be  discontinued  when  the  exudate 
becomes  bloody  (from  lung  injury),  when  friction  develops,  when  pain  is 
felt  or  when  coughing  (from  congestion  of  the  relaxed  lung)  begins. 

36 


562  DISEASES   OF   THE  RESPIRATORY   TRACT 

Repetition  of  pu7icture  depend?,  on  the  results  attained;  it  maybe  repeated 
every  two  or  three  days.  Favorable  results  are  slowing  and  strengthen- 
ing of  the  pulse,  relief  of  oppression,  increased  diuresis,  and  improved 
appetite;  but  relief  of  pressure  on  the  lung  and  absorption  of  the 
exudate  are  of  the  greatest  importance.  Unfavorable  results  are  (a) 
syncope  due  to  cerebral  aneemia  which  in  turn  results  from  restoration 
of  circulation  in  the  collapsed  lung,  which  contained  little  blood  before 
it  was  relieved  by  the  puncture,  a  relatively  uncommon  occurrence; 
(6)  pulmonary  oedema,  the  albuminous  expectoration  described  by 
Terillon,  Besnier,  Jolmson,  Duffin,  and  Scriba,  which  is  due  to  the 
sudden  withdrawal  of  too  much  fluid  (two  to  five  liters)  at  one 
tapping;  it  should  take  a  half -hour  to  evacuate  one  and  a  half  quarts 
or  1 ,500  c.  c.  (Fraentzel) ;  oedema  pulmonum  is  treated  most  efiicaciously 
by  hvpodermics  of  morphine,  gr.  ^  and  some  clinicians  advise  giving 
it  before  aspiration;  (c)  sudden  death  from  pulmonary  embolism  or 
cerebral  embolism;  the  latter  results  from  discharge  of  clots  from 
vessels  in  the  relaxing  lung,  and  causes  the  so-called  pleuritic  hemi- 
plegia; some  of  these  cases  are  hysterical  hemiplegia ;  {d)  injury  to  the 
heart,  liver  or  spleen;  (e)  pneumothorax  or  subcutaneous  emphysema 
may  occur  though  the  author  has  never  seen  either  of  them.  (/)  The 
author  once  witnessed  an  extensive  hsemothorax  and  subcutaneous 
hsematoma  in  a  pleural  puncture,  in  which  the  trocar  was  impatiently 
thrust  in  and  out  during  an  unsuccessful  thoracocentesis,  {g)  Fi- 
brinous bronchitis  has  apparently  followed  paracentesis.  When  repeated 
punctures  fail  to  produce  the  desired  results,  the  advisability  of 
operation  (as  in  empyema)  should  be  considered. 

Empyema  in  all  cases  necessitates  operation  (practised  by  Euryphon 
and  after  him  by  Hippocrates) .  Some  cases  may  recover  spontaneously, 
but  this  cannot'be  depended  upon.  A  day  before  operation,  aspiration 
is  indicated  when  the  fluid  is  under  high  tension,  thereby  relieving  the 
heart.  Some  surgeons  advocate  treating  tuberculous  empyema  without 
operation,  as  Volkmann  treated  other  cold  abscesses;  Kronlein  ob- 
served, after  operation  on  these  cases,  recovery  in  36  per  cent.,  improve- 
ment in  28  per  cent,  and  death  in  36  per  cent.  Results  depend  on  the 
etiology  and  bacteriology.  Though  the  mortality  in  Velpeau's  cases 
was  100  per  cent,  and  that  of  Dupuytren  was  92  per  cent.,  at  the 
present  time  it  is  but  little  over  1  per  cent. 

Putrid  pleurisy  should  be  treated  like  empyema. 
Hemorrhagic  effusions  may  necessitate  injections  of  gelatin   sub- 
cutaneously;    the  amount  aspirated  should  not  exceed  one  pint  (500 
c.  c.)  and  aspiration  should  be  repeated  as  seldom  as  possible. 

After-treatment  is  directed  toward  prevention  of  thoracic  retraction, 
to  which  end  gymnastics  and  deep  breathing  are  essential.  A  patient 
having  suffered  from  a  "primary"  effusive  pleurisy  should  be  treated 
as  one  with  latent  tuberculosis. 


PNEUMOTHORAX  563 


(B).   PNEUMOTHORAX. 

Definition. — Pneumothorax  is  an  accumulation  of  gas  or  air  in 
the  pleural  sac.  It  was  named  by  Itard  of  Paris  (1803)  and  was 
described  fully  by  Laennec  (who  made  the  first  diagnosis)  and  Skoda. 
As  it  excites  pleurisy  in  more  than  half  the  cases,  the  following  varie- 
ties are  distinguished:  yyo-,  sero-,  and  hoBmopneumothorax.  There  is 
no  name  for  putrid  pneumothorax. 

Etiology. — Diseases  of  the  lungs  and  pleura  cause  about  95  per 
cent,  of  all  cases.  In  Biach's  collection  of  918  cases  in  Vienna,  pul- 
monary tuberculosis  was  causal  in  77  per  cent.,  gangrene  in  7  per  cent., 
empyema  5  per  cent.,  trauma  3  per  cent.,  bronchiectasis  and  abscess 
each  1  per  cent.,  the  etiology  was  unknown  in  2  per  cent,  and  the 
remaining  4  per  cent,  was  due  to  emphysema,  infarct,  thoracocentesis, 
echinococcus  and  contiguous  disease  perforating  into  the  pleura,  as 
gastric  or  oesophageal  ulceration,  or  caries  of  the  sternum.  By  other 
writers  (a)  tuberculosis  is  thought  to  cause  80  per  cent,  or  even  over 
90  per  cent.;  Mosheim  found  that  84  per  cent,  were  tuberculous,  of 
which  6  per  cent,  were  curable;  acute  forms  are  more  important 
than  chronic  tuberculosis  in  which  there  are  protecting  pleural  adhe- 
sions; pneumothorax  develops  in  two  (Drasche)  to  six  (Eichhorst) 
per  cent,  of  tuberculous  cases,  (b)  Ulcerative  lesions  of  the  lung,  as 
gangrene,  abscess,  bronchiectasis,  tumors,  parasites  and  infective 
infarcts  may  naturally  erode  the  pleura  and  admit  air.  (c)  Trauma, 
rupturing  of  the  lung  directly  or  by  contra-coup,  thoracocentesis  or 
stab  wounds,  occur  far  less  frequently  than  one  would  expect,  (d) 
Empyema;  it  may  rupture  into  the  lung  without  allowing  ingress  of 
air  from  the  opposite  direction,  (e)  Rupture  of  a  healthy  lung  after 
coughing  or  muscular  straining  is  a  possible  though  very  exceptional 
cause.     Pneumothorax  has  followed  violent  coughing  in  pertussis. 

Perforative  lesions  in  the  mediastinum,  oesophagus,  peritoneum, 
stomach  or  colon  and  subphrenic  abscess  are  uncommon  {v.  s.)  causes. 

Pneumothorax  may  occur  spontaneously.  It  is  always  possible, 
however,  that  a  point  of  rupture  in  the  lung  is  overlooked  or  has 
healed  over,  and  the  fact  remains  that  air  enters  the  pleura  chiefly 
from  the  lung  or  from  a  gas-containing  organ.  The  view  held  by 
Oppolzer,  Biermer  and  others  that  putrefaction  may  occasionally 
develop  primarily  (without  rupture)  has  received  confirmation  by 
discovery  of  the  Bacillus  aerogenes  capsulatu^  and  other  gasogenic 
organisms  (Lewy,  Welch  and  Fraenkel). 

Pneumothorax  occurs  largely  in  adults  and  four  to  seven  times  as 
frequently  in  males  as  in  females.  Eichhorst  and  Drasche  find  it 
more  often  on  the  right  side,  Powell  on  the  left,  and  West  on  either 
side  with  equal  frequency. 

Pathology. — When  the  chest  is  opened,  air  or  gas  escapes  with  a 
force  sufficient  to  blow  out  a  candle.  The  volume  of  air  may  exceed 
2,000  c.c,  and  its  tension,  which  was  studied  first  by  Wintrich  and 


564  DISEASES   OF   THE  RESPIRATORY  TRACT 

then  bv  Weil,  compresses  the  lung  and  causes  it  to  collapse,  dislocates 
the  heart  and  mediastinum  and  depresses  the  diaphragm  and  sub- 
phrenic organs.  The  gas  may  be  odorless  or  foetid.  The  pathological 
and  clinical  findings  varv  (a)  as  the  gas  is  encapsulated  or  occupies 
the  entire  pleural  ca'V'ity;  (6)  as  the  air  is  aseptic  (producing  a  pure 
pneumothorax,  or  one  "v^-ith  slight  exudation)  oris  infected  by  tubercle 
bacilli,  pyogenic  organisms,  colon  bacillus,  or  monads  according  to 
the  primal  disease;  microorganisms  excite  serous,  purulent  or  putrid 
pleurisy;  (c)  as  the  air-containing  cavity  is  "closed,"  "open"  (into 
a  bronchus,  or  sometimes  also  open  externally)  or  possesses  a  valve, 
thus  alloT\'ing  passage  of  air  in  one  but  not  in  the  opposite  direction. 
These  points  will  be  considered  below. 

Symptoms. — The  onset  is  usually  sudden,  for  rupture  may  occur 
spontaneously  or  may  follow  coughing  or  muscular  exertion;  it  is 
characterized  by  sudden  pain  in  the  side,  cyanosis,  dyspnoea  and  col- 
lapse,  which  are  due  to  reflex  action  on  the  vagus ;  there  may  be  sudden 
evacuation  of  pus  from  the  breaking  into  the  lung  of  an  empyema; 
an  urticaria  (Gerhardt,  Senator)  occasionally  develops,  just  as  a  toxic 
rash  may  follow  echinococcus  rupture;  decreased  diuresis,  albumin- 
uria, stasis  and  subcutaneous  emphysema  are  sometimes  observed. 
The  onset  may  be  insidious  for  pneumothorax  sometimes  constitutes 
an  unexpected  post  mortem  finding.  In  other  instances  the  pre%'ious 
history  or  the  course  may  justify  a  presumptive  diagnosis,  as  in  a 
case  clearly  tuberculous;  and  in  still  other  cases,  a  latent  lung  lesion 
(a  small  caseous  focus)  may  burst  and  thus  produce  its  first  symptom. 

Physical  Findings. — 1.  Inspection. — (a)  The  affected  side  w  dis- 
tended 2  to  4  inches  (5  to  10  cm.)  and  immobile,  and  contrasts  sharply 
with  the  widely-moving  sound  lung,  (b)  The  interspaces  are  obliter- 
ated, (c)  The  heart  and  liver  or  spleen  are  dislocated,  (d)  There  are 
dyspnoea  and  cyanosis,  (e)  The  attitude  is  characteristic;  the  patient 
most  often  hes  on  the  affected  side  to  afford  ample  play  to  the  sound 
lung;  sometimes  there  is  orthopnoea  and  if  the  point  of  rupture  opens 
into  the  lung  or  bronchus,  a  pecuHar  decubitus  may  be  assumed,  in 
order  to  drain  the  pleura.  (f)  The  x-rays  show  that  the  hmg  w 
flattened  near  the  spine,  that  the  diaphragm  is  depressed  and  motion- 
less, and  they  also  show  the  shadow  of  the  effusion. 

2.  Palpation. — (a)  Vocal  fremitus  is  absent,  unless  adhesions  hold 
part  of  the  lung  to  the  chest  wall.  (6)  The  chest  wall  feels  resistant 
and  (c)  sometimes  splashing,  fluctuation  or  a  "pillow  sensation"  is 
noted,  (d)  The  dislocated  apex  beat  and  the  edge  of  the  liver  or  spleen 
are  felt. 

3.  Percussion. — Somewhat  different  results  are  obtained  by  per- 
cussion according  to  the  tension  of  the  gas  and  of  the  chest  walls. 
(a)  In  open  pneumothorax  the  note  is  full  and  tympanitic,  and  even 
metalhc  when  percussion  is  made  on  a  solid  object,  as  a  coin;  this 
metallic  reverberation  was  called  bruit  d'arain  by  Trousseau;  cracked- 
pot  resonance  and  AYintrich's  change  of  note  may  be  elicited  when 
the  mouth  is  opened,     (b)  In  closed  pneumothorax  the  note  is  full  and 


PNEUMOTHORAX 


565 


loud;  it  is  tympanitic  when  there  is  moderate  pressure  and  the  inter- 
costal muscles  are  relaxed;  again  the  note  may  be  dull  (Skoda)  if  the 
tension  is  great,  or  if  the  chest  muscles  are  spasmodically  contracted, 
as  in  sudden  pneumothorax  (vagus  reflex  action),  (c)  Flatness  over 
the  lower  thorax  usually  results  from  pleural  effusion.  (This  dulness 
may  occur  without  coincident  pleurisy,  and,  conversely,  the  author 
has  seen  tympany  prevail  over  the  entire  side,  even  when  there  was 
much  coincident  pleural  effusion.)  {d)  On  change  of  posture,  a 
changing  level  of  the  fluid  is  readily  elicited,  the  gas  being  found  above 
and  the  fluid  below,  for  the  gas  acts  in  this  respect  as  a  spirit-level; 

Fig.  36. 


k 


n_ 


I.  Left-sided  effusive  pleurisy,  showing  relative  heart  dulness  (A),  effusion  (B),  liver  flatness 
(C),  and  fluid  impinging  on  Traube's  half-moon  space,  of  which  but  a  small  part  remains 
resonant  (D). 

In  larger  effusions  reaching,  e.  g.,  up  to  the  dotted  black  line,  the  relative  heart  dulness  may  be 
pushed  over  to  the  dotted  line  (over  C). 

II.  Left-sided  pneumothorax  marked  by  tympany  (T.  T.),  pushing  over  the  mediastinum  and 
also  the  heart  to  the  right,  and  pushing  down  the  left  lobe  of  the  liver  and  the  spleen. 

this  change  is  far  more  important  than  in  simple  pleurisy,  as  there  are 
no  adhesions,  (e)  The  pitch  over  the  gas-distended  part  changes 
with  change  of  posture  (Biermer's  change  of  note).  It  becomes  deeper 
as  the  patient  sits  up,  because  the  vertical  dimension  of  the  chest  is 
thus  increased  by  the  pushing  down  of  the  diaphragm.  (/)  The  heart 
dulness  is  replaced  by  resonance  in  left-sided  pneumothorax,  and  is 
found  to  the  right  of  the  sternum;  in  right-sided  pneumothorax  it  is 
pushed  to  the  left  axilla,  (g)  The  dulness  of  the  liver  or  spleen  is 
pushed  well  doivnward. 

4.  Auscultation. — (a)  The  breath  sounds  are  usually  absent  in  the 
closed  variety  of  pneumothorax,  and  this,  with  ectasia  and  hyperreso- 
nance,  is  most  characteristic.  In  the  open  and  sometimes  in  the  closed 
form,  the  breath  sounds  are  bronchial,  amphoric  or  metallic,  the 
voice  sounds,  especially  under  the  clavicle,  are  metallic  (metallic 
bronchophony),  and  coincident  rales  in  the  bronchi  are  also  metallic. 


566  DISEASES   OF   THE  RESPIRATORY   TRACT 

(b)  Air  passing  through  the  point  of  rupture  may  produce  curious 
snapping  or  whistling  sounds;  the  point  of  rupture  is  oftenest  at  the 
lower  anterior  part  of  an  upper  lobe,  i.  e.,  between  the  second  and 
fourth  interspaces,  and  between  the  mammary  and  axillary  lines,  (c) 
The  gutta  cadens  (the  metallic  "falling  drop")  ma.y  be  due  to  dripping 
of  fluid  from  fibrin  shreds  as  the  patient's  posture  is  changed,  or  to 
rales,  (d)  The  Hippocratic  splashing  (succiissio  Hippocratis)  is 
elicited  by  placing  the  ear  to  the  chest  and  sharply  shaking  the  patient ; 
it  is  sometimes  heard  at  some  distance  from  the  patient,  and  in  three 
cases  patients  have  spontaneously  called  the  author's  attention  to  a 
"splashing  in  the  chest";  it  is  oftenest  heard  in  the  side  or  in  the 
interscapular  area,  (e)  The  heart  tones  may  be  metallic,  and  the  heart's 
action  may  even  cause  splashing  sounds. 

Diagnosis. — ^The  ectasia,  the  resonant  note,  suppressed  or  amphoric 
breathing,  cardiac  and  other  luxations  and  succussion  are  most  char- 
acteristic. 

Type. — Contrary  to  the  usual  statements,  Weil  recently  proved  that 
dislocation  occurs  in  all  types,  though  it  varies  in  degree,  (a)  In  the 
open  form  Wintrich's  change  of  note  on  opening  the  mouth,  metallic 
sounds,  the  fistula  murmur,  periodic  expectoration  of  large  amounts 
of  pus,  moderate  cardiac  and  other  dislocations  and  no  manometric 
increase  of  the  tension  in  the  pleura  are  distinctive.  Colored  fluid 
(methyl  blue),  if  injected  into  the  pleura,  is  coughed  up.  (b)  The 
closed  type  is  distinguished  by  increased  manometric  tension,  absence 
of  breath  sounds,  marked  ectasia,  change  of  note  on  sitting  but  not  on 
opening  the  mouth,  and  marked  luxations,  (c)  In  the  valvular  form 
air  may  enter  the  pleural  cavity  but  cannot  escape  back  and  therefore 
pus  cannot  be  voided.  Some  of  the  auscultatory  findings  of  the  open 
type  are  noted.  The  manometer  shows  increased  pressure.  The 
fistula  may  become  permanently  closed  by  organic  change  (organic 
type),  so  that  aspiration  of  the  air  is  not  followed  by  further  accumu- 
lation; or  the  fistula  may  be  only  mechanically  closed,  and  air  may 
accumulate  again  after  its  aspiration. 

DifEerentiation. — (a)  Cavities  may  be  simulated  by  circumscribed 
pneumothorax,  but  in  cavities  the  interspaces  are  sunken,  the  fremitus 
is  increased  (when  they  are  empty),  luxation  is  absent  and  the  Hippo- 
cratic succussion  and  coin  sound  are  extremely  rare.  (6)  Pleurisy 
can  be  distinguished  on  careful  examination,  (c)  Meteorism  is  at  once 
excluded  by  filling  the  stomach  or  colon  with  water,  (d)  Diaphrag- 
matic hernia  is  very  frequently  confused  with  pneumothorax;  out  of 
433  cases  collected  by  Grosser  only  12  were  recognized.  The  rc-rays 
will  determine  the  condition,  as  in  Dehio's  recent  case.  Respiratory 
excursion  is  present  and  the  tympany  and  metallic  sounds  are  usually 
accompanied  by  such  symptoms  of  marked  incarceration  as  vomiting, 
colic,  obstipation  and  indicanuria.  The  intestines  push  the  heart  to 
the  right.  Ninety  per  cent,  of  cases  of  diaphragmatic  hernia  are  left- 
sided,  (e)  Pyopneumothorax  subphrenicus  (q.  v.  under  Peritonitis, 
Localized    Forms),  especially   described  by   Leyden,  results   from 


HYDROTHORAX  567 

abdominal  lesions,  such  as  cancer,  ulcer,  appendicitis,  disease  of  the 
gall-tracts,  trauma,  and  foreign  bodies  whose  history  is  at  least  suggest- 
ive. Thoracic  symptoms,  as  cough,  sputum,  and  dyspnoea,  are  not 
conspicuous,-'  at  least  early  in  the  process,  and  the  lungs  may  show 
perfect  excursion,  though  the  diaphragm  is  sometimes  paretic.  The 
manometer  shows  that  the  pressure  is  increased  during  inspiration  and 
decreased  during  expiration,  the  converse  of  which  is  true  in  pneumo- 
thorax. The  x-rays  show  that  the  diaphragm  is  above  the  fluid,  while 
in  pneumothorax  it  is  below  the  fluid. 

Prognosis. — The  prognosis  varies  with  the  cause,  the  condition  of 
the  lungs,  and  the  character  of  the  fluid,  but  it  is  always  serious.  Cases 
following  exertion  in  a  healthy  lung,  trauma  or  infarct  (when  operated) 
are  relatively  favorable.  The  closed  and  open  are  more  auspicious 
than  the  valvular  type.  In  tuberculosis,  pneumothorax  seems  to  arrest 
the  tuberculous  focus  if  it  is  small  (Herard,  Toussant,  Fraentzel)  and 
if  no  mixed  infection  occurs,  but  even  in  these  cases  complete  ultimate 
recovery  is  infrequent.  Eichhorst  observed  one  case  which  lasted  for 
five  years.  Gabb  records  a  case  which  recovered  and  relapsed  four 
times,  the  attacks  being  two  to  four  years  apart.  According  to  Weil 
25  per  cent,  die  within  a  week  and  50  per  cent,  within  a  month;  West 
observed  a  mortality  of  70  per  cent.,  of  which  three-quarters  died 
within  two  weeks,  nine-tenths  in  less  than  a  month  and  one  case  in 
twenty  minutes. 

Treatment. — ^The  results  of  treatment  are  disappointing,  (a)  Nar- 
cotics and  stimulants  are  imperative  at  the  time  of  the  rupture,  for 
collapse,  dyspnoea,  and  cyanosis.  (6)  Aspiration  is  of  most  value  in 
the  serous  forms ;  however,  it  has  been  said  that  we  may  tap  or  oper- 
ate but  never  aspirate,  (c)  The  radical  operation  is  indicated  in 
putrid  or  purulent  pneumothorax.  Though  some  physicians  prefer 
not  to  interfere  in  the  tuberculous  cases  on  the  ground  that  the  com- 
pression exerted  upon  the  lung  by  the  pneumothorax  is  semicurative, 
others  advise  operation ;  Leyden  reported  66  per  cent,  and  Richardiere 
50  per  cent,  of  recoveries. 


(C).   HYDROTHORAX. 

Definition. — Hydrothorax  is  a  transudation  of  serous  fluid  into  the 
pleural  sac. 

Etiology. — (a)  Stasis,  from  cardiac,  pulmonary  or  vascular  factors 
may  be  the  cause.  In  failure  of  the  right  heart  the  superior  cava  is 
imperfectly  drained,  which  congests  the  vena  azygos  and  hemiazygos, 
and  this  leads  in  turn  to  pleural  transudation.  It  may  occur  alone  or 
precede  dropsy  but  is  oftener  a  part  of  general  dropsy.  Local  venous 
obstruction,  by  pressure  or  thrombosis,  may  induce  hydrothorax,  as 
from  mediastinal  tumor  or  aneurysm,  (b)  Blood  changes,  resulting 
from  multitudinous  anaemic,  marantic  or  cachectic  states,  may  be 
causative;  nephritis,  cancer  and  blood  diseases  may  be  cited  as  specific 


568  DISEASES   OF   THE  RESPIRATORY   TRACT 

types.     Under  this  caption  may  be  brought  diseases — often  identical 
with  the  above — -which  aker  the  ivalls  of  the  vessels. 

Symptoms  and  Diagnosis. — 1.  The  symptoms  of  hydrothorax  do 
not  include  pain  or  fever.  The  disease  accentuates,  sometimes  con- 
siderably, the  dyspnoea  attending  the  causal  stasis  or  cachexia.  The 
amount  of  fluid  varies  from  ounces  to  quarts  (or  even  to  two  gallons). 

2.  The  physical  signs  are  essentially  those  of  moderate  effusive 
pleurisy,  except  that  the  rub  is  absent;  the  fluid  shifts  with  much 
greater  facility  on  change  of  posture  and  produces  a  moderate  com- 
pression of  the  lungs,  and  luxation  of  the  heart,  liver  and  spleen.  The 
transudate  is  usually  bilateral  (in  83  per  cent.,  according  to  J.  Dutton 
Steele),  but  is  sometimes  unilateral  and  often  right-sided,  in  cardiac, 
renal  and  hepatic  disease,  or  when  previous  adhesions  obliterate  the 
opposite  pleura. 

3.  The  fluid  is  clear,  slightly  green,  possibly  moderately  blood-tinged 
if  It  develops  during  the  death  agony,  and  shows  a  specific  gravity  of 
about  1,010  to  1,012;  it  contains  but  little  fibrin  and  at  the  most 
develops  only  light  delicate  flocculi.  The  potassium  iodide  test  is 
unreliable  (v.  Diagnosis  of  Pleurisy),  and  centrifuging  brings  down 
only  a  few  leukocytes,  endothelial  cells  and  red  disks,  but  no  bacteria. 
Right  hydrothorax  may  prove  very  obstinate,  probably  because  a  low 
grade  of  inflammation  eventually  supervenes. 

The  prognosis  and  treatment  are  those  of  the  cause:  aspiration  often 
prolongs  life. 

(D).  H.ffiMOTHORAX. 

Blood  effusion  into  the  pleura  is  a  rare  malady.  It  may  be  caused 
by  trauma,  scurvy  or  allied  blood  diseases,  by  rupture  of  aneurysm 
of  the  aorta,  by  ulceration  of  the  pulmonary  or  pleural  veins  and  by 
various  necrosing  lung  diseases.  It  may  occur  with  pleurisy  and  pneu- 
mothorax and  has  resulted  from  thoracocentesis.  Its  symptoms  are 
essentially  those  of  hydrothorax;  it  is  suspected  only  by  a  sudden 
onset  with  signs  of  acute  annemia,  and  is  proven  only  by  the  exploring 
needle.  Its  treatment  is  symptomatic;  for  the  occasional  syncope,  the 
usual  stimulants  should  be  given;  ice  should  be  applied  to  the  chest, 
ergot  should  be  given,  or  a  2  per  cent,  gelatin  solution  should  be  in- 
jected for  hfemostasis;  and  operation  should  be  invoked  when  in- 
dicated bv  the  causal  lesion. 


(E).   CHYLOTHORAX. 

A  very  rare  affection,  in  which  true  chjle  or  chyliform  fluid  is 
found  in  the  pleura.  Its  etiology  is  much  disputed;  (a)  in  the  genuine 
chylous  cases  true  chyle  containing  sugar  is  found,  though  of  late 
years  sugar  has  been  found  in  very  many  forms  of  serositis  and  in 
most  transudates;    only  30  cases  of  this  type  are  recorded.     In   11 


PLEURAL  TUMORS  569 

cases  (of  which  4  died  and  of  which  9  were  right-sided),  traumatic 
rupture  of  the  thoracic  duct  has  been  found.  In  others  the  duct  has 
been  obstructed  by  thrombosis  of  the  subclavian  vein  or  by  glands 
and  tumors^  (6)  In  a  second  group,  the  pseudochylous  (chyliform  or 
adipose),  there  is  no  chyle  and  the  milky  appearance  is  due  to  fatty 
globules  or  minute  albuminous  granules  held  in  suspension.  This 
variety  is  chiefly  tuberculous  or  carcinomatous.  It  has  been  thought 
that  old  empyemas  may  become  chyliform.  The  characters  of  both 
forms  of  fluids  will  be  considered  under  chylous  and  adipose  ascites, 
with  which  they  are  frequently  associated.  The  signs  are  those  of 
transudation  or  exudation.  Sixty  per  cent,  of  cases  occur  on  the  right 
side. 

(F).  PLEURAL   TUMORS. 

Pleural  tumors  are  nearly  always  secondary  to  pulmonary,  medi- 
astinal or  extrathoracic  growths.  Carcinoma  and  sarcoma  are  the  most 
frequent  forms;  enchondroma  and  dermoids  are  very  uncommon. 
The  pleura  is  involved  by  contiguity  or  metastasis.  Wagner,  Fraenkel 
and  Riedel  described  a  primary  endothelioma  of  the  pleura,  but,  as 
stated  under  the  etiology  of  pleurisy,  it  is  considered  by  some  as  solely 
inflammatory;  clinically  it  presents  the  picture  of  chronic  pleurisy  plus 
occasional  metastatic  deposits  in  the  liver,  lungs,  kidneys,  muscles 
and  lymph  glands.  The  signs  are  those  of  lung  tumor  plus  those 
of  pleurisy;  the  clinical  diagnosis  of  primary  tumor  is  at  the  best 
but  probable,  even  if  tumor  particles  are  obtained  by  puncture  or  if 
a  tumor  develops  at  the  seat  of  puncture. 


DISEASES  OF  THE  MEDIASTINUM. 

(A).   MEDIASTINAL  TUMORS. 

Mediastinal  tumors  are  very  rare  (1  in  10,000  medical  cases). 
They  are  usually  primary.  Sarcoma  is  the  most  common  form,  and 
then  carcinoma;  lipoma,  substernal  struma,  thymic  growths,  fibroma, 
osteoma,  enchondroma,  echinococcus,  dermoid  (57  cases  collected  by 
R.  S.  ]\Iorris  previous  to  1905),  teratoma,  gumma,  tubercle,  leuksemic, 
pseudoleuksemic  and  chloromatous  adenopathies  are  rarer  forms. 
Sixty  per  cent,  occurs  in  males  between  twenty  and  thirty  years  of  age. 

Symptoms.— Symptoms  develop  gradually.  (1).  There  may  be  local 
signs,  (a)  Bulging  may  be  present  in  the  jugulum  or  under  and  near 
the  sternum,  especially  in  lymphosarcoma,  or  it  may  show  in  the 
anterior  mediastinum,  and  cause  stretching  of  the  skin.     (6)  There 


570  DISEASES   OF   THE  RESPIRATORY   TRACT 

may  be  pulsation,  imparted  by  the  heart,  aorta  or  its  branches,  (c)  The 
tumor  or  secondarily  involved  glands  may  be  palpable  deep  in  the  jug- 
ular notch.  The  vocal  fremitus  varies,  (d)  The  sternum  may  be  ex- 
quisitely tender  from  erosion,  (e)  Dulness  may  be  elicited  under  or 
near  the  sternum,  or,  if  the  posterior  mediastinum  is  involved,  in  the 
back;  the  dulness  may  blend  with  the  heart,  suggesting  aneurysm  or 
effusive  pericarditis,  though  it  is  more  irregular  than  in  either  of 
these  affections.  (/)  Auscultation  gives  variable  results;  sometimes 
there  is  bronchial  breathing,  or  if  the  bronchi  are  closed  the  breath 
sounds  may  be  absent. 

2.  Compression  symptoms,  as  in  aneurysm,  may  predominate  in  tu- 
mors of  the  posterior  and  middle  mediastinum,  though  local  physical 
findings  may  be  slight  or  absent,  (a)  The  vagus  and  its  branches  may 
be  affected.  Paroxysmal  asthma  and  orthopnoea  are  common.  Dysp- 
noea is  the  earliest  and  most  frequent  symptom  of  mediastinal  tumor, 
is  partly  due  to  compression  of  the  vagus,  and  partly  to  tracheal,  cardiac 
and  pleuritic  involvement.  Other  vagus  symptoms  are  brazen  cough 
from  paralysis  of  the  vocal  cords,  tachy-  or  bradycardia,  hiccough, 
vomiting  or  oesophageal  spasm.  (6)  The  trachea  or  bronchi  may  be 
compressed  from  without  or  may  be  occluded  by  ingrowth  into  their 
lumen,  in  which  case  the  symptoms  of  tracheal  or  bronchial  stenosis 
may  be  pronounced.  Tracheal  tugging  and  shrinking  of  one  side 
of  the  chest  (instead  of  bulging)  may  be  noted.  The  sputum  may 
contain  blood,  tumor  tissue,  or  hair.  The  larynx  may  show  lateral 
deviation,  (c)  The  vessels  may  be  involved.  The  arteries  of  the  neck 
may  show  a  systolic  stenotic  murmur,  but  the  veins  are  more  often 
compressed,  especially  the  innominates  or  the  superior  cava,  which 
cause  bilateral  or  unilateral  oedema  and  cyanosis  of  the  face,  neck 
and  arms;  enlargement  of  the  veins  on  the  thorax  indicate  the  col- 
lateral circulation,  (d)  The  heart  may  be  compressed  and  dislocated, 
downward  and  outward  if  the  growth  emanates  from  the  anterior 
mediastinum,  forward  if  from  the  posterior  mediastinum.  Disloca- 
tion of  the  liver  and  spleen  are  less  common,  (e)  The  oesophagus 
may  be  so  compressed  and  dysphagia  may  be  so  extreme  that  death 
from  inanition  results.  (/)  The  sympathetic  ganglia  may  show  symp- 
toms; inequality  in  the  pupils  is  uncommon,  (g)  Neuralgias,  mus- 
cular paralysis  or  even  spinal  paraplegia  may  result. 

Diagnosis. — A  diagnosis  is  either  positive  from  the  signs,  or  pre- 
sumptive from  the  symptoms.  Dyspnoea,  ectasia,  irregular  substernal 
dulness,  venous  stasis,  bronchial  stenosis,  heart  luxation  and  the  .T-rays 
picture  make  the  diagnosis  probable;  puncture  may  both  eliminate 
the  possibility  of  aneurysm  and  withdraw  tissue  or  dermoid  material 
(Tiirck);  the  sputum  sometimes  voids  tumor  particles,  booklets,  and 
hair.  Deep  aneurysm  (v.  Diagnosis  of  Aneurysm)  is  most  difficult 
to  eliminate.  The  irregular  dulness  and  the  apex  beat  at  its  extreme 
limit  to  the  left  exclude  pericarditis.  Tumors  of  the  lung  and  pleura 
produce  less  pressure  symptoms,  though  this  differentiation  is  of  less 
moment. 


MEDIASTINITIS  571 

Prognosis  and  Treatment. — The  prognosis  is  unfavorable,  as  malig- 
nant growths  cause  rapid  emaciation,  and  death  from  inanition,  com- 
pression, ejjjhaustion  or  pneumonia  results  within  a  few  months.  Benign 
tumors  run  a  longer  course,  sometimes  five  to  seven  years,  or  even 
forty  in  Lebert's  dermoid  case.  Treatment  is  palliative.  A  few 
successful  operations  are  reported;  in  twenty  operated  cases  of  der- 
moid, 70  per  cent,  recovered  (R.  S.  Morris). 


(B).   MEDIASTINITIS. 

Acute  inflammation  is  uncommon,  but  may  follow  various  local 
lesions,  as  pleurisy,  pericarditis,  pneumonia,  acute  lymphadenitis  and 
kindred  processes  (v.  Mediastinal  Pleurisy)  by  contiguity  or  by 
metastasis,  (a)  Acute  nonsuppurative  cases  begin  with  chill,  fever, 
pain  in  the  mediastinum  and  tenderness  anteriorly  over  the  sternum  or 
high  in  the  back;  there  may  be  oedema  over  the  sternum;  dysphagia, 
dyspnoea  and  vague  cardiac  symptoms  may  develop.  The  diagnosis 
is  difficult,  but  a  presumptive  diagnosis  is  made  from  acute  inflam- 
matory symptoms  with  mediastinal  localization.  The  prognosis  is 
grave  and  the  treatment  is  symptomatic;  an  ice-bag  should  be  applied 
over  the  sternum  and  opiates  should  be  given  for  pain.  (6)  Of  medi- 
astinal abscess,  Hare  (Prize  Essay  on  Mediastinal  Disease,  1889)  col- 
lected 115  cases,  in  most  of  which  the  anterior  mediastinum  was 
affected.  They  occurred  chiefly  in  males.  Acute  cases,  which  are 
most  often  traumatic  or  sequential  to  the  eruptive  diseases,  were  found 
more  frequently  than  chronic  cases,  which  were  usually  tuberculous 
(v.  Mediastinal  Pleurisy). 

S3miptoms. — The  symptoms  are  local  (mediastinal),  as  in  simple 
acute  mediastinitis,  and  general  (septic).  A  throbbing  retrosternal 
pain  is  common  and  dyspnoea  may  result  from  pressure  by  large  pus 
pockets.  (Edema,  fluctuation  and  pointing  in  the  upper  interspaces 
or  in  the  jugular  notch  may  be  noted.  Fatal  hemorrhage  may  follow 
simultaneous  erosion  of  the  aorta  and  bronchus.  External  rupture 
may  occur  in  the  second  interspace  (Daude)  or  internal  rupture  into 
the  air  passages,  bloodvessels,  oesophagus  or  pleura;  deep  burrowing 
to  the  abdomen  has  occurred.  The  exploring  needle  is  of  great  diag- 
nostic aid  in  doubtful  cases.  Operation  is  indicated:  Auvray  (1904) 
found  in  the  literature,  36  operations  with  33  recoveries. 

(c)  Chronic  mediastinitis  (mediastinopericarditis)  is  discussed  under 
adhesive  pericarditis. 


(C).  MEDIASTINAL  HEMORRHAGE. 

Small  hemorrhages  of  no  clinical  importance  may  result  from  "  blood 
dissolution,"  as  in  icterus,  hemorrhagic  blood  diseases  or  acute  infec- 


572  DISEASES  OF   THE  RESPIRATORY   TRACT 

tions.    Larger  hemorrhages  may  follow  trauma  or  erosion  of  the  large 
vessels,  both  of  which  usually  overshadow  the  mediastinal  incident. 


(D).  INTERSTITIAL  EMPHYSEMA. 

(See  DiFPEEENTIATION  OF  EMPHYSEMA.) 


SECTION  IV. 


DISEASES  OP  THE  DIGESTIVE  TRACT. 


DISEASES  OF  THE  MOUTH. 

(A).   CATARRHAL  STOMATITIS. 

Etiology. — Simple,  acute  or  erythematous  stomatitis  is  the  most 
frequent  form.  In  children  it  may  develop  with  dentition,  improper 
feeding,  rude  cleansing  of  the  mouth,  and  digestive  disorders,  especially 
in  those  who  are  poorly  nourished;  it  is  part  of  various  infections, 
notably  of  the  exanthemata  and  syphilis.  In  adults  it  results  from 
thermal,  mechanical  and  chemical  irritants;  hot  food,  alcohol,  tobacco, 
various  chemicals  (iodine,  mercury,  arsenic,  copper,  etc.),  acidulous 
vomiting,  inflammatory  extension  from  the  salivary  glands,  carious 
teeth,  nose  and  throat  disease,  uncleanliness,  anaemias  and  stasis  are 
among  its  causal  factors. 

S3rmptoms. — Symptoms  are  chiefly  redness,  swelling  and  increased 
secretion,  and  in  the  acute  forms  burning  pain  which  makes  eating 
difficult.  The  increased  saliva  is  usually  acid  and  irritates  the  lips 
or  chin  if  it  flows  over  them.  The  gums  are  turgid  {gingivitis)  and  the 
tongue  broadened,  lax  and  therefore  indented  by  the  teeth,  as  is  also 
the  buccal  mucosa.  The  tongue  is  generally  coated.  Vesicles  some- 
times form  and  break  down  into  small  erosions  which  heal  with  cica- 
trices. The  whitish  areas  sometimes  seen  are  epithelial  thickening. 
Fever,  thirst  and  general  symptoms  are  absent,  except  in  some  infantile 
cases.  Acute  stomatitis  lasts  but  a  week  or  two,  but  may  become 
chronic.    Transient  stomatitis  is  almost  physiological  in  the  new-born. 

Treatment. — In  children  the  mouth  should  be  gently  washed  after 
each  nursing.    Cold  water  or  ice  mitigates  pain.    Boracic  acid  is  excel- 

573 


574         DISEASES  OF  THE  DIGESTIVE   TRACT 

lent  and  safe.  In  adults  the  teeth  should  be  cared  for.  Tincture  of 
myrrh  and  tincture  of  rhatany — equal  parts — are  excellent  astringents. 
Stronger  antiseptics  may  be  used  in  adults  but  are  dangerous  in 
children,  who  may  swallow  them;  for  instance,  2  per  cent,  sodium 
salicylate,  2  per  cent,  chlorate  of  potash,  1  per  cent,  carbolic  solution; 
erosions  may  be  touched  with  1  per  cent,  silver  nitrate. 


(B).  STOMATITIS  ULCEROSA. 

Etiology. — Though  probably  a  mycotic  affection,  its  bacteriology  is 
unknown.  In  some  cases  the  same  microorganisms  are  found  as  in  Vin- 
cent's angina  (See  Diagnosis  of  Diphtheria  and  Acute  Pharyn- 
gitis). Sporadic  cases  are  more  common  than  epidemics,  which 
may  occur  in  asylums  or  prisons.  It  may  be  induced  by  malnutrition, 
uncleanliness,  oral  or  dental  disease,  phthisis,  leukaemia,  diabetes,  toxic 
factors  (principally  mercury),  and  occurs  especially  at  dentition  and 
more  in  city  than  in  country  children. 

Symptoms. — ^The  symptoms  are  those  of  catarrhal  stomatitis  plus 
necrosis  and  then  ulceration.  The  gums,  especially  about  the  incisors 
and  canines,  are  red,  swollen,  loose  and  spongy;  they  bleed  readily, 
secrete  pus  and  ulcerate;  over  the  ulcers  a  membrane  develops.  The 
teeth  are  exposed,  loosened  and  perhaps  fall  out.  Necrosis  of  the  jaw 
sometimes  results.  The  tongue  and  cheek  ulcerate  less  often  and  the 
pharynx  is  nearly  exempt.  The  breath  is  foetid,  the  saliva  is  increased, 
the  submaxillary  lymph  glands  and  the  salivary  glands  are  swollen 
and  mastication  is  almost  impossible.  Fever,  prostration  and  signs 
of  sepsis,  as  erythema,  chills,  and  rapid  pulse,  may  mark  the  severest 
cases.  Acute  cases  last  one  to  two  weeks  and  chronic  cases  weeks  or 
months. 

Varieties. — (a)  Mercurial  stomatitis  may  occur  in  workers  in  the 
metals  or  from  clinical  administration.  The  author  saw  a  hospital 
case  of  nephritis  in  which  one  dose  of  five  grains  of  calomel  caused 
necrosis  of  the  entire  tongue,  which  rotted  off  at  its  root  (See  intoxi- 
cations). Mercurial  and  other  stomatitis  may  cause  "  erosions  "  of  the 
enamel  in  the  developing  teeth  of  children;  they  become  pitted,  dis- 
colored and  transversely  furrowed,  (b)  Riga's  disease,  described  by 
Riga  (1881)  in  South  Italy,  is  an  affection  in  which  there  is  a  pearly 
induration  which  occurs  only  between  the  tip  of  the  tongue  and  the 
frajnum,  appears  with  the  first  dentition,  sometimes  ulcerates,  is 
occasionally  epidemic,  is  often  observed  with  the  status  lymphaticus 
and  is  invariably  fatal,  (c)  In  nursing  women,  ulcers,  3  to  4  mm. 
in  diameter,  may  develop  from  the  lymph  follicles  of  the  lip  and  cheek; 
they  usually  indicate  malnutrition,  sometimes  are  quite  painful,  and 
respond  to  general  tonics  and  hygiene,  (d)  Herpetic  or  pemphigoid 
stomatitis  is  seen  in  neurotics  (Jacobi's  stomatitis  chronica  neurotica) 
and  is  frequently  recurrent,  (e)  Bednar  described  (aphthous)  white 
plaques  on  the  posterior  part  of  the  hard  palate  near  the  alveolar  border 


APHTHOUS  STOMATITIS  575 

of  the  upper  jaw,  which  may  ulcerate;  they  occur  in  the  first  three 
months  of  life,  and  are  apparently  due  to  sucking,  are  not  syphilitic, 
and  are  onynous  only  in  marantic  children.  (/)  Parrot's  ulcers  occur 
in  the  new-born  on  the  hard  palate  near  the  median  line;  they  occur 
in  marantic  children  and  seldom  heal. 

Treatment. — ^Treatment  includes  that  of  catarrhal  stomatitis.  Po- 
tassium permanganate  1  to  1,000  relieves  the  foetor  ex  ore.  Necrotic 
areas  may  be  touched  with  silver  nitrate  solution  or  equal  parts  of 
tincture  of  the  chloride  of  iron  and  glycerine.  Potassium  chlorate 
gargles  may  be  combined  in  children  with  gr.  x  to  xx  of  the  drug  every 
day  internally  and  twice  the  amount  for  adults,  but  it  must  be  re- 
membered that  toxic  effects  may  result.  Opium  and  belladonna  are 
used  in  severe  cases  for  pain  and  salivation. 


(C).  APHTHOUS  STOMATITIS. 

Etiology. — It  may  occur  alone  or  with  fevers  and  other  diseases, 
sporadically  or  epidemically.  It  is  probably  contagious  but  its  nature 
is  still  undetermined;  it  is  classed  by  some  with  impetigo,  due  to  the 
staphylococcus,  and  by  others  with  foot-and-mouth  disease;  when 
due  to  milk  it  ceases  on  withdrawal  of  the  milk.  Besides  the  general 
causes  of  stomatitis  (v.  s.),  it  occurs  chiefly  in  children  between  ten 
and  thirty  months  old. 

SjTinptoms. — Symptoms  begin  with  restlessness,  slight  fever,  thirst, 
salivation  and  pain  in  the  mouth.  Round,  yellow-white  and  slightly 
elevated  areas  as  large  as  a  pea  appear  on  the  surface  and  edges  of  the 
tongue  and  less  often  on  the  lip  and  buccal  mucous  membrane.  The 
mucosa  is  slightly  reddened  about  them.  They  cannot  be  scraped  off 
and  attempts  to  do  so  produce  bleeding.  Pathologically  they  are 
areas  of  superficial  necrosis,  into  which  exudation  of  fibrin  and  round 
cells  occurs  (stomatitis  fibrin osa  disseminata).  Vesicles  are  described 
but  seem  to  be  no  part  of  the  process,  though  they  may  occur  on  the 
skin  near  the  mouth.  Occasionally  there  is  tumefaction  of  the  lym- 
phatic and  salivary  glands.  Their  clinical  evolution  is  rapid;  they 
last  one  to  two  weeks,  and  recurrence  is  frequent.  The  treatment  is 
that  of  stomatitis. 


(D).  PARASITIC   STOMATITIS. 

Etiology. ^ — Thrush,  muguet,  soor,  or  stomatomycosis  o'idica  is  due  to 
the  Oidium  albicans,  closely  allied  to  the  saccharomyces,  which  con- 
sists of  branching  mycelia  and  ovoid  granular  and  refracting  spores. 
It  occurs  chiefly  in  very  young  children  whose  mouths  have  been  im- 
properly cared  for,  or  who  have  stomatitis  and  reduced  nutrition.  It 
prevails  especially  among  the  poor  and  in  institutions.  Dirty  nipples 
are  probably  the  most  frequent  mode  of  inoculation.     Thrush  may 


576  DISEASES  OF  THE  DIGESTIVE   TRACT 

develop  in  adults,  as  in  weakly  convalescents,  or  in  tuberculous  and 
diabetic  subjects. 

Symptoms. — A  few  thin,  punctate,  whitish  spots  develop  on  the 
tongue,  cheek  and  soft  palate;  they  become  yellowish  as  the  areas 
o-row  or  fuse.  The  fungus  is  at  first  deposited  on  the  epithelium,  be- 
tween the  layers  of  which  it  proliferates  and  penetrates.  The  mouth 
is  dry,  or,  with  diffuse  stomatitis,  is  moist  from  increased  salivary  flow. 
In  the  more  severe  cases  the  fungus  may  reach  the  pharynx,  larynx, 
oesophagus,  and  even  the  stomach  and  intestine.  Its  deposit  is  gen- 
erally limited  to  areas  with  flat  epithelium,  and  epithelia  of  the  cylin- 
drical and  ciliated  order  usually  escape.  It  may,  in  exceptional  cases, 
cause  oesophageal  occlusion,  or  bronchopneumonia;  or  by  unusually 
deep  penetration  to  the  submucous  vessels  it  may  cause  cerebral,  renal 
and  other  embohsm.    The  outlook  is  good  except  in  marantic  subjects. 

Treatment. — Prophylaxis  is  most  essential  in  regard  to  cleansing 
of  the  mouth,  sterilization  of  bottles  and  nipples,  and  maintenance  of 
the  general  health  by  fresh  air  and  by  early  treatment  of  dyspeptic  dis- 
orders. In  some  cases  the  stomatitis  persists  until  a  wet-nurse  is 
substituted  for  the  feeding  with  cow's  milk.  Cleansing  the  mouth  with 
borax,  boric  acid,  sodium  bicarbonate  and  lime  water  is  most  effective. 
If  unusual  extension  occurs,  a  teaspoonful  of  a  resorcin  solution  (1  to 
100  or  300  parts)  may  be  given  every  two  hours. 

Stomatitis  may  in  rare  cases  result  from  other  parasites,  as  the  sar- 
cina  or  leptothrix,  and  from  such  bacteria  as  the  pneumococcus,  gono- 
coccus,  Friedlander's  baciflus,  etc. 

(E).   GANGRENOUS   STOMATITIS.    » 

Etiology. — "Gangrene  of  the  cheek,"  noma  or  cancrum  oris,  is  a 
rare  affection.  Age:  of  Brun's  415  cases,  only  11  occurred  in 
persons  over  fifteen  years  of  age  and  only  6  in  infants.  The  author 
recently  saw  a  case  in  a  man  forty  years  old,  which  was  fatal  on  the 
fifth  day.  Sex:  more  cases  occur  in  girls  than  in  boys.  Malnutrition 
and  neglect  are  causes  of  some  cases,  and  others  follow  acute  infec- 
tions; sb  per  cent,  follows  measles;  t}'phoid,  scarlatina,  etc.,  are  less 
frequent  factors.  A  bacillus  resembhng  that  of  diphtheria  has  been 
isolated  (Bac.  necroseos).  Cladothrix  threads  similar  to  those  in  Vin- 
cent's angina  may  be  seen. 

Ssnnptoms. — Symptoms  usually  begin  with  ulceration  of  the  gums 
or  buccal  mucosa  near  the  angle  of  the  mouth.  Rapid  necrosis  and 
gangrene  follow  with  extensive  brawny  oedema  of  the  face.  The  foetor 
is  intense  and  much  tissue  is  frequently  sloughed  off.  Perforation  of 
the  cheek,  necrosis  of  the  jaw  and  extension  to  the  throat,  orbit  or 
ears  are  not  uncommon.  Seventy  per  cent,  of  cases  die  within  a  week; 
they  show  septic  symptoms,  such  as  high  fever,  weak  heart,  prostra- 
tion, diarrhoea,  colitis,  and  meningitis,  or  symptoms  of  lobular  pneumonia 


ECZEMA  577 

becoming  gangrenous.  The  other  cases  exhibit  less  general  reaction 
and  may  leave  only  an  extensive  scar  or  fistula  on  the  cheek.  The 
mortality  was  92  per  cent,  in  Springer's  collation. 

Treatment. — Treatment  is  ineffectual.  A  full  diet  and  free  exhibi- 
tion of  alcohol  are  indicated  as  in  sepsis,  and  disinfectants  should  be 
applied  to  the  necrotic  focus;  local  measures  as  excision,  the  live 
cautery  and  caustics  are  employed,  usually  without  success,  and  some- 
times with  aggravation  of  the  necrosis. 


DISEASES  OF  THE  TONGUE. 

(A).   ECZEMA. 

In  eczema  the  epithelium  thickens  and  desquamates,  leaving  red- 
dish, smooth  and  circular,  serpiginous  or  geographical  areas,  which 
heal  centrally  and  extend  peripherally.  It  may  cause  local  irritation  or 
worry  to  the  patient,  who  may  think  he  has  syphilis  or  cancer.  Again, 
it  is  an  accidental  finding  on  the  tongue  or  cheeks.  Its  cause  is  un- 
known, its  course  is  quite  chronic,  and  its  treatment  by  silver  nitrate 
is  quite  inadequate. 

(B).  LEUKOPLAKIA. 

Leukoplakia  (psoriasis,  ichthyosis,  keratosis)  is  an  affection  closely 
resembling  the  "geographical  tongue,"  in  connection  with  which  it 
is  often  described.  Irregularly-shaped,  smooth,  pale  plaques,  measur- 
ing one  to  two  centimeters,  develop  on  the  tongue  and  less  often  on 
the  lips,  cheek  or  tonsils;  they  consist  of  thickened  epithelium.  Eighty 
per  cent,  of  cases  occur  in  men  (98  per  cent.,  Fournier);  the  use  of 
tobacco  and  alcohol,  and  gout  and  gastric  disease  are  probable  factors; 
syphilis  is  not  a  cause  and  antisyphilitic  remedies  are  directly  injurious, 
though  Fournier's  experience  with  324  cases  convinced  him  that  80 
per  cent,  came  from  syphilis  and  20  per  cent,  from  tobacco.  Its  symp- 
toms are  not  marked,  its  course  is  very  chronic  and  its  treatment  is 
nearly  always  without  results.  Ten  per  cent,  solutions  of  sodium 
salicylate;  chromic  acid,  5  per  cent.;  strong  silver  nitrate  applications, 
especially  to  fissured  places;  corrosive  sublimate  (1  to  500  parts)  and 
the  galvanocautery  are  recommended.  Excision  is  necessary  for  papil- 
lomatous or  epitheliomatous  outgrowths,  which  are  said  to  develop 
in  one-third  to  nearly  one-half  the  cases. 


37 


578  DISEASES   OF   THE   DIGESTIVE  TRACT 


(C).   ACUTE   GLOSSITIS. 

Acute  glossitis  may  be  localized  or  diffuse,  and  usually  ends  in  sup- 
puration. It  follows  stings,  burns,  erosions  or  the  entrance  of  pyogenic 
cocci  through  the  lymph  follicles.  The  tongue  is  swollen,  sometimes 
so  greatly  that  it  protrudes  beyond  the  lips,  and  is  painful.  Eating, 
and  even  speaking  or  oral  breathing  are  impossible.  Early  scarifica- 
tion and  later  incision  of  purulent  foci  are  indicated, 

(D).  GLOSSITIS  DESICCANS. 

Glossitis  desiccans  is  a  rare,  chronic,  intractable  affection  in  which 
deep  indentations  of  the  margins  of  the  tongue,  and  consequent  lobula- 
tion occur.  Melanoglossia  (nigrities  lingucB)  results  from  proliferation 
of  the  filiform  papillae  at  the  base  of  the  tongue,  which  appear  like  hair 
(melanotrichia  linguae,  black-haired  tongue);  they  are  removed  by  a 
10  per  cent,  salicylic  acid  solution  or  by  curetting.  The  mucor  niger 
may  cause  a  black  coating  on  the  tongue. 


DISEASES  OF  THE  SALIVAEY  GLANDS. 

(A).  PTYALISM,  SALIVATION,  HYPERSECRETION,  SIALORRH(EA. 

Etiology,- — The  chief  causes  are  (a)  disease  of  the  mouth,  stomatitis, 
dentition;  (6)  toxic  substances  as  jaborandi,  tobacco,  physostigma, 
digitalis,  mercury,  iodides  and  various  metals;  (c)  nervous  affections, 
as  trigeminal  neuralgia,  diseases  of  the  pons  and  medulla,  paretic 
dementia,  hypochondriasis,  and  hydrophobia;  a  close  distinction 
should  be  drawn  between  oversecretion  and  lesions  in  which,  like 
bulbar  paralysis,  the  saliva  cannot  be  swallowed;  {d)  reflex  saHvation, 
which  may  also  occur  from  diseases  of  the  tympanum  through  the 
chorda  tympani,  from  gastro-intestinal  disease  (gastric  ulcer,  pancre- 
atic lesions,  etc.)  by  way  of  the  vagus  and  sympathetic  nerves,  and  from 
genital  conditions,  as  pregnancy. 

Symptoms. — The  physiological  salivary  flow  measures  seven  ounces 
to  three  pints  (200  to  1500  c,  c),  which  pathologically  may  amount  to 
quarts;  a  flow  of  over  twelve  quarts  has  been  recorded.  The  salivary 
glands  are  tense,  swollen,  and  even  hard.  The  reaction  of  the  saliva 
may  become  neutral  or  acid ;  it  is  chiefly  thin  and  fluid,  but  may  con- 
tain some  ropy  mucus  or  scattered  pus  cells;  the  ptyalin  disappears 
together  with  the  potassium  sulphocyanide.     The  saliva  may  trickle 


XEROSTOMIA  579 

into  the  larynx  during  sleep,  and  thus  cause  violent  coughing;  it  may 
flow  into  the  stomach,  and  produce  vomiting,  of  an  alkaline  or  neutral 
vomitus,  especially  in  the  morning;  it  may  stream  from  the  lips,  and 
cause  the  adjacent  skin  to  become  erythematous. 

Prognosis  and  Treatment. — The  prognosis  depends  wholly  on  the 
causal  affections,  whose  operation  may  be  transient,  intermittent  or 
permanent.  Treatment  is  likewise  causal.  Any  toxic  cause  should  be 
removed.  In  nervous  and  reflex  types,  potassium  bromide  is  often 
valuable  and  the  iodides  are  sometimes  efficacious  in  pregnancy.  The 
more  severe  cases  necessitate  opium  and  occasional  doses  of  bella- 
donna. 

(B).  XEROSTOMIA. 

Hyposecretion  or  arrested  secretion  was  first  described  by  Jonathan 
Hutchinson.  Besides  its  occurrence,  as  a  result  of  atropine  and  allied 
remedies,  it  occurs  in  diabetes  insipidus  and  mellitus,  in  some  cases  of 
contracted  kidney,  and  finally,  as  an  independent  neurosis  or  a  neurotic 
symptom.  Women  (80  per  cent.)  are  affected  more  often  than  men. 
The  tongue  and  mouth  are  dry,  red  and  glistening,  which  may  render 
speaking,  chewing  and  swallowing  most  difficult.  The  tongue  may 
cleave  to  the  roof  of  the  mouth.  The  digestion  of  carbohydrates  is 
impaired.  Treatment  consists  in  painting  the  mouth  with  iodine, 
potassium  iodide  and  glycerine  (1,  10,  100  parts  respectively),  the  ad- 
ministration of  pilocarpine  hydrochlorate  i'2  to  h  of  a  grain  and  galvanic 
applications  to  the  parotid. 


(0).  PAROTITIS. 

Besides  acute  specific  parotitis  (mumps),  infection  may  reach  the 
parotid  or  other  salivary  glands  by  way  of  the  blood  stream  or  by 
infection  entering  their  ducts.  Acute  parotitis  may  be  simple  but  is 
oftener  suppurative,  the  staphylococcus  being  the  most  common  pyo- 
genic organism,  (a)  Any  of  the  acute  infections  may  be  complicated  by 
parotitis,  of  which  typhoid  is  the  most  common;  parotitis  may  develop 
in  measles,  scarlatina,  pneumonia,  septicopysemia,  and  syphilis.  (6) 
Diseases  or  trauma  of  the  abdominal  or  pelvic  structures  are  some- 
times complicated  by  acute  parotitis,  to  which  Paget  drew  special 
attention;  they  include  diseases  of  or  operations  on  the  ahmentary  and 
genito-urinary  tracts,  peritoneal  disease,  pancreatitis,  trauma  to  the 
abdominal  viscera,  which  may  result  from  pessaries  or  from  external 
violence,  injury  of  the  abdominal  wall,  etc.;  many  of  these  cases  are 
clearly  attenuated  sepsis.  Wagner,  in  1904  was  able  to  collect  61  cases 
of  postoperative  parotitis;  31  were  operations  upon  the  genitalia;  he 
believes  the  cause  is  not  hsematogenous  infection,  but  an  infection 
ascending  along  the  duct  from  the  mouth,  (c)  A  rare  form  of  acute 
parotitis  in  facial  neuritis  is  described  by  Gowers. 


580  DISEASES   OF   THE   DIGESTIVE   TRACT 

Chronic  parotitis  sometimes  follows  epidemic  or  symptomatic  paro- 
titis; it  may  occur  in  poisoning  by  mercury  or  lead,  and  in  syphilis  or 
chronic  nephritis.  The  parotid  is  usually  painless,  though  it  is 
sometimes  both  painful  and  tender.  jNIikulicz  has  described  a  "  chronic 
symmetrical  hypertrophy  of  the  salivary  and  lachrymal  glands  "  which 
is  often  of  long  duration. 

Treatment. — In  acute  parotitis,  local  derivants  as  leeches,  the  early 
application  of  cold  and  the  later  use  of  hot  fomentations,  and  finally 
of  surgical  incision,  if  there  is  pus  formation,  are  indicated.  Chronic 
forms  respond  slowly  to  treatment;  iodine  or  mercurial  ointments 
should  be  employed.    Iodide  is  useful  in  Milkulicz's  disease. 

The  parotid  gland  and  its  duct  may  become  inflated  with  air  in 
persons  having  such  occupations  as  blowing  wind-instruments  or  in 
glass-blowing.    In  rare  cases  gas  forms  in  the  gland  or  its  duct. 


,       (D).  ANGINA  LUDOVICI. 

Ludwig's  angina  is  generally  due  to  a  streptococcic  infection  begin- 
ning in  the  submaxillary  gland,  and  extending  to  the  floor  of  the  mouth 
and  to  the  cervical  cellular  tissue.  In  some  cases  no  promoting  cause 
is  found,  or  trauma  may  be  its  immediate  antecedent,  but  most  cases 
are  secondary  to  typhoid,  diphtheria,  scarlatina  and  kindred  acute 
infections.  It  is  the  analogue,  though  differing  in  location,  of  acute 
phlegmon  of  the  pharynx  and  larjfnx  (submucous  suppurative  inflam- 
mation or  oedema).  The  streptococcic  inflammation  spreads  rapidly, 
causing  fever,  redness,  pain  and  swelling  under  the  tongue,  cellulitis 
and  sometimes  gangrene  in  the  neck  (cynanche  gangrcBneuse).  Masti- 
cation and  deglutition  may  be  impossible  and  glottis  oedema  is  not 
infrequent.  The  parotids  are  sometimes  invaded.  Resolution  is  very 
exceptional  and  external  pointing  of  pus  is  not  likely  to  occur,  whence, 
without  early  surgical  intervention,  septic  and  pysemic  complications 
or  laryngeal  and  pharjmgeal  oedema  or  phlegmon  very  frequently 
develop. 

(E).  SIALODOCHITIS  FIBRINOSA. 

Inflammation  of  the  salivary  ducts  with  formation  of  membrane 
(Kussmaul)  results  from  infection  ascending  from  the  oral  ca^dty  and 
is  characterized  by  fever  and  tenderness,  pain  and  tumefaction  of  the 
salivary  gland,  due  to  retained  secretion  and  infection.  The  duct  is 
kept  patent  by  pressure  or  sounding. 


(F).  SIALOLITHIASIS. 

Stones  of  calcium  phosphate  or  carbonate  occur  more  frequently  in 
Wharton's  duct  than  in  the  other  salivary  ducts.    Their  usual  cause  is 


ACUTE  PHARYNGITIS  581 

stagnation  of  the  salivary  secretion  by  foreign  bodies,  bacterial  or 
fungus  invasion  or  mechanical  stricture  following  ulceration.  Roberg 
(1904)  foun(i  stones  in  Wharton's  duct  fifty  times,  in  the  submaxillary 
gland  twenty-eight  times,  in  Stenson's  duct  six  times  and  in  the  parotid 
gland  twice. 


DISEASES  OF  THE  PHAEYNX. 

(A).  ACUTE  PHARYNGITIS. 

Etiology. — Acute,  superficial,  simple  angina  may  be  caused  by  (a) 
rheumatism,  cold  or  exposure;  (b)  infections,  either  acute  (measles, 
scarlatina,  variola)  or  chronic  (malaria  or  syphilis);  (c)  gout,  dyspep- 
sia, or  smoking;  (d)  in  many  cases  the  cause  is  obscure;  though  pro- 
bably always  mycotic,  no  one  germ  is  especially  found.  It  is  most 
common  in  youth. 

Symptoms. — (a)  Local: — The  throat  is  red,  glazed  and  streaked  with 
mucopus  which  is  easily  wiped  away.  The  soft  palate  and  uvula  are 
sometimes  swollen;  superficial  erosions,  small  vesicles  on  the  palate 
and  swollen  mucous  follicles  are  occasionally  seen.  In  some  cases  the 
local  findings,  especially  when  hidden  in  the  nasopharynx,  are  very 
slight  in  proportion  to  the  local  pain  and  general  symptoms.  There  is  a 
scratching,  tickling  sensation  in  the  throat  which  may  radiate  into  Ihe 
posterior  nares  or  into  the  ear.  The  patient  hawks,  but  raises  little, 
unless  there  is  coincident  rhinitis  or  laryngitis.  Swallowing  is  rather 
painful,  slight  deafness  is  quite  common,  the  speech  is  sometimes 
slightly  nasal,  and  the  angular  lymph  nodes  are  painful  and  tender. 
(b)  Constitutional  symptoms  are  usually  slight.  At  the  onset  there  are 
chilliness,,  moderate  fever,  aching  in  the  muscles  tind  in  some  individ- 
uals extreme  cutaneous  hyperaesthesia,  which,  on  superficial  examina- 
tion, may  be  falsely  attributed  to  changes  in  the  deeper  parts  of  the 
body.  With  or  without  coincident  tonsillitis,  there  ma^,  be  high  fever, 
and  in  labile  indi\dduals,  marked  nervous  intoxication.  Herpes  facialis 
occasionally  develops.  Complications,  as  acute  endocarditis,  or 
nephritis,  are  very  uncommon.  In  a  few  days  the  process  is  complete 
and  convalescence  is  rapid. 

Treatment. — (a)  Local: — painting  the  entire  pharynx  with  a  20 
per  cent,  silver  nitrate  solution  usually  affords  not  only  local  but 
general  relief.  (6)  General: — Dover's  powder  ard  aspirin,  each  ten 
grains,  may  be  exhibited  for  unusual  pain^  aconite  for  high  fever,  calo- 
mel, followed  by  salines,  for  elimination,  and  a  1  per  cent,  solution 
of  carbolic  acid  for  the  irritated  throat. 

The  pneumococcic  sore  throat  may  be  suppurative,  pseudodiphther- 
itic,  follicular  (like  tonsillitis),  erythematous  or  herpetiform;  its  onset 


582  DISEASES   OF   THE  DIGESTIVE   TRACT 

is  severe,  like  that  of  pueiimonia,  it  produces  a  thicker,  denser  and 
more  adherent  membrane  than  does  the  streptococcus  and  the  prog- 
nosis is  generally  poor. 

(B).  CHRONIC  PHARYNGITIS. 

f  Etiology. — The  causes  are:  («)  repeated  acute  pharyngitis;  (6) 
excessive  smoking  or  use  of  alcohol;  (c)  abuse  or  over-use  of  the 
voice,  as  in  clergymen,  vendors,  etc;  {d)  extension  from  or  association 
with  chronic  nasopharyngitis  or  laryngitis;  (e)  various  conditions  of 
the  blood,  as  in  chronic  nephritis,  syphilis,  arthritism,  etc.  These 
causal  factors  are  most  common  in  adolescence  and  middle  life. 

Symptoms. — The  symptoms  are  local.  The  mucosa  of  the  naso- 
pharynx is  generally  red  and  lined  with  turgid  venules;  the  pillars  and 
uvula  are  relaxed,  and  the  drooping  uvula  may  occasion  tickling  of  the 
tongue  or  even  of  the  epiglottis,  thus  causing  chronic  coughing.  The 
sides  of  the  pharvnx  may  show  isolated  whitish  areas  of  epithelial 
thickening  or  more  often  small,  round,  reddish,  hypertrophied  lymph 
follicles  (pharyngitis  granulosa),  sometimes  in  linear  distribution. 
The  pharynx  is  dry  and  burning,  exciting  hawking  efforts  which  are 
not  only  unproductive  but  in  themselves  are  irritating  to  the  pharynx 
and  may  cause  morning  vomiting.  The  mucous  glands  are  at  times 
hyperplastic.  Slight  bleeding  occasionally  causes  unnecessary  worry. 
Middle  ear  involvement  is  common,  through  the  Eustachian  tube. 
Pharyngitis  sicca  is  an  atrophic  type,  unalogous  to  rhinitis  sicca 
(atrophica)  and  marked  by  a  pallid^  glazing,  chiefly  of  the  posterior 
pharyngeal  wall,  and  by  formation  of  crusts. 

Treatment. — (a)  The  carnal  factors,  as  improper  straining  or 
tension  of  the  voice  in  speaking,  excessive  alcoholism  or  smoking,  etc. 
should  be  corrected  respectively,  by  rest  and  avoiding  irritant  foods  or 
stimulants.  Alkaline  laxatives  are  frequently  beneficial.  (6)  Galvano- 
functure  of  the  turgid  veins  or  hyperplastic  follicles  is  indicated; 
marked  improvement  is  probably  more  frequent  than  aggravation  of 
the  condition  by  over-zealous  treatment,  (c)  Local  medical  treatment 
is  less  efficacious,  as  2  to  20  per  cent,  solution  of  tannin  in  glycerine, 
equal  parts  of  tr.  ferri  chloridi  and  chlorate  of  potash,  1  to  5  per 
cent,  solution  of  chloride  of  zinc,  or  2  to  20  per  cent,  nitrate  of  silver 
solution. 

Acidi  carbolici       gr.  xx. 

Acidi  tannici oss. 

Aluminis 6J . 

Glycerini oij- 

Aquae  rosse q-s.  ad  ov. 

M.  et  ft.  gargarismus. 
S. — As  gargle,  properly  diluted. 

{d)  For  dry  atrophic  pharyngitis,  iodine,  potassium  iodide  and  gly- 
cerine (1:10:100  parts,  respectively),  massaged  thoroughly  into  the 
pharynx,  is  the  best  known  measure: 


RETROPHARYNGEAL   ABSCESS  583 

lodi gr.  iij. 

Potassii  iodidi .    3ss. 

Glycerjni §j, 

M.  et  S. — Locally. 

(C).  PHLEGMONOUS  PHARYNGITIS. 

Angina  phlegmonosa,  especially  described  by  Senator,  is  not  super- 
ficial as  is  simple  pharyngitis,  but  invades  the  submucosa.  It  is  usually 
primary  but  may  be  metastatic  from  distant  suppuration.  The  throat 
is  painful,  swollen  and  oedematous,  the  neck  enlarges  and  suppuration 
occurs  with  high  fever,  septic  symptoms  and  difficulty  in  swallowing 
and  breathing,  especially  when  the  subject  lies  down.  The  inflamma- 
tion may  be  hemorrhagic  or  necrotic.  Phlegmonous  angina  is  the 
analogue  of  suppurative  submucous  laryngitis  and  of  angina  Ludovici. 
Without  surgical  intervention  or  early  spontaneous  rupture  into  the 
throat,  death  occurs  from  septicopyemia,  mediastinitis  or  from  oedema 
of  the  glottis. 

(D).  RETROPHARYNGEAL  ABSCESS. 

Various  forms  are  described,  (a)  The  'primary  form  occurs  in  chil- 
dren under  two  years  of  age;  the  early  symptoms  are  dysphagia,  a 
nasal  voice  and  retropharyngeal  suppuration,  either  as  a  visible  pro- 
trusion on  the  posterior  pharyngeal  wall  Or  as  a  palpable  fluctuation 
there;  in  a  week  or  two  dyspnoea,  cyanosis  and  inspiratory  retraction 
of  the  chest  develop.  It  is  a  primary  lymphadenitis,  (b)  Secondary 
types  are  less  common  in  (i)  caries  of  the  cervical  spine,  (w')  diphtheria, 
erysipelas,  scarlatina  and  (in)  suppurative  inflammation  in  the  retro- 
pharyngeal lymph  glands.  The  secondary  type  is  caused  by  infection 
travelling  along  the  lymph  vessels,  or  rarely  by  metastasis.  Unless 
surgical  measures  are  instituted  or  spontaneous  rupture  occurs  early, 
death  occurs  from  asphyxia,  mediastinitis,  glottis  stenosis,  inhalation 
pneumonia  or  sepsis.  After  incision  the  head  should  be  promptly 
thrown  well  forward  to  obviate  occlusion  of  the  air  passages. 


(E).  PHARYNGEAL  ULCERATION. 

Syphilitic  and  tuberculous  ulceration  have  been  considered.  Follic- 
ular ulcers  are  superficial  and  small  and,  like  all  ulcers  in  the  mucous 
membrane  only,  heal  without  a  cicatrix.  Ulceration  also  occurs  in 
diphtheria  and  the  diphtheroid  group,  due  chiefly  to  the  streptococcus. 
Malignancy  too,  causes  ulceration.  Cancer  and  tuberculosis  are  us- 
ually diagnosticated  with  ease,  and  syphilis  is  separated  ex  juvantibus 
by  the  use  of  mercury  and  iodides  in  doubtful  cases. 

Vincent's  angina  is  discussed  under  Diagnosis  of  Diphtheria; 
according  to  Vincent,  it  constitutes  two  per  cent,  of  all  anginas  including 


584  DISEASES  OF  THE  DIGESTIVE  TRACT 

diphtheria.  It  occurs  especiallj'  in  children  between  six  and  ten 
years  of  age  and  in  medical  students  and  servants  in  anatomical  labora- 
tories, between  the  years  of  eighteen  and  thirty.  Tobacco,  scurvy, 
anaemia,  tuberculosis,  syphilis,  scarlatina,  measles  and  the  eruption  of 
the  wisdom  teeth  are  predisposing  factors.  The  two  causative  organ- 
isms were  first  described  by  Rauchfus  (1893);  (a)  the  fiisiform  bacillus 
has  pointed,  sometimes  rounded  ends,  is  sometimes  bent,  measures  six  to 
twelve  fx  in  length  and  may  be  flagellated;  (6)  the  spirillum  or  spir- 
ochsete  is  long,  delicate,  twisted  and  always  occurs  in  severe  forms. 
They  stain  with  carbol-fuchsin  but  not  by  Gram's  method, 

Ssnuptoms. — (1)  In  the  first  period,  there  is  congestion  and  oedema. 
(2)  In  the  second  stage,  a  grayish  yellow  membrane  forms  which  is 
thick,  friable  and  cheesy  and  is  usually  removable.  (3)  Under  the 
membrane,  an  ulcer  develops;  it  is  usually  single,  round  or  oval  and 
has  an  irregular  edge,  an  uneven  granulating  floor  and  seldom  any 
extension  laterally. 

The  general  symptoms  are  lassitude,  indigestion,  vomiting  or  epi- 
staxis;  fever  is  uncommon  and  complications  rare  (albuminuria,  en- 
teritis or  noma).  SyphiHs  and  diphtheria  require  differentiation.  The 
affection  heals  in  one-half  to  seven  weeks,  under  applications  of  iodine 
locally,  pencilling  with  silver  nitrate,  gargles  of  hydrogen  peroxide  or> 
chlorate  of  potash  internally. 


DISEASES  OF  THE  TONSILS. 

(A).  ACUTE  FOLLICULAR  OR   LACUNAR  TONSILLITIS. 

Definition. — An  acute,  largely  parenchymatous,  inflammation  of  the 
tonsils,  due  to  local  mycotic  invasion  and  marked  usually  by  decided 
constitutional  reaction. 

Etiology. — (a)  Bacteriologically ,  the  streptococcus  is  the  most  fre- 
quent cause,  though  the  staphylococcus  and  Fraenkel's  diplococcus  are 
also  encountered;  it  is  claimed  that  somewhat  attenuated  diphtheria 
bacilli  are  found,  particularly  at  the  time  of  diphtheria  epidemics,  but 
in  such  cases  it  is  more  correct  to  consider  it  as  a  sub-type  of  diphtheria 
(q.  v.).  (b)  The  still  unknown  virus  of  rheumatism  is  thought  to  gain 
access  to  the  blood  by  way  of  the  tonsils  or  pharynx;  affections  com- 
monly regarded  as  associated  with  rheumatism,  as  erythema  nodosum, 
chorea,  and  some  forms  of  endocarditis,  may  follow  acute  tonsillitis 
(Packard).  Tonsillitis  may  begin  the  rheumatic  cycle,  as  described 
under  rheumatism  in  children,  or  it  may  appear  later  in  the  rheu- 
matic process,  with  endocarditis,  pericarditis,  arthritis,  and  chorea. 
Endemics  and  the  spread  of  the  disease  through  a  household  or  institu- 


ACUTE  FOLLICULAR  OR  LACUNAR  TONSILLITIS  585 

tion  strengthen  the  theory  that  tonsillitis  is  an  acute  contagion,  (c) 
Cold  and  dampness  are  directly  predisposing  causes;  these  conditions 
obtain  in  thje  United  States  largely  in  the  spring,  in  some  other  countries 
largely  in  the  fall  months,  (d)  Tonsillitis  occurs  chiefly  in  youth  and 
adolescence;  infants  are  seldom  affected,  (e)  Individual  predisposition 
depends  on  some  unknown  factor  and  tonsillitis  itself  is  of  etiological 
importance,  for  one  attack  may  induce  recurrence.  (/)  Poor  hygiene 
and  possibly  sexual  activity,  especially  in  young  married  people 
(Shepard),  may  be  conducive  to  tonsillitis. 

Symptoms. — (a)  The  onset  occurs  with  chilliness  or  rigor,  severe 
pains  in  the  back  and  limbs,  fever,  rising  within  a  day  to  103  or  even 
to  106  degrees  in  children  or  susceptible  adults,  pain  in  the  throat, 
particularly  on  swallowing,  and  tenderness  of  the  glands  at  the  angle 
of  the  jaw.  (6)  Local  findings: — the  tonsils  are  swollen  and  soon  show 
on  the  deeply  injected  surface  three  to  ten  yellowish-white  or  creamy 
points,  corresponding  to  the  crypts  or  lacunae;  the  crypts  contain  bac- 
teria, epithelium,  leukocytes  and  sometimes  cholestearin  or  fatty 
needles  and  are  essentially  small  abscesses.  Pathologically  the  tonsil 
is  the  seat  of  serocellular  infiltration.  Occasionally  there  are  small 
superficial  areas  of  necrosis,  slight  erosions  or  even  formation  of  mem- 
brane. The  voice  may  acquire  a  somewhat  nasal  twang,  the  pain 
increases  for  a  few  days  and  the  angular  glands  remain  both  painful 
and  tender,  whence  the  head  is  often  held  rigidly  forward  and  the  jaws 
are  opened  only  with  difficulty.  Pain  in  the  ear  is  not  uncommon,  (c) 
The  chief  constitutional  symptoms  have  been  considered  under  (a). 
Anorexia,  heavily  coated  tongue,  feverish  breath,  hypersesthetic  skin, 
marked  depression,  accelerated  pulse  and  respiration,  are  common.  In 
some  cases  the  systemic  symptoms  are  disproportionately  severe  and 
children,  as  well  as  some  adults,  may  exhibit  delirium;  in  two  cases 
seen  by  the  writer,  in  adults,  retraction  of  the  neck  with  headache, 
delirium  and  vomiting  was  thought  indicative  of  meningitis.  Herpes 
facialis  is  quite  frequent. 

Complications. — Complications  are  not  common.  Acute  pericar- 
ditis, endocarditis  or  nephritis  may  develop.  Functional  heart  mur- 
murs, febrile  albuminuria  and  erythema  (from  the  toxins  or  from 
medication)  are  not  very  infrequent.  As  a  rule,  however,  convalescence 
is  complete  within  a  week,  though  marked  prostration  and  considerable 
residual  swelling  remain  for  some  time.  Repeated  attacks  may  cause 
nephritis  or  endocarditis. 

Diagnosis.— The  typical  case  cannot  be  confused,  (a)  Diphtheria 
produces  a  membrane,  more  whitish  in  color,  which  has  an  almpst 
pathognomonic  tendency  to  spread  to  the  uvula,  soft  palate  or  pharynx; 
it  leaves  bleeding  raw  points  when  it  is  stripped  off;  it  recurs  after 
removal;  it  sometimes  extends  to  the  larynx;  it  is  followed  not  infre- 
quently by  paralysis,  which  almost  never  results  from  tonsillitis;  it 
responds  with  more  or  less  promptness  to  serotherapy,  and  shows  in 
practically  all  cases  the  Klebs-Loeffier  bacillus,  (b)  Tonsillitis  necro- 
tica  leaves  an  ulcer;   its  bacteriology  is  disputed,  some  cases  showing 


586  DISEASES  OF   THE  DIGESTIVE  TRACT 

the  fusiform  bacillus  and  spirilla  of  Vincent  (see  Ulcerative  Pharyn- 
gitis and  Diphtheria),  and  others  are  alleged  to  be  due  to  the  Bacil- 
lus diphtherise;  in  some  cases  there  is  much  fever;  in  others  none; 
the  general  reaction  is  severe,  (c)  The  possibility  of  incipient  scarlatina 
should  always  be  kept  in  mind. 

Treatment. — 1.  Prevention. — The  subject  should  be  hardened  by 
cool  baths  or  sponges,  and  tonsillotomy  should  be  performed.  Douch- 
ing of  the  nose  and  gargling  with  Dobell's  solution  should  be  part  of  the 
daily  toilet. 

2.  Local  Measures. — Though  many  local  remedies  are  recom- 
mended, the  best  in  the  author's  experience  is  silver  nitrate;  after 
cocainizing  the  throat,  a  small  probe  is  bent  at  right  angles  near  its  end 
and  introduced  into  each  swollen  crypt  in  order  to  puncture  it  and 
secure  free  drainage;  then  Dobell's  solution  should  be  applied,  un- 
diluted, on  small  bits  of  cotton  in  each  crypt ;  this  is  followed  by  20  per 
cent,  silver  nitrate  solution ;  the  results  are  often  immediate,  sometimes 
aborting  the  attack.  Squeezing  out  the  crypts  with  a  spatula  is  ex- 
tremely painful  but  relieves  the  patient  when  the  physician  has  no 
probe  at  hand.  Hot  water  or  hot  fomentations  may  be  applied  to  the 
neck. 

3.  Constitutional  Treatment. — In  a  relatively  small  number  of  cases 
sodium  salicylate,  given  as  in  rheumatism,  affords  relief.  Hydrargyri 
biniodide  gr.  geo  given  every  fifteen  minutes  for  ten  doses  often  aborts 
the  process.  Guaiac,  though  generally  used,  has  produced  unsatisfac- 
tory results  in  personal  experience;  the  dose  is  tr.  guaiaci  ammoniat. 
TT^  X  to  xl  every  two  hours.  Aspirin,  and  Dover's  powder  aa  gr.  x, 
reHeve  pain  in  the  throat,  body,  and  limbs.  Aconite  and  belladonna 
are  often  beneficial  in  children  with  high  fever,  and  rather  less  so  in 
adults;   thev  are  given  as  in  coryza  or  influenza. 


(B).  SUPPURATIVE  TONSILLITIS. 

Etiology. — The  etiology  is  almost  identical  with  that  of  the  follicu- 
lar type.  Suppurative  tonsillitis  is  most  common  in  adolescence,  and 
individual  disposition  for  unknown  reasons  is  an  important  factor. 

S3nnptoms. — The  early  symptoms,  local  and  general,  resemble 
those  of  the  follicular  type  but  are  often  more  severe  from  the  onset; 
one,  or  less  often  both,  tonsils  are  greatly  swollen,  tense,  oedematous, 
deep  red  and  may  show  distended  lacuna.  The  pain  often  radiates  to 
the  ears.  The  swollen  tonsils  may  come  in  contact,  or  if  but  one  tonsil 
is  swollen  it  may  reach  over  to  the  sound  side.  There  is  often  coin- 
cident stomatitis  and  a  free  salivary  flow.  The  palate  and  uvula  are 
frequently  oedematous  and  covered  with  muco-pus.  Swallowing 
causes  great  pain  in  the  throat,  the  jaw  cannot  be  depressed  because 
of  the  swollen,  painful  angular  glands,  and  the  speech  is  nasal.  The 
toxsemic  prostration  is  often  profound,  the  fever  ranges  between  103 
and  105  degrees  and  the  pulse  between  100  and  140. 


CHRONIC  TONSILLITIS  587 

Incision  in  the  first  two  or  three  days  evacuates  no  pus  and  only 
blood  and  serum  escape.  In  a  few  days  fluctuation  is  felt  in  the  tonsil, 
or  anterior  to  and  above  the  tonsil  (peritonsillar  abscess).  Introduction 
of  a  probe  into  the  early  and  often  unsuccessful  incision  is  followed  by 
escape  of  pus  and  by  immediate  relief.  The  abscess  may  break  spon- 
taneously, usually  forward  and  rarely  toward  the  throat,  when,  in  rare 
cases,  especially  when  rupture  occurs  during  sleep,  suffocation  or 
aspiration  pneumonia  may  follow.  In  equally  rare  instances  ulceration 
may  reach  the  carotid  with  sudden  and  fatal  hemorrhage. 

Treatment. — (a)  For  prevention  tonsillectomy  by  the  knife  or  gal- 
vanic snare  is  indicated  after  an  individual  tendency  is  manifested. 
(6)  In  local  treatment  an  ice-bag  placed  over  the  neck  is  beneficial. 
Local  applications  to  the  tonsils  are  at  the  best  uncertain  remedies. 
It  is  good  practice,  early  in  the  course,  to  introduce  a  knife,  covered 
with  adhesive  plaster  to  within  half  an  inch  of  its  point,  above  and 
somewhat  inside  the  tonsil;  blood  and  serum  escape,  tension,  oedema 
and  pain  are  relieved  and  the  later  abscess  more  readily  points  toward 
the  cut;  the  wound  is  carefully  opened  with  a  blunt  probe  every  day; 
early  incision  is  preferable  to  scarification,  (c)  Salicylates  apparently 
help  and  possibly  hasten  maturation.  Opium  and  coal  tar  products 
relieve  the  pain  to  some  extent,  (d)  In  exceptional  cases,  intubation, 
tracheotomy  or  immediate  excision  of  the  tonsil  are  indicated,  because 
of  great  swelling  or  collateral  cedema.  (e)  The  diet  is  necessarily  liquid. 
(/)  In  convalescence,  iron  and  strychnine  overcome  the  resulting  pros- 
tration and  anaemia. 


(C).  CHRONIC  TONSILLITIS. 

Synonyms. — Chronic  inflammation;  tonsillar  hypertrophy;  hyper- 
plasia of  the  pharyngeal  or  lingual  tonsils;   adenoids;   aprosexia. 

Etiology. — (a)  Repeated  acute  attacks  of  tonsillitis  cause  chronic 
hypertrophy  in  some  cases,  and  in  others  the  tonsils  gradually  indurate 
and  shrink,  (6)  Waldeyer's  "Schlundring"  of  lymphadenoid  tissue 
consists  of  the  two  tonsils,  the  adenoid  tissue  in  the  nasopharyngeal 
vault  (Kollicker's  pharyngeal  tonsil,  or  "adenoids"  in  the  common 
acceptation),  and  the  so-called  lingual  tonsil.  Variously  combined 
hypertrophies  of  these  structures  may  be  noted,  occasionally  as  con- 
genital growths,  but  most  frequently  in  young  children,  and  sometimes 
in  adults.  They  generally  begin  during  the  third  or  fourth  year  and  may 
develop  until  puberty.  Adenoids  are  found  in  1  per  cent,  of  children 
(Meyer),  though  other  statistics  give  3  per  cent,  or  even  higher 
figures.  Rickets,  scrofula,  the  lymphatic  constitution  and  various  acute 
infections  involving  the  throat,  as  diphtheria,  are  cited  as  predisposing 
conditions. 

Symptoms. — 1.  Local  Changes. — (a)  The  enlarged  tonsil  may  con- 
tain in  its  qrypts  cheesy  plugs,  which  occasion  an  extreme  ja?tor  ex 
ore.    The  plugs  may  be  expressed ;  calculi  may  result  from  a  deposit  of 


588  DISEASES  OF  THE  DIGESTIVE  TRACT 

lime  salts.  The  pharyngeal  mucus  is  increased,  is  sometimes  tinged 
with  blood,  and  is  expectorated  with  difficulty.  (6)  Adenoids  in  the 
nasopharyngeal  vault  occur  alone  or  with  tonsillar  hyperplasia.  They 
are  most  often  papillomatous,  less  often  sessile;  they  are  reddish,  very 
vascular  and  range  up  to  the  size  of  a  bean,  (c)  Hypertrophy  of  the 
"lingualtonsil"  often  disturbs  deglutition.  Enlarged  tonsils  and  adenoids 
produce  most  of  the  following  changes  by  stenosing  the  posterior  nares. 

2.  Sequences. — (a)  Oral  breathing  is  the  earliest  symptom,  and  is 
first  noticed  during  the  night,  when  sleep  is  disturbed  by  night  terrors 
{favor  nocturnus)  and  by  disordered  and  sometimes  irregular  breathing, 
for  a  time  stertorous,  and  then  interrupted.  Jjjing  down  may  occasion 
asthmatic  seizures  or  Balne's  paroxysmal  cough.  (6)  After  some  time 
changes  in  the  mouth  are  noted.  The  'palatal  vault  is  high  from  atmos- 
pheric pressure  in  the  mouth,  and  the  transverse  measurement  between 
the  upper  teeth  is  proportionately  diminished;  there  is  less  room  for 
the  teeth  to  erupt,  (c)  In  the  nose,  the  anterior  nares  are  small  and 
retracted,  and  the  voice  is  nasal  {rhinolalia  claustra);  the  consonants 
n  and  m  are  pronounced  with  difficulty.  Bloch  associated  oral  breath- 
ing with  stuttering.  The  senses  of  smell  and  taste  are  obtunded. 
Hearing  is  impaired  by  pressure  of  adenoids  on  the  Eustachian  tubes, 
by  inflammation  in  the  tubes  or  by  retraction  of  the  tympana  from  low 
atmospheric  pressure  in  the  nasopharynx,  {d)  The  fades  is  charac- 
teristic; it  is  vacuous  and  apathetic,  the  nose  is  pinched,  the  mouth  open 
and  the  lips  swollen.  The  so-called  "adenoid  habitus"  may  be  ob- 
served Tvdthout  adenoids,  as  a  stigma  of  degeneracy,  (e)  The  mentality 
is  altered  in  chronic  cases;  the  cerebral  reaction  is  slow,  the  memory 
tardy,  the  disposition  sullen  and  the  power  of  concentration  diminished; 
this  latter  condition  was  named  aprosexia  by  Guye.  Woodward  refers 
the  physical  changes  to  some  toxin  (cytotoxin)  elaborated  in  the 
hyperplastic  lymphoid  tissue.  (/)  There  are  other  nervous  symptoms. 
Headache  is  common.  Adenoids  cause  some  cases  of  habit-spasm. 
Night  terrors  have  been  mentioned.  Enuresis  nocturna  results  from 
carbon  dioxide  operating  on  the  brain  during  sleep  (Schech).  {g) 
Development  is  sometimes  retarded,  {h)  Changes  in  the  contour  of  the 
thorax  were  noted  by  Dupuytren  (1828),  J.  M.  Warren  (1839)  and 
Lambron  (1861).  The  pigeon-  or  chicken-breast  is  the  most  common 
deformity.  The  sternum  juts  forward,  from  which  the  ribs  slant 
sharply  backward;  at  the  level  of  the  diaphragm  there  is  a  circular 
depression,  and  inspiratory  retraction  is  caused  by  the  contraction  of 
the  diaphragm.  The  funnel  breast,  marked  by  a  deep  depression  of 
the  lower  part  of  the  sternum,  is  less  commonly  due  to  adenoids,  and 
like  the  chicken-breast  also  results  from  other  causes.  The  "emphy- 
sema chest "  may  result  from  adenoids,  (i)  Scheir  finds  that  the  cervical 
lymph  glands  are  also  enlarged  and  that  the  blood  evidences  a  decrease 
in  haemoglobin,  two-  to  three-fold  increase  in  the  white  cells,  and  a 
distinct  lymphocytosis.     (Plate  XI). 

Diagnosis. — The  oral  breathing,  the  adenoid  facies  and  mental 
disturbance,  palpation  of  the  adenoids  in  young  children  and  their 


PLATE  XI. 


FIG.  1. 


Types  of  the  "Adenoid"  bacies.     (Posey  and  Wright. 


(ESOPHAGEAL  INFLAMMATION,  NECROSIS,    ULCERATION        589 

rhinoscopic  detection  in  older  ones,  and  the  mere  inspection  of  hyper- 
plastic tonsils  determine  the  diagnosis.  In  the  'prognosis  of  untreated 
eases,  the  possibility  of  deafness,  mental  deficiency,  retarded  growth, 
asthma,  and  emphysema  should  be  borne  in  mind.  Colds,  acute  re- 
current tonsillitis,  diphtheria  and  probably  other  infections  are  more 
likely  both  to  develop  and  to  produce  disproportionate  symptoms.  In 
some  few  cases  the  hyperplastic  tissues  may  indurate  and  atrophy,  but 
this  spontaneous  issue  should  have  no  essential  influence  in  their 
management. 

Treatment.— Palliative  treatment  by  astringents  is  useless.  The 
general  health  should  be  maintained  by  out-door  life,  an  ample  diet, 
hydrotherapy,  and  by  cod-liver  oil,  iron  and  other  measures  which  are 
employed  in  scrofula  and  tuberculosis.  Hypertrophied  tonsils  should 
be  removed  at  once  by  the  knife  or  in  several  sittings  by  the  galvanic 
cautery,  for  details  of  which  the  reader  is  referred  to  special  treatises. 
Adenoids  large  enough  to  cause  symptoms  should  always  be  removed 
early  under  anaesthesia,  by  the  finger  or  curette;  ether  is  far  less  dan- 
gerous than  chloroform,  which  frequently  causes  death  in  any  disease 
of  the  lymphadenoid  tissues  (the  status  thymicus  or  lymphoid  constitu- 
tion). The  sequences  above  described  usually  subside  soon  after 
operation,  though  oral  breathing  is  a  habit  somewhat  hard  to  break. 
At  night  a  bandage  should  be  used  to  keep  the  mouth  closed. 


DISEASES  OF  THE  (ESOPHAGUS. 

(A).  INFLAMMATION,  NECROSIS,  ULCERATION. 

1.  (Esophagitis. — This  is  an  uncommon  finding  at  autopsy.  Its 
causes  are  (a)  mechanical,  as  from  foreign  bodies,  strictures  or  dilata- 
tion of  the  oesophagus;  (6)  chemical,  as  from  alcohol,  tobacco,  corros- 
ive poisons  or  acid  vomitus;  (c)  thermal;  {d)  hypostatic,  in  cardiac  or 
pulmonary  affections;  (e)  rarely  extension  from  pharyngeal  or  laryn- 
geal inflammation;  (/)  acute  infections,  as  measles,  smallpox,  scar- 
latina, and  diphtheria.  OEsophagitis  is  almost  physiological  in  the 
new-born  after  the  ingestion  of  the  first  meals  of  life.  Its  pathology  in 
general  is  that  of  pharyngeal  or  nasal  inflammation;  it  is  marked  by 
local  or  diffuse,  acute  or  chronic  redness,  swelling  and  hypersecretion. 
Special  pathological  forms  are  follicular  catarrh,  sometimes  resulting  in 
follicular  ulcers  or  retention  cysts  in  the  submucosa;  exfoliative 
oesophagitis  (o.  dessicans  superficialis) ;  the  fibrinous  form,  observed 
in  various  acute  infections,  in  urtemia  and  rarely  in  hysteria;  genu- 
ine diphtheria;  the  pustular  eruption  of  smallpox;  the  toxic  form 
resulting  from  caustics  or  acids;  the  very  rare  phlegmonous  or  purulent 


590  DISEASES  OF  THE  DIGESTIVE  TRACT 

form  (only  12  cases  are  on  record)  which  occurs  as  a  single  bulging 
submucous  abscess  or  as  diffuse  submucous  suppuration  and  often 
perforates  in  many  places  into  the  oesophagus  which  then  presents  a 
sieve-like  aspect;  forms  due  to  the  oidium  albicans,  or  ray  fungus,  of 
which  primary  cases  are  reported.  In  chronic  cases  the  epithelium 
may  thicken  (leukoplakia)  or  hypertrophy  (in  papillomatous  forms). 

Symptoms. — Symptoms  are  absent  in  slight  grades  of  inflammation. 
In  marked  cases  there  is  pain,  which  is  sometimes  continuous  and 
substernal,  and  at  other  times  is  elicted  by  speaking,  movement  or 
pressure  on,  or  movement  of,  the  spine.  Dysphagia  is  constant  in 
marked  inflammations.  Mucus,  blood,  pus  or  eschars,  depending  on 
the  nature  and  cause  of  the  inflammation,  are  brought  up  by  gagging 
efforts.  Fever  is  common  in  the  more  severe  types,  in  which  the  local 
symptoms  may  be  wholly  subordinate  to  the  causal  disease  (diphtheria, 
smallpox,  etc.).  In  inflammation  due  to  acids  or  alkalies,  the  history, 
local  symptoms  and  eschars  in  the  mouth  and  pharynx  are  distinctive. 

Treatment. — Treatment  is  usually  palHative  at  the  best,  depend- 
ing on  the  cause.  Narcotics  are  given  for  pain,  demulcents  as  acacia 
and  ice,  ice-cream  and  a  liquid  diet  for  the  local  irritation,  and  if  these 
cause  oesophageal  irritation  nutrient  enemata  are  given  (v.  Gastric 
Ulcer). 

2.  Necrosis. — ^This  may  be  due  to  intense  corrosive  poisoning;  to 
pressure  from  without,  as  from  struma,  aneurysm,  foreign  bodies,  or 
sounds  which  are  left  in  the  oesophagus  to  dilate  strictures ;  or  to  decu- 
bitus or  "bed  sores  of  the  gullet,"  first  described  by  Dittrich  (1850)  in 
connection  with  laryngeal  perichondritis,  due  to  pressure  of  the  larynx 
upon  the  gullet  and  promoted  by  fever,  inanition  and  infections. 
CEsophagomalacia  is  softening  of  the  part  by  regurgitation  into  it  of  the 
gastric  acid;  it  occurs  chiefly  after  death,  but  some  few  cases  appear 
to  develop  during  the  death  agony. 

3.  Ulceration. — Aside  from  cancer  (v.  i.),  follicular  ulceration, 
caustic  ulcers,  syphihs  and  tuberculosis,  there  is  the  peptic  or  round 
ulcer.  Peptic  ulcer  was  first  described  by  Cruveilhier,  who  correctly 
identified  it  with  round  ulcer  of  the  stomach.  Twenty-three  cases  are 
recorded  in  the  literature.  It  appears  in  four  main  conditions  (a)  b} 
extension  from  the  round  ulcer  of  the  cardiac  orifice,  (h)  in  ulcers  at  the 
pylorus  or  duodenum,  which  produce  gastric  dilatation,  (c)  in  multiple 
hemorrhagic  infiltrations  of  the  oesophagus,  stomach  and  duodenum 
and  (d)  in  alcoholism,  arteriosclerosis  and  other  as  yet  imperfectly 
investigated  conditions.  Its  chief  symptom  is  dysphagia;  its  pathology 
and  comphcations,  as  hemorrhage,  perforation  and  stenosis,  as  well  as 
its  treatment,  are  practically  identical  with  those  of  gastric  ulcer,  with 
which  it  is  often  associated. 

(B).  STENOSIS  OR  STRICTURE  OF  THE   (ESOPHAGUS. 

Stenosis  is  the  most  important  and  frequent  of  oesophageal  diseases. 
In  this  connection  von  Mikulicz's  conclusion  is  important,  viz.  that 


(ESOPHAGEAL  STEXOSIS  OR  STRICTURE  591 

the  oesophagus  is  a  closed  tube  only  in  its  cervical  segment  and  that  its 
cardiac  orifice  is  not  physiologically  closed. 

Etiology. — (a)  Interstitial  factors,  i.  e.,  in  the  wall  of  the  oesophagus, 
are  the  most  important;  cancer  (v.  i.)  causes  90  per  cent,  of  all  stenoses 
(v.  Leyden,  Kraus,  Rosenbach);  stenosis  from  ulceration  by  caustics 
and  acids  comes  next ;  then  comes  stenosis  by  diyerticulaorpouches('U.  i.) 
which,  bulging  out  of  and  beside  the  oesophagus,  exert  upon  it  a  lateral 
compression;  other  rarer  ulcerative  stenoses  result  from  healing  gum- 
mata,  tuberculous  lesions,  smallpox  and  other  suppurative  affections, 
and  from  peptic  and  diphtheritic  ulcers ;  muscular  spasm  causes  a  few 
cases;  congenital  stenosis  or  atresia  is  very  rare  (15  cases  recorded) 
and  occurs  chiefly  as  a  cul  de  sac,  incomplete  development  or  fistulous 
communications  with  the  trachea  or  bronchi.  (6)  Extra-cesophageal 
factors,  compressing  the  tube  from  without,  are  next  in  importance  and 
include  aortic  aneurysm  or  abnormal  branches  from  the  aorta;  verte- 
bral lesions,  (tumor,  cold  abscess,  exostosis,  great  deformation); 
anthracotic  lymphadenitis  and  malignant  lymphoma;  thyroid  or 
thymic  inflammation  or  hypertrophy;  mediastinitis  callosa,  pericarditis 
effusiva,  pulmonary  neoplasms,  and  luxation  of  the  hyoid  bone  or 
cla'\Tlcle.  (c)  Intra-oesophageal  factors  comprise  the  fewest  causal 
agents,  as  foreign  bodies,  pedunculated  polyps  which  usually  form  from 
the  lower  pharynx,  and  Oidium  albicans. 

Apart  from  the  special  pa^/ioZo^?/ of  these  causes,  stenosis  occur  chiefly 
(a)  at  the  lower  third  of  the  oesophagus,  (b)  near  the  level  of  the  bifurca- 
tion of  the  trachea,  or  (c)  high  up  in  the  oesophagus.  The  stenosis  is 
more  often  single  than  multiple  and  more  often  annular  than  longi- 
tudinal; it  varies  from  slight  stenosis  to  complete  atresia,  in  which  the 
tube  may  be  seen  as  an  impervious  cord.  Above  the  stenosis  the  tube 
is  dilated  and  its  musculature  is  usually  vicariously  hypertrophied  in 
order  to  force  food  through  the  narrowed  point. 

Sjrmptoms. — Symptoms  vary  with  the  cause  and  its  extent;  thus 
mechanical  dysphagia  may  be  quite  secondary  to  aortic  aneurysm  and 
may  vary  from  time  to  time  with  the  pressure  exerted  upon  it;  in  the 
cicatrizing  ulcers  dysphagia  is  the  only  symptom.  When  stenosis  is 
advanced,  the  food  and  later  the  fluids  taken,  regurgitate  after  a  short 
time,  if  the  stenosis  is  low,  or  at  once  if  the  stenosis  lies  just  below  the 
pharynx;  as  a  rule,  the  subjective  localization  described  by  the  patient 
is  unreliable.  The  regurgitated  food  is  neutral,  macerated,  fermented, 
and  often  contains  round  cells,  mucus,  or  blood,  but  never  HCl  nor 
pepsin.  (Esophageal  pain  is  common,  but  its  occurrence  depends  on 
the  causal  lesion.  Singultus  is  rather  frequent  when  the  lesion  lies  near 
the  diaphragm.  Dyspnoea  may  result  from  pressure  upon  the  air 
passages  by  the  dilated  portion  of  the  oesophagus  above  the  stricture. 

Physical  Examination  and  Diagnosis. — The  chest  should  be 
examined  for  aneurysm,  retrosternal  struma,  and  lung  tumors,  and  the 
finger  should  be  introduced  as  far  as  possible  down  the  throat,  to 
exclude  the  possibility  of  lesions  situated  high  up  in  the  oesophagus  or 
larynx.     Illumination  of  the  oesophagus  (oesophagoscopy)  may  give 


592  DISEASES  OF  THE  DIGESTIVE  TRACT 

excellent  results  if  done  by  an  expert,  but  its  general  application  is  very 
limited.  Local  signs  are  elicited  chiefly  in  three  ways — by  sounding, 
by  auscultation  and  by  the  a:-rays. 

1.  Sounding. — A  soft  sound  is  far  less  dangerous  than  a  hard  one,  at 
least  for  the  first  examination  and  does  the  least  damage  in  cases  of  acute 
oesophagitis,  aneurysmal  compression,  and  ulcerating  cancer.  It  is 
not  sufiicient  to  pass  one  stricture,  as  there  may  be  others  lower  down, 
whence  the  sound  should  be  passed  into  the  stomach.  The  length  of 
the  oesophagus  is  10  inches  or  25  cm.  (or  15  per  cent,  of  the  patient's 
height);  from  the  upper  incisor  teeth  to  the  oesophagus  6  inches  or 
15  cm.,  from  the  teeth  to  the  cardia  16  inches  or  40  cm.  Recently  it 
is  maintained  that  the  last  measurement  should  be  19.7  inches,  or 
50  cm.  The  length  of  the  cervical  portion  is  2  inches  or  5  cm.,  of 
the  thoracic  6f  inches  or  17  cm.,  and  of  the  abdominal  part  1^  inches 
or  3  cm.  From  the  teeth  to  the  level  of  the  tracheal  bifurcation  is  9 
inches  or  23  cm. 

2.  Auscultation. — Deglutition  is  marked,  physiologically,  by  two 
murmurs,  which  can  be  heard  with  the  stethoscope  six  to  eight  seconds 
after  the  beginning  of  the  act,  first  a  short  murmur  and  then  a  longer 
one.  In  cases  of  marked  stenosis  the  swallowing  sound  is  heard  at  a 
point  just  above  the  lesion;  this  is  a  valuable  help  when  aneurysm  is 
suspected  and  sounding  is  therefore  feared.  In  the  cervical  part  of  the 
oesophagus  the  noise  results  chiefly  from  the  movements  of  the  phar- 
ynx; in  the  thoracic  segment  the  stenotic  murmur  is  heard  to  the  left 
of  the  spine  from  the  first  to  the  ninth  dorsal  vertebra.  Stenosis  near 
the  tracheal  bifurcation  often  gives  a  delayed  first  murmur,  and  a 
gurgling,  spurting  character  in  both  murmurs ;  in  the  lowest  segment 
the  murmurs  are  heard  just  above  the  cardia,  at  the  ninth  or  tenth 
dorsal  vertebra. 

3.  X-rays. — The  x-rays  may  show  the  outline  of  the  dilatation  above 
the  stricture  (v.  i.  Dilatation  op  (Esophagus). 

Prognosis. — The  prognosis  depends  on  the  cause.  Cancerous 
stricture  may  ulcerate,  thus  reheving  the  local  symptoms,  though  the 
cachexia  increases.  Strictures  resulting  from  caustics  often  improve. 
In  cases  where  the  cause  cannot  be  relieved,  the  same  symptoms  result 
as  in  oesophageal  cancer  (q.  v.).  Perforation  into  the  lungs,  pleura,  or 
air  passages,  or  into  the  mediastinum  or  vessels,  may  follow.  Aspira- 
tion pneumonia,  which  is  often  gangrenous,  is  not  infrequent. 

Treatment. — The  remediable  etiological  factors  are  few,  except 
that  iodides  may  be  given  in  syphilis  or  aneurysm.  Foreign  bodies  may 
sometimes  be  removed  by  a  long  forceps,  though  of  course  with  the 
direction  of  the  oesophagoscope.  In  cancerous  and  aneurysmal 
strictures,  probing  and  dilatation  are  dangerous.  Dilatation  by  sounds 
is  attended  by  the  risk  of  perforating  the  oesophagus.  Sounds  should  be 
introduced  beside  the  index  finger,  and  the  patient's  head  should  be 
thrown  slightly  backward ;  severe  gagging  may  be  overcome  ^  by 
painting  the  pharynx  with  cocaine,  though  it  is  often  as  much  psychical 
as  oesophageal,  and  assurance  is  a  better  preventive  than  drugs.    The 


(ESOPHAGEAL  DILATATION.     DIVERTICULUM  593 

subject  should  first  swallow  some  olive  oil  to  facilitate  passage  of  the 
sound.  In  passing  the  sound  it  should  be  held  like  a  pen  and  pushed 
with  exceeding  gentleness.  Trousseau's  tapering  ivory  olive  points  are 
excellent,  but  care  is  necessary,  and  successively  larger  sizes  should  be 
used.  Sounds  may  be  left  in  the  oesophagus  for  some  minutes  or  an 
hour,  or  even  permanently,  but  pressure  necrosis  may  then  result. 
It  is  at  times  necessary  to  introduce  filiform  bougies,  such  as  are  used 
in  passing  very  narrow  urethral  strictures.  Silver  balls  (2  to  7  mm.  in 
diameter)  with  threads  attached,  may  be  swallowed;  they  should  be 
carefully  pulled  out  after  remaining  in  over  night.  When  the  obstruc- 
tion is  high,  external  rather  than  internal  oesophagotomy  is  advisable, 
though  oesophageal  surgery  is  still  in  its  infancy.  As  first  practiced  by 
von  Bergmann,  after  opening  the  stomach,  dilatation  may  be  employed 
from  below.  Impermeable  strictures  call  for  gastrostomy  and  rectal 
alimentation.  See  Treatment  of  Intestinal  Obstruction  for 
thiosinamin. 

(C).  DILATATION.     DIVERTICULUM. 

Etiology. —  Dilatation  involves  the  entire  circumference;  diverticulum 
involves  but  part  of  it.  Secondary  dilatation  may  occur  above  stenosis 
of  the  oesophagus  or  above  the  cardiac  end  of  the  stomach.  It  seldom 
extends  more  than  an  inch  and  a  half  (4  cm.)  above  the  stricture;  it 
rarely  follows  pyloric  stenosis.  Primary  (idiopathic)  dilatation  may 
be  local  or  total.  Marked  dilatation  above  the  cardia,  Luschka's  so- 
called  "fore-stomach"  is  an  example  of  the  local  form,  which  is  usually 
congenital.  The  diffuse  idiopathic  dilatation  results  without  any  causal 
organic  stenosis  and  is  seen  chiefly  between  the  years  of  twenty  and 
forty.  Its  actual  cause  is  disputed.  Most  clinicians  incline  to  the  view 
advanced  in  1888  by  Meltzer,  of  New  York,  that  its  cause  is  a  cardio- 
spasm due  to  abolition  of  cerebral  inhibition  on  the  cardia;  in  fact 
Kraus  reports  a  case  with  great  atrophy  of  both  vagi;  Rosenheim 
maintains  that  atony  and  ectasia  are  primary  and  cardiospasm  second- 
ary. The  role  of  trauma,  acute  oesophagitis  and  congenital  weakness 
of  the  oesophageal  musculature  is  uncertain.  Cardiospasm  pro- 
duces a  great  hypertrophy  of  the  cardiac  muscle,  even  six  times  its 
normal  thickness,  and  diffuse  total  dilatation  so  that  the  oesophagus 
may  measure  18  inches  (46  cm.)  instead  of  10  inches  (25  cm.)  in  length 
or  12  inches  (30  cm.)  in  circumference  (Luschka).  Though  Zenker 
collected  but  18  cases  in  1878,  the  number  is  increasing;  nearly  a  dozen 
were  reported  in  1904  (Sippy,  Tyson,  Kinnicutt,  and  Sossen),  and  up  to 
1905  over  90  are  recorded.  The  mucosa  is  catarrhal,  thickened,  or 
eroded,  and  the  muscularis  is  hypertrophied  or  fatty. 

Symptoms. — The  symptoms  are  gradual  or  sudden  in  onset.  There 
is  dysphagia,  which  may  often  be  overcome  by  effort;  the  patient  feels 
that  the  food  does  not  reach  the  stomach.  Regurgitation  of  the  food, 
especially  the  portion  last  swallowed,  usually  occurs  soon  after  eating 
or  when  the  patient  lies  down;    it  may  measure  a  quart,  is  neutral, 

38 


594         DISEASES  OF  THE  DIGESTIVE  TRACT 

b'..'-,'       .....  ■   . 

decomposed  if  it  has  been  retained  for  some  time,  and  contains  lactic 
and  butyric  acids  but  no  hydrochloric  acid,  pepsin  or  rennet.  The 
regurgitated  food  may  again  be  swallowed  (rumination).  Vomiting  of 
course  is  impossible.  The  pressure  of  the  stagnant  food  or  fluid  in  the 
gullet  may  produce  vagus  symptoms,  such  as  dyspnoea  or  palpitation. 
The  sound,  when  introduced,  moves  freely  from  side  to  side,  but  meets 
at  least  temporary  resistance  at  the  cardia,  though  pressure  usually 
overcomes  the  obstructing  cardiospasm.  One  sound,  introduced  into 
the  stomach,  may  recover  HCl,  pepsin,  etc.,  but  another,  introduced 
to  but  not  beyond  the  cardia,  recovers  fluid  or  food  with  a  neutral  re- 
action; methylene  blue  solution  poured  through  the  first  tube  returns 
blue;  that  recovered  by  the  second  tube  is  colorless.  Distention  of  the 
oesophagus  with  carbon  dioxide  gives  tympany,  or  with  water  dulness, 
near  the  left  of  the  sixth  to  the  ninth  dorsal  vertebrse,  sometimes  above 
the  left  costal  arch,  or  even  in  the  epigastrium.  The  cesophagoscope 
may  reveal  the  dilatation;  a  distinct  shadow  may  often,  though  not 
always,  be  seen  by  using  the  rr-rays  after  the  patient  has  eaten  potatoes 
or  bread  which  have  been  well  mixed  with  bismuth.  The  second 
swallowing  bruit  may  be  absent  or  altered,  or  sometimes  sounds  like 
fluid  running  into  fluid.  Marasmus  and  constipation  and  often  death 
result,  but  the  clinical  course  may  cover  years  or  decades. 

Treatment. — Treatment  is  rather  unsatisfactory.  Internal  galvan- 
ization or  faradization  has  been  recommended.  Olive  oil  §ss.  before 
meals  may  help  the  fluid  (or  the  sound)  to  pass  the  cardia.  Continued 
use  of  the  stomach  tube  may  be  effective,  but  in  some  instances  causes 
oesophagitis;  its  life-long  use  is  often  required.  Lockwood's  pneu- 
matic bag  may  be  introduced  empty  on  a  sound  into  the  stomach,  then 
inflated  and  withdrawn  slowly  and  gently  through  the  cardia;  Strauss 
praises  this  method.  Gastrostomy  and  rectal  feeding  may  be  indi- 
cated. Operation  should  not  be  delayed  too  long.  The  cardia  has 
been  operated  upon  a  number  of  times.  Mikulicz  operated  six  times — 
with  five  cures — by  entering  the  stomach,  forcibly  distending  the  cardia 
and  rupturing  its  fibers  submucously. 

Diverticulum. — This  involves  only  an  arc  of  the  oesophageal  circum- 
ference. Two  types  are  distinguished:  1.  Zenker's  pressure  diver- 
ticulum (pulsion-diverticulum)  of  which  Rosenthal  (1902)  could  collect 
but  180  cases.  It  is  found  chiefly  in  men  (77  per  cent.),  and  is  a  pouch 
which  forms  very  gradually  on  the  posterior  oesophageal  wall,  usually 
near  the  junction  of  the  pharynx  and  oesophagus,  and  nearly  always 
consists  of  only  the  mucosa  and  submucosa, — a  kind  of  pyriform  or 
bottle-shaped  oesophageal  hernia.  Its  onset  is  very  gradual,  for  the 
muscle,  which  is  probably  congenitally  weak,  yields  before  intra-oesoph- 
ageal  pressure,  trauma,  foreign  bodies,  and  the  stagnating  food.  The 
early  symptoms  are  signs  of  pharyngo-oesophagitis,  hawking  and 
dysphagia,  and  food  entering  the  sac  rather  than  the  oesophagus ;  the 
axis  of  the  sac,  which  dips  between  the  gullet  and  the  spine,  is  roughly 
parallel  with  that  of  the  oesophagus;  many  of  its  symptoms  are  those 
of  a  high  oesophageal  stenosis.     The  food  stagnates  and  regurgitates 


CANCER  OF  THE  (ESOPHAGUS  595 

with  a  foetid  odor.  In  33  per  cent,  of  cases  a  tumor  appears  in  the 
supraclavicular  region,  which  is  dull  when  filled  with  food  or  tym- 
panitic when  distended  with  carbon  dioxide;  it  sometimes  can  be 
smoothed  out,  but  this  makes  the  food  regurgitate.  The  murmurs  on 
swallowing  are  protracted  (in  50  per  cent.).  A  sound,  if  introduced, 
usually  enters  the  sac,  and  another,  if  slightly  bent,  enters  the  gullet; 
this  also  differentiates  the  diverticulum  lower  in  the  gullet,  which  is 
even  less  common.  Examination  by  the  oesophagoscope  is  generally 
negative,  but  the  a;-rays  may  show  a  characteristic  shadow.  There  may 
be  pressure  on  the  heart,  trachea,  vagus,  recurrent  laryngeal  nerve,  and 
brachial  plexus.  The  clinical  course  is  usually  protracted,  even  to 
twenty  or  forty-nine  years,  and  the  spontaneous  evolution  is  inanition 
in  over  50  per  cent,  of  the  cases,  gangrene  (15  per  cent.)  or  perforation 
with  cervical  phlegmon.  Treatment  includes  feeding  by  means  of  the 
sound,  rectal  nutrition,  gastrostomy,  and  surgical  resection;  this  was 
first  performed  by  von  Bergmann  (1890),  24  cases  being  recorded  with 
20  per  cent,  mortality.  Diverticula  low  in  the  oesophagus  can  only  be 
treated  by  long-continued  sounding. 

2.  Rokitansky's  traction-diverticulum  is  frequent;  according  to 
Riebold  it  is  found  in  3.5  per  cent,  of  all  autopsies.  It  is  due  to  extra- 
oesophageal  traction,  which  draws  a  small  part  of  the  gullet  out  into  a 
funnel-like  form.  Over  80  per  cent,  is  due  to  indurative  periadenitis 
around  caseous  or  anthracotic  lymph  glands.  Cicatricial  mediastinitis 
from  pleuritis,  pericarditis  or  vertebral  disease  may  produce  the  same 
effects.  It  usually,  therefore,  occurs  at  the  level  of  the  tracheal  bifur- 
cation. Diverticula  may  result  from  both  traction  and  pressure. 
Traction-diverticulum  begins  early  in  life,  is  usually  single,  is  less 
marked  on  the  anterior  or  lateral  wall,  barely  exceeds  five  to  ten  mm. 
in  depth  and  is  rarely  discovered  during  life,  though  some  have  been 
seen  with  the  oesophagoscope.  Its  chief  danger  is  ulceration  at  its  apex 
and  perforation  into  the  trachea,  bronchi,  vessels,  pericardium,  pleurae, 
or  mediastinum,  with  resulting  gangrene  of  the  lungs,  fatal  hemorrhage, 
pneumothorax  or  phlegmonous  mediastinitis.    There  is  no  treatment. 


(D).  CANCER  OF  THE  (ESOPHAGUS. 

Etiology. — Its  frequency  is  rated  at  j  to  1  per  cent,  of  autopsies,  and 
it  is  said  by  Petersen-Borstell  to  rank  third  among  cancers  (stomach 
33  per  cent.,  uterus  15  per  cent,  and  oesophagus  6  per  cent.).  Its  etiology 
is  unknown,  (a)  Scars,  trauma,  ulceration  and  traction  diverticulum 
are  promoting  causes;  (6)  75  per  cent,  occurs  in  males,  and  80  per 
cent,  between  the  fortieth  and  sixtieth  years;  8  per  cent,  occurs  before 
the  fortieth  year;  Stewart  records  a  case  aged  twenty-three,  and  Hei- 
mann  one  aged  nineteen. 

Pathology. — Cancer  of  the  oesophagus  is  almost  always  single  and 
primary,  though  cancer  of  the  stomach,  pharynx  or  mediastinum  may 
rarely  involve  the  oesophagus  secondarily.     Most  cases  are  squamous 


596  DISEASES  OF  THE  DIGESTIVE  TRACT 

epithelioma,  arising  from  its  pavement  epithelium;  scirrhus,  colloid 
and  medullary  forms  are  rare.  Localization;  most  cases  (57  per  cent.) 
develop  in  the  lowest  third  of  the  oesophagus;  many  (33  per  cent.)  in 
the  middle,  and  the  least  (10  per  cent.)  in  the  upper  third;  its  favorite 
sites  are  near  the  cardia,  at  the  tracheal  bifurcation  level  and  just  back 
of  the  cricoid  cartilage.  The  muscularis  sometimes  hypertrophies  above 
the  cancer,  where  some  dilatation  may  occur,  but  not  very  frequently. 

Symptoms. — The  onset  is  usually  insidious.  Signs  of  oesophagus 
stenosis  (v.  s.)  develop  in  varying  grades;  stenosis  generally  advances 
slowly  but  is  occasionally  sudden.  It  may  lessen  as  the  cancer  ulcer- 
ates. Its  symptoms  are  those  of  stenosis,  as  dysphagia,  rather  indefi- 
nitely located  pain,  regurgitation  of  food  and  perhaps  also  of  bloody 
mucus  or  of  necrotic  cancer  tissue.  Its  signs  are  also  identical,  as 
obstruction  on  sounding,  alteration  of  the  murmurs,  sometimes  the 
detection  by  the  cesophagoscope  of  a  papillomatous  or  ulcerated  neo- 
plasm, and  quite  rarely  tumor  particles  found  in  the  fenestrse  of  the  tube. 
Cachexia  develops;  constipation,  indicanuria  and  peptonuria  are 
usual;  acetonuria  is  fairly  frequent.  Extension,  by  contiguity,  occurs 
to  the  spine,  mediastinum,  and  cardia,  or  in  60  per  cent,  of  cases  by 
metastasis ;  the  mediastinal  and  peribronchial  lymph  nodes  are  usually 
invaded,  the  supraclavicular  often  and  the  upper  cervical  seldom. 

Complications. — ^There  may  be  pressure  on  the  recurrent  laryngeal 
(13  per  cent.),  vagus  or  mediastinal  veins  and  arteries,  on  the  sym- 
pathetic gangha  (13  per  cent.)  or  brachial  plexus.  Perforation  occurs 
in  over  50  per  cent.,  most  often  into  the  larger  air  passages,  when  aspir- 
ation pneumonia  or  gangrene  may  follow;  into  the  lung,  pleura  (ichor- 
ous pleurisy  or  pneumothorax  resulting);  into  the  aorta  (fatal  hemor- 
rhage), heart,  pericardium,  and  mediastinum.  Pyaemia,  pulmonary 
tuberculosis,  and  marantic  thrombosis,  occur  in  some  cases.  Death 
is  the  inevitable  outcome, usually  within  thirteen  months;  it  occurs  with 
emaciation,  subnormal  temperature,  small  slow  pulse,  slow  shallow 
breathing,  flattened  abdomen,  and  perhaps  intoxication  symptoms,  as 
coma  and  fever. 

Diagnosis. — ^The  diagnosis  is  based  (a)  on  the  fact  that  there  is  a 
stricture  of  the  oesophagus,  which  in  90  per  cent,  of  all  cases  is  car- 
cinomatous; (b)  on  evidences  of  neoplasm,  as  age,  cachexia,  cancerous 
nodes,  metastases,  and  perhaps  tumor  particles  on  the  sound,  (c) 
Other  tumors,  as  Hpoma,  myxoma,  myoma  (11  cases,  Bryant,  1906), 
fibroma,  or  sarcoma,  are  of  greater  pathological  than  clinical  import- 
ance, except  accessible  fibropapillomata  of  the  upper  gullet  or  lower 
pharynx. 

Treatment.— The  treatment  is  that  of  stricture  or  stenosis;  nourish- 
ing enemata,  feeding  by  the  stomach  tube,  gastrostomy  and  for  pain, 
narcotics  are  indicated.  (Esophagectomy  is  seldom  necessary,  as 
less  than  10  per  cent,  of  these  tumors  occur  in  the  cervical  portion, 
accessible  to  surgical  interference.  Most  of  the  operated  cases  die.  As 
to  gastrostomy,  Schmidt  in  1897  reviewed  236  cases,  in  which  45  per 


PERFORATION,  RUPTURE,  HEMORRHAGE  OF  THE  (ESOPHAGUS    597 

cent,  did  not  live  longer  than  a  week,  and  nearly  90  per  cent,  not  more 
than  one  hundred  days. 


(E).  PERFORATION;    RUPTURE;    HEMORRHAGE  OF  THE 
(ESOPHAGUS. 

1.  Perforation  may  result  from  causes  within  or  without  the 
oesophagus.  Internal  causes  include  ulcers,  foreign  bodies,  diverticula, 
cancer,  and  use  of  the  sound ;  external  causes  are  aneurysm,  gravitating 
abscess,  lung  cavities  or  gangrene,  suppurating  lymph  glands  or 
trauma.  It  is  marked  clinically  by  mediastinitis  and  cervical  cellulitis, 
which  is  usually  phlegmonous.  (Esophageal  fistulas  may  communicate 
with  the  air  passages,  from  which  fluid  or  food  are  seen  by  the  laryngeal 
mirror  to  be  expectorated;  a  communicating  tuberculous  cavity  may 
become  flat  when  the  patient  drinks  or  eats,  and  the  flatness  is  changed 
to  tympany  when  the  food  or  drink  is  expectorated ;  this  is  well  tested 
by  giving  the  patient  milk,  which  will  be  brought  up  from  the  larynx. 
Aspiration  gangrene,  pneumopericardium,  pneumothorax,  and  fatal 
hemorrhage  are  quite  common  causes  of  death. 

2.  Spontaneous  rupture  (so-called)  is  a  very  rare  affection,  there 
being  only  twenty-five  certain  cases  on  record.  It  is  often  confused 
with  oesophagomalacia,  in  which  the  rupture  is  not  longitudinal  nor 
clean-cut  as  in  genuine  rupture.  The  first  case,  and  one  of  the  clearest, 
was  reported  by  Boerhave  (1714).  It  follows  over-eating  or  severe 
vomiting,  and  most  victims  have  been  alcoholics.  There  is  great  and 
sudden  pain  over  the  lower  oesophagus  (where  most  ruptures  occur) 
and  over  the  xiphoid,  severe  vomiting,  hsematemesis,  collapse,  and 
subcutaneous  emphysema.  Death  is  the  rule  from  collapse,  phlegmon- 
ous or  ichorous  mediastinitis,  pleuritis,  or  pneumothorax.  Treatment 
is  wholly  expectant. 

3.  Hemorrhage  may  follow  all  varieties  of  oesophageal  ulceration, 
external  or  internal  trauma,  toxic  oesophagitis,  softening,  and  aneurys- 
mal or  other  perforations.  Varicose  veins  in  the  lower  oesophagus, 
first  described  by  Le  Derberden  (1837),  are  most  often  complica- 
tions of  liver  cirrhosis,  less  often  of  syphilis,  senile  atrophy,  and  pyle- 
thrombosis.  The  diagnosis  and  localization  of  the  bleeding  point  is 
at  best  only  suggested  by  the  history  and  previous  physical  findings. 
Treatment  consists  chiefly  of  keeping  the  patient  absolutely  quiet,  of 
giving  morphine,  and  of  rectal  feeding,  as  in  gastric  hemorrhage. 


(F).  MOTOR  AND  SENSORY  DISTURBANCES  OF  THE  (ESOPHAGUS. 

These  will  be  considered  under  Affections  of  the  Vagus  (q.  v., 
under  Nervous  Diseases). 


598  DISEASES  OF  THE  DIGESTIVE  TRACT 

DISEASES  OF  THE  STOMACH. 

(A).  ACUTE  GASTRITIS  (ACUTE  CATARRH,  ACUTE  DYSPEPSIA). 

Acute  gastritis  is  a  better  term  than  catarrh,  which  impHes  a  super- 
ficial inflammation  of  the  mucosa.  Simple  gastritis  will  be  first  con- 
sidered. 

I.  Simple  Gastritis. 

Etiology. — It  is  a  very  common  primary  and  secondary  affection. 
(a)  Its  most  important  mechanical  cause  is  improper  food  or  improper 
eating;  rich  food,  an  excessive  amount,  partial  mastication,  washing 
down  the  food  with  water,  hurried  eating,  eating  when  very  hungry, 
idiosyncrasies  to  certain  kinds  of  food,  decomposed  articles  containing 
bacteria  (B.  coli)  or  ptomaines  (tainting  of  food  is  most  common  in  hot 
weather),  and  excessive  ingestion  of  cold  water  and  fruit  are  accessory 
factors,  (b)  Thermal  factors  include  too  hot  or  too  cold  foods, 
especially  when  taken  on  an  empty  stomach,  (c)  Chemical  causes; 
aside  from  acids  and  caustics  (see  Toxic  Gastritis),  alcohol  ranks  fore- 
most; autotoxins  may  excite  acute  gastritis,  as  those  of  acute  or 
chronic  nephritis,  cholsemia,  or  gout,  (d)  Some  cases  are  clearly  in- 
fectious; the  condition  may  occur  in  variola,  measles,  typhoid,  grippe, 
and  pneumonia,  as  a  secondary  manifestation,  or  occasionally  as  an 
independent  febrile  affection ;  this  happened  in  the  Christiana  epidemic 
reported  by  Hausemann  (1880),  in  which  6,000  persons  were  affected 
within  three  weeks,  (e)  Certain  conditions  are  somewhat  predisposing 
to  acute  gastritis;  for  example,  stasis  (from  diseases  of  the  heart,  lung, 
or  liver),  tuberculosis,  cancer,  syphilis,  chlorosis,  diabetes,  leukaemia,  or 
affections  of  the  higher  alimentary  mucosa.  In  some  cases  a  familial  or 
even  hereditary  tendency  is  noted,  known  as  "the  delicate  stomach" 
by  the  laity.  Nervous  factors,  as  anger  or  excitement,  are  sometimes 
apparently  causative,  though  they  may  be  confused  with  the  digestive 
neuroses. 

Symptoms. — 1.  Digestive  Symptoms. — These  are  sometimes  absent, 
as  was  demonstrated  by  Beaumont  in  the  celebrated  St.  Martin  case 
of  gastric  fistula.  The  appetite  is  usually  lost  or  perverted.  The  tongue 
is  thickly  coated  with  white  fur  and  rather  dry  mucus.  The  mouth  is 
dry  and  there  is  a  disagreeable  taste,  great  thirst,  even  though  the 
salivary  flow  is  often  increased.  Hiccough,  eructations,  a  sense  of 
gastric  distention,  pressure,  or  pain  and  tenderness  over  the  stomach, 
are  common.  Nausea  and  vomiting  characterize  the  more  marked 
cases;  the  vomitus  is  pale  yellow,  bitter,  and  contains  little  or  no  hydro- 
chloric acid,  though  lactic,  butyric  and  fatty  acids  are  common;  there 
is  much  mucus,  which  is  frequently  flecked  with  blood.  Corresponding 
anatomical  changes  are  found,  though  few  uncomphcated  cases  come 


SIMPLE  GASTRITIS  599 

to  autopsy;  the  mucosa,  particularly  near  the  pylorus,  is  red,  swollen, 
smeared  with  adherent  mucus,  sometimes  slightly  eroded  or  dotted  with 
punctate  ecchymoses;  the  dilated  racemous  vessels,  as  seen  by  the 
gastroscope,  or  through  a  gastric  fistula,  are  less  conspicuous  at  autopsy 
for  the  blood  in  great  part  leaves  the  organ  after  death ;  microscopically 
the  salient  findings  are  leukocyte  emigration  and  granular  degeneration 
and  swelling  of  the  mucous  and  other  glandular  cells. 

2.  General  and  Other  Symptoms, — Herpes  is  an  occasional  finding. 
Constipation  is  the  rule,  though  diarrhoea  or  icterus  sometimes  occurs 
in  gastro-enteritis.  The  uriiie  is  scanty  because  of  the  vomiting;  it 
deposits  a  lateritious  sediment  and  sometimes  contains  indican  or 
acetone.  Nervous  symptoms — as  frontal  headache,  vertigo,  intercostal 
neuralgia,  and  depression — are  common,  but  convulsions  (acetonaemia) 
and  other  marked  nervous  manifestations  occur  infrequently  in  young 
and  sensitive  individuals.  Fever  is  quite  uncommon;  when  present, 
it  is  usually  irregular  and  ephemeral. 

Diagnosis. — The  diagnosis  is  not  difficult  when  the  course  is  short 
and  afebrile,  as  is  usually  the  case.  With  fever  or  some  constitutional 
symptoms  it  is  an  excellent  practice  to  regard  the  acute  gastritis  as  a 
symptom,  until,  at  least,  typhoid,  exanthematous  disease,  or  nephritis 
can  be  excluded  by  the  later  clinical  evolution.  Confusion  is  possible 
with  a  tabetic  crisis  or  with  the  vomiting  of  pregnancy  and  hysteria. 

Treatment. — (a)  Prophylaxis  embraces  the  etiological  factors. 
(6)  Complete  rest  of  the  stomach  for  one  or  more  days  is  the  first  active 
indication ;  no  rectal  feeding  is  required  for  twenty-four  to  forty-eight 
hours,  by  which  time  the  gastric  equilibrium  is  in  great  part  restored; 
warm  water  may  be  given  by  rectum  to  unload  the  bowels  and  to  allay 
thirst,  (c)  If  gastric  irritation  persists,  the  stomach  should  be  thor- 
oughly washed  out  by  the  stomach  tube,  using  warm  water  with  a  spoon- 
ful of  sodium  bicarbonate  to  the  quart.  Gastric  lavage  is  a  better 
measure  than  the  use  of  calomel  or  salines,  which  may  irritate  the 
inflamed,  perhaps  eroded  mucosa.  For  the  same  reason  emetics  (apo- 
morphine  hypodermics,  or  ipecac  by  mouth)  are  to  be  avoided.  Epi- 
gastric fomentations  alleviate  pain.  Obstinate  irritation  and  vomiting 
usually  respond  to  Bartholow's  prescription,  modified  as  follows: 

Ac.  carbolic!      gr.  iv. 

Ac.  hydrocyanici  dil OSS. 

Bismuthi  subnitratis 

Sodii  bromidi 

Cerii  oxalatis aa  oiss. 

Mucilaginis  acacise q.s. 

Aquae  menthse  piperitse       q.s.  ad  oij-  • 

M.  et  S.-^One  teaspoonful  without  dilution  every  half  to  one  hour  for  six  to 
ten  doses. 

Opiates  give  immediate  relief,  but  secondary  nausea  is  an  insuper- 
able obstacle  to  their  use.  (d)  In  convalescence,  dilute  hydrochloric 
acid  TTj^  V  to  XV  and  bitters  are  given  after  meals,  to  stimulate  and  supple- 
ment the  gastric  secretion.  The  diet  should  be  simple,  moderate  in 
bulk  and  the  food  should  be  thoroughly  chewed. 


600  DISEASES  OF  THE  DIGESTIVE  TRACT 


II.  Gastritis  Toxica  (Venemata). 

Etiology  and  Pathology. — Acute  toxic  gastritis  is  caused  by  various 
alkalies,  acids,  and  metallic  poisons.  Sulphuric  acid  produces  a  gray 
eschar,  nitric  acid  a  yellow  one,  alkalies  a  brown,  copper  a  greenish 
blue,  silver  a  deep  black  eschar,  and  phosphorus  produces  an  opaque 
milky  stain.  The  pathological  changes  are  usually  severe,  particularly 
in  places  with  which  the  corrosives  remain  longest  in  contact,  as  the 
pylorus  and  posterior  wall;  these  changes  range  between  simple 
epithelial  desquamation  and  catarrh,  to  hemorrhagic  infiltration, 
diphtheroid  patches,  suppuration,  and  ulceration. 

Symptoms. — The  symptoms  are  those  of  gastritis  simplex,  but  more 
severe;  pain  is  intense  in  the  mouth,  throat,  oesophagus,  and  stomach, 
and  is  not  relieved  by  the  repeated  vomiting.  The  vomitus  is  often 
bloody,  the  epigastrium  tender,  and  the  abdomen  tympanitic. 

Prognosis. — The  outcome  varies;  (a)  collapse  after  a  few  hours  to  a 
day  or  so  is  frequent,  with  small  pulse,  shallow  breathing,  subnormal 
temperature,  bloody  albuminous  urine,  and  other  symptoms  which 
vary  with  the  poison  ingested,  (b)  The  stomach  symptoms  may 
subside,  and  death  may  occur  later  from  blood  or  visceral  changes,  (c) 
Strictures  may  develop,  or  (d)  there  may  be  atrophy  of  the  secretory 
glands  (achylia  gastrica). 


III.  Phlegmonous  Gastritis. 

Etiology. — This  is  a  rare  form,  of  which  85  cases  are  recorded  (1903). 
It  is  an  acute  suppurative  inflammation  of  the  stomach,  usually  caused 
by  the  streptococcus ;  it  begins  in  the  submucosa  and  infiltrates  the  other 
coats  diffusely  or  forms  a  circumscribed  mural  abscess.  It  may  be  a 
primary  affection  (only  20  are  recorded,  1905),  but  most  often  occurs 
secondarily  (75  per  cent.)  in  sepsis,  the  acute  infections,  anthrax,  or  in 
local  diseases  as  gastric  cancer.  The  writer  has  seen  only  one  case, 
which  followed  erysipelas.  Eighty-five  per  cent,  occur  in  adult  males. 
Alcoholism  and  traumatism  are  predisposing  factors. 

Symptoms. — The  symptoms  are  gastric  and  septic.  Besides  the 
symptoms  of  acute  gastritis,  the  vomitus  sometimes  contains  pus,  the 
epigastric  pain  is  intense,  meteorism  is  well  marked,  and  there  are  many 
symptoms  of  peritonitis,  which  is  a  most  common  complication.  In  a 
few  cases  an  epigastric  tumor  marks  the  circumscribed  variety.  Sepsis, 
usually  in  a  severe  form,  causes  the  high  fever  (103-5  degrees),  the 
pronounced  status  typhosus,  the  small  pulse,  occasional  icterus,  and 
petechise. 

Diagnosis  and  Treatment.^ — A  diagnosis  is  almost  impossible,  the 
outcome  is  generally  fatal  during  the  second  week,  and  the  treatment  is 
symptomatic,  viz.,  rectal  nutrition  and  stimulation,  narcotics  for  pain 
and  vomiting,  and  hydrotherapy  for  fever.    Some  cases  apparently  heal 


DIPHTHERITIC,  PARASITIC  AND  CHRONIC  GASTRITIS        601 

by  rupture  into  the  stomach  with  cicatrization,  and,  if  the  affection  is 
suspected,  the  advisabihty  of  operation  can  be  considered. 


IV.  Diphtheritic  Gastritis. 

This  form  is  due  to  the  Bacillus  diphtherise,  and  is  very  rare.  Diph- 
theroid gastritis,  caused  by  streptococcic  and  other  infections,  is  more 
common;  it  may  develop  after  gastritis  toxica,  smallpox,  pneumonia 
and  kindred  maladies. 


V.  Parasitic  Gastritis. 

This  form  is,  in  rare  instances,  due  to  the  Oidium  albicans,  favus 
parasite  (Kundrat),  anthrax  bacilli,  larvse  of  insects  and  tinese. 


(B).   CHRONIC   GASTRITIS. 

Chronic  gastritis  (dyspepsia,  catarrh)  is  characterized  pathologi- 
cally by  degeneration  of  the  parenchymatous  and  infiltration  of  the 
interstitial  tissue,  and  clinically  by  mucus  formation  and  decreased 
secretion. 

Etiology. — (a)  The  factors  are  the  same  as  in  acute  gastritis,  from 
repeated  attacks  of  which  chronic  inflammation  may  result.  Abuse  of 
drugs,  especially  cathartics,  is  an  important  factor.  Alcoholism  and 
improper  eating  are  most  important.  Eating  hurriedly  or  at  irregular 
hours,  inadequate  mastication,  washing  down  the  food  with  much  fluid, 
excessive  use  of  coffee,  tea,  ice  water,  carbohydrates,  pastries,  or  fried 
foods,  are  salient  factors.  The  chewing  of  tobacco  and  to  a  lesser 
degree  smoking  may  cause  chronic  gastritis ;  stomatitis,  carious  teeth, 
and  pyorrhoea  alveolaris,  are  important  causes.  Most  cases  occur  in 
adult  males,  (b)  It  often  accompanies  other  gastric  diseases,  as  cancer 
or  ectasia,  (c)  It  is  frequent  in  tuberculosis,  in  the  anaemias  as  chlo- 
rosis or  pernicious  anaemia,  and  in  nephritis,  gout,  diabetes,  syphilis, 
amyloidosis,  and  Addison's  disease. 

The  acid  form  (see  Symptoms)  of  chronic  gastritis  is  usually  caused 
by  excesses  in  eating,  drinking,  and  smoking;  the  subacid  form,  by  the 
abuse  of  spirits. 

Pathology. — The  pathological  changes  are  observed  chiefly  in  the 
pyloric  region.  The  vessels  are  dilated,  imparting  a  reddish-brown 
color,  which  in  the  later  stages  changes  to  gray.  The  mucosa  is  swollen, 
lax,  and  covered  with  tenacious  mucus.  Sometimes  punctate  hemor- 
rhages or  erosions  are  observed.  In  a  few  cases  the  mucosa  is  rough, 
even  papillomatous  (gastritis  polyposa,  etat  mamellone).  The  mus- 
cularis  is  not  essentially  changed,  as  a  rule,  but  is  sometimes  hyper- 
trophied  near  the  pylorus,  or  it  may  be  atrophied.    Histologically,  the 


602  DISEASES  OF   THE  DIGESTIVE   TRACT 

glandular  cells  are  granular  and  fatty,  or  show  a  mucoid  degeneration 
which  extends  from  the  surface  toward  the  deeper  layers ;  the  parietal 
cells  cannot  be  distinguished  from  the  principal  cells,  the  glands  are 
often  large,  sacculated,  or  cystic,  and  the  tubules  show  irregular  rami- 
fications; eventually  the  glandular  structures  may  completely  atrophy 
(see  next  sub-heading,  Achylia,  Atrophy).  The  interstitial  tissue 
shows  leukocytic  infiltration. 

Symptoms. — The  symptoms  resemble  those  of  acute  gastritis,  but 
begin  more  insidiously  and  endure  longer. 

1.  Oral  Symptoms. — The  tongue  is  generally,  but  not  always,  coated 
with  moist  white  fur,  reddish  at  its  tips  and  indented  on  its  edges; 
these  conditions  may  also  result  from  alcoholic  or  nicotine  stomatitis. 
There  is  frequently  a  bitter,  sour,  salty  taste  in  the  mouth,  and  some- 
times a  marked  joetor  ex  ore.  Increase  in  the  saliva  results  chiefly  from 
the  coincident  stomatitis. 

2.  Gastric  Symptoms. — (a)  Gastric  pain  sometimes  results  from 
spasm  of  the  gastric  musculature  but  is  less  frequent  than  is  a  sense  of 
distention  or  pressure  after  eating.  Soup  and  fluids  (unless  they  are 
cold)  generally  cause  no  distress;  coarse  or  hard  foods,  as  beefsteak, 
hard  bread,  smoked  meat,  cabbage,  hard-boiled  eggs,  or  cheese,  do 
cause  distress.  (In  functional  dyspepsia,  any  kind  of  food,  hard  or  soft, 
may  cause  distress).  In  some  cases  of  gastritis  there  is  distress  when  the 
stomach  is  empty.  There  may  be  some  tenderness,  but  it  is  much  less 
than  in  cancer  or  ulcer  and  responds  readily  to  treatment.  (6)  Belch- 
ing of  gas  is  common;  eructations  may  be  odorless,  or  may  contain 
fatty  acids  and  even  inflammable  gas.  Eructations  of  hydrochloric  acid 
are  rare,  (c)  Nausea  is  more  frequent  than  is  vomiting,  which  may 
result  from  other  coincident  conditions,  notably  from  chronic  pharyn- 
gitis. The  vomitus  shows  the  same  findings  as  the  test  meal  (see  Gas- 
tric Chemism).  In  alcoholics  morning  vomiting  is  common  (vomitus 
matutinus  'potatorum),  chiefly  of  saliva  swallowed  during  the  night,  and 
of  mucus. 

3.  Gastric  Chemism. — Our  intimate  knowledge  of  the  chemical 
changes  in  the  stomach  dates  from  the  introduction  of  the  stomach  tube 
by  Leube,  and  the  vast  amount  of  work  done  by  many  workers, 
especially  Riegel,  Ewald,  and  Boas.  After  washing  out  the  stomach, 
the  Ewald  test  breakfast  is  given,  consisting  of  a  piece  of  dry  bread  and 
a  cup  of  weak  tea  without  sugar  or  cream.  In  an  hour  the  stomach  tube 
is  again  introduced  and  the  gastric  contents  withdrawn  by  expression 
(the  patient  compressing  the  abdomen  and  straining),  or  by  Ewald's 
aspiration  bag,  similar  to  Politzer's  ear  bag;  it  is  seldom  necessary  to 
pour  in  any  water  unless  some  condition  obtains  in  which  the  hydro- 
chloric acid  is  much  decreased.  Innumerable  errors  result  from  con- 
fidence in  a  single  examination  and  assigning  undue  importance  to  the 
gastric  chemism  alone.  It  is  best  to  examine  the  contents  chemically 
without  filtration. 

(a)  The  gross  examination  of  the  stomach  contents  shows  coarse 
particles  of  food  when  the  hydrochloric  acid  is  absent  or  greatly  reduced, 


CHRONIC  GASTRITIS  '  603 

or  fine  subdivision  when  it  is  present  in  fair  amounts.  A  rancid  odor 
denotes  fatty  acids,  and  a  foaming  appearance  is  caused  by  fermen- 
tation. Mucus  is  seen  in  practically  all  cases,  and  most  clinicians  do 
not  recognize  a  simple  gastritis  without  mucus  formation,  though 
Ewald  distinguishes  (i)  simple  gastritis  in  which  the  acid  and  ferments 
are  decreased;  (ii)  a  mucous  gastritis,  in  which  the  acid  is  greatly  de- 
creased, the  ferments  are  present,  and  there  is  much  mucus;  and  (iii)  an 
atrophic  gastritis  which  will  be  considered  separately.  Mucus  usually 
indicates  a  reduction  in  the  hydrochloric  acid.  Normally  there  is  little 
or  no  gastric  mucus,  though  there  is  rather  more  with  an  amylaceous 
than  with  a  proteid  diet.  Mucus  of  gastric  origin  is  intimately  mixed 
with  the  food  and  is  not  yellow,  nummular,  pigmented,  or  mixed  with 
cells,  as  occurs  when  the  mucus  comes  from  the  mouth  or  respiratory 
tract. 

(&)  The  HCl  is  reduced.  It  is  recognized  by  the  Giinzburg  test 
(2  gm.  phloroglucin  and  1  gm.  vanillin  dissolved  in  30  c.c.  of  absolute 
alcohol) ;  a  few  drops  of  the  solution  are  added  to  an  equal  amount  of 
the  filtered  gastric  contents  and  slightly  heated,  without  boiling,  in  a 
porcelain  dish,  when  a  carmine-red  color  develops,  indicating  free 
hydrochloric  acid  even  in  dilution  of  1  to  20,000  parts,  and  not  reacting 
to  lactic  or  butyric  acids;  the  solution  should  be  kept  in  a  dark  bottle, 
for  it  degenerates  in  the  sunlight.  The  solution  should  not  be  kept  over 
two  months.  Boas  recommends  the  following  test,  which  gives  the 
same  reaction  as  Gtinzburg's  test  and  is  less  expensive:  resorcin  0.5, 
sugar  0.3,  dilute  alcohol  q.  s,  ad  10.0  gram.  HCl  exists  in  a  combined 
form  or  as  free  acid,  which  latter  probably  serves  as  an  antiseptic. 

To  find  the  total  free  HCl,  one  of  three  simple  methods  may  be 
employed,  (a)  Filter  paper  is  saturated  with  a  0.5  per  cent,  alcoholic 
solution  of  dimethylamidoazobenzol,  and  dried;  HCl  colors  this 
solution  a  cherry-red  color ;  when  the  reaction  is  obtained  on  the  paper 
with  the  gastric  contents  diluted  three  to  six  times,  about  the  normal 
percentage  of  HCl  is  present;  if  obtained  with  less  than  three  dilu- 
tions, subacidity  (hypochlorhydria)  exists;  if  with  more  than  six 
dilutions  there  is  hyperacidity  (hyperchlorhydria).  (b)  To  10  c.c.  of 
the  gastric  contents,  25  to  30  c.c.  of  Gtinzburg's  reagent  is  added,  and 
then,  little  by  little,  the  decinormal  soda  solution  is  added  until  the 
characteristic  red  no  longer  appears  on  the  porcelain  dish;  the  per- 
centage of  HCl  is  obtained  by  multiplying  each  c.c.  of  decinormal 
solution  used  by  0.00365  (for  each  c.c.  of  the  decinormal  solution  is 
neutralized  by  0.00365  of  HCl),  and  again  multiplying  by  10.  (c) 
To  10  c.c.  of  gastric  contents  is  added  a  few  drops  of  the  indicator 
(0.5  per  cent,  solution  of  dimethylamidoazobenzol  in  strong  alcohol); 
it  is  placed  in  a  beaker  and,  if  free  HCl  is  present,  the  yellow  color 
imparted  by  the  indicator  will  change  to  bright  red;  a  decinormal 
solution  of  caustic  soda  (4  gm.  to  1,000  c.c.  of  distilled  water)  is  then 
added  drop  by  drop  to  the  gastric  contents,  until  the  color  of  the  in- 
dicator has  been  changed  from  red  to  bright  yellow;  the  number  of  c.  c. 
of  decinormal  solution  used  is  multiplied  by  0.00365  and  again  by  10  to 


604  DISEASES  OF  THE  DIGESTIVE  TRACT 

give  the  amount  of  free  HCl.  Very  often  the  result  is  expressed  in 
terms  of  the  number  of  c.c.  of  decinormal  solution  used;  i.e.,  if  4  c. c. 
were  employed,  4  x  10  =  40,  the  free  HCL  The  usual  amount  is  30  to 
40. 

The  total  acidity  (HCl,  lactic  and  other  organic  acids,  acid  phos- 
phates and  albumins,  albumoses  and  peptones)  is  estimated  by  adding 
two  drops  of  a  1  per  cent,  alcoholic  solution  of  phenolphthalein  (as 
an  indicator)  to  10  c.c.  of  the  gastric  contents;  to  this  is  added,  drop 
by  drop,  a  decinormal  solution  of  caustic  soda  (4  gm.  to  1,000  c.c.  of 
distilled  water)  until  the  red  color,  due  to  the  alkali  acting  upon  the 
phenolphthalein,  no  longer  disappears  on  gentle  shaking;  this,  how- 
ever, is  not  the  true  end  reaction,  for  the  decinormal  solution  must  be 
added  till  the  rose-red  color  is  no  longer  even  deepened  in  hue  by  the 
alkali.     As  4  to  8  c.  c,  of  the  decinormal  solution  are  usually  required, 

4  or  8  X  10  =  normal  total  acidity;  i.  e.,  40  to  80  expressed  in  terms  of  the 
decinormal  solution  (corresponding  to  0.15  to  0.25  per  cent.  HCl). 
If  the  acid  reaction  of  the  gastric  contents  is  due  to  HCl  alone,  and  no 
organic  acids  are  present,  each  c.  c.  of  the  decinormal  solution  cor- 
responds to  0.00365  gm.  HCl  and  therefore  the  number  of  c.c.  re- 
quired to  neutralize  the  gastric  juice  x  0.00365  x  10  =  the  per  cent,  of 
HCL  In  most  cases  determination  of  the  total  acidity  is  sufficient. 
A  total  acidity  under  20  gives  no  reaction  with  Congo  paper;  i.  e.,  there 
is  no  free  HCL  The  bread  of  the  test  breakfast  (phosphates  chiefly) 
accounts  for  the  acidity  of  5  to  6 ;  if  the  total  acidity  ranges  from  5  to  8, 
we  may  be  almost  certain  that  the  gastric  glands  are  atrophied. 

Combined  Hydrochloric  Acid. — "The  method  elaborated  by  Cohn- 
heim  and  Krieger,  modified  by  Fisher,  is  accurate  and  convenient. 
The  method  is  as  follows;  Determine  the  total  acidity  by  titrating  5 
c.c.  of  the  gastHc  filtrate  with  0.1  normal  NaOH  solution,  using  a  1  per 
cent,  alcoholic  solution  of  phenolphthalein  as  an  indicator.  Take  another 

5  c.c.  of  the  filtrate  and  sufficient  calcium  phosphotungstate  solution  to 
make  20  c.c.  and  call  this  Tai.  Let  it  stand  three  or  four  minutes,  add 
animal  charcoal,  and  filter.  Determine  the  total  acidity  of  this  filtrate, 
using  a  1  per  cent,  solution  of  rosolic  acid  as  an  indicator;  call  this  Ta2. 
Then  Tai  minus  Ta2  equals  the  combined  HCl  in  the  5  c.c.  of  the 
filtrate  of  the  gastric  contents  used.  If  the  gastric  contents  show  an 
absence  of  free  HCl,  proceed  as  follows : 

1.  Determine  the  hydrochloric  acid  deficiency  by  adding  0.1  normal 
hydrochloric  acid,  using  a  1  per  cent,  alcohohc  solution  of  dimethyl- 
amidoazobenzol  as  an  indicator.  Determine  the  total  acidity  of  this 
mixture,  using  phenolphthalein  as  an  indicator.  This  total  acidity 
minus  the  quantity  of  hydrochloric  acid  added  will  give  the  original 
total  acidity  of  the  5  c.c.  of  the  filtrate  of  gastric  contents  employed. 

2.  Take  5  c.c.  of  the  gastric  filtrate,  add  0.1  normal  hydrochloric 
acid  sufficient  to  make  the  new  total  acidity  at  least  60  per  cent. ;  add 
sufficient  calcium  phosphotungstate  solution  to  make  30  c.c,  and 
titrate  with  rosolic  acid  as  an  indicator,  calling  the  resulting  acidity  Tag. 
The  difference  between  Tas  and  Ta2  will  represent  the  quantity  of 


CHRONIC  GASTRITIS  605 

hydrochloric  acid  combined  with  all  the  albumin  in  the  5  c.c.  of 
gastric  filtrate  employed.  Call  this  total  CHCl.  Then  this  total  CHCl 
minus  the  hydrochloric  deficiency  equals  the  combined  HCl  in  5  c.c. 
of  the  gastric  filtrate. 

Employed  subacid  gastric  contents 5  c.c. 

HCl  deficiency  (dimethylamidoazobenzol) 1     "  =20 

Total  acidity  (phenolphthalein)      3     "  =  60 

Original  total  acidity (60-20)    "  =40 

Tai  Added  HCl  in  excess 3     "  =  60 

Added  calcium  phosphotungstate   .    .  ■ 18     "  = 

Tao  Total  acidity  (rosolic  acid)  of 30     "  =30 

Total  CHCl  Total  possible  combined  HCl (60-30)    "  =  30 

Actual  combined  HCl  in  gastric  contents      ....  (30-20)    "  =  10 

Ta2  —  Ta3  =  Total  HCl. 

Total  CHCl  —  HCl  deficiency  =  combined  HCl."     (Musser,  Medical 

Diagnosis.) 

In  chronic  gastritis  the  hydrochloric  acid  is  found  decreased,  or  even 
absent  by  these  tests.  In  a  few  cases,  as  described  by  Riegel  and  Boas, 
the  acid  is  normal,  showing  a  total  acidity  of  43  to  56;  this  form  is 
called  gastritis  acida,  though  its  separation  as  a  type  is  scarcely  justi- 
fiable; these  are  usually  light  or  incipient  cases  and  probably  some  of 
them  are  neurotic. 

(c)  Rennet  and  pepsin  are  rarely  totally  absent,  though  usually 
decreased.  Pepsin  is  tested  by  mixing  the  gastric  juice  with  egg  al- 
bumin; 25  c.c.  of  normal  gastric  juice  will  dissolve  0.05  gm.  of  serum 
albumin  in  one  hour,  the  same  amount  of  fibrin  in  one  and  one-half 
hours,  and  of  egg  albumin  in  three  hours;  Petit  claims  that  pepsin  will 
dissolve  500,000  times  its  weight  of  fibrin  in  seven  hours.  Pepsinogen 
is  tested  in  the  same  way  with  the  addition  of  a  few  drops  of  hydro- 
chloric acid,  which  liberates  the  enzyme  (pepsin)  from  the  pro-enzyme 
(pepsinogen).  Boas  especially  has  insisted  on  the  importance  of  the 
rennet  ferment,  which  coagulates  milk;  if  no  rennet  is  present,  the 
gastric  filtrate  will  not  coagulate  milk. 

Lactic  acid  is  seldom  found  (see  Cancer  of  Stomach).  The  mo- 
tility of  the  stomach  is  unimpaired.  Leukocytes  and  epithelial  cells 
are  found  at  times,  and  in  rare  cases  shreds  of  gastric  mucosa  (Gas- 
tritis exfoliativa,  Parisier). 

4.  Other  Symptoms. — (a)  Vertigo  e  stomacho  lasso  (Trousseau), — 
gastric  vertigo,  is  probably  neurasthenic  rather  than  gastric.  The  so- 
called  dyspeptic  asthma  is  not  really  asthma,  but  a  dyspeptic  dyspnoea, 
and  probably  results  from  pressure  of  the  distended  stomach  on  the 
heart.  Headache,  physical  and  mental  lassitude,  a  degree  of  melan- 
cholia, intercostal  neuralgia,  tender  points  between  the  shoulders  or  over 
the  lower  cervical  spines,  and  palpitation,  are  fairly  common.  (6)  The 
bowels  are  generally  constipated;  diarrhoea  and  tympany  at  times 
result  from  marked  gastric  fermentation  or  extension  of  the  catarrh 
to  the  gut,  when  catarrhal  icterus  may  result.  Boas  and  Schmidt  find 
regularly  undigested  connective  tissue  in  the  movements,  (c)  The  urine 
is  frequently  reduced  and  shows  a  lateritious  deposit,  phosphates  and 
oxalates,     {d)  The  general  nutrition  is  usually  fairly  well  maintained 


606  DISEASES  OF  THE  DIGESTIVE  TRACT 

if  the  intestines  functionate  well,  (e)  The  motive  and  absorptive 
power  of  the  stomach  is  variously  regarded;  it  may  be  impaired, normal, 
or  even  exaggerated,  the  food  being  sometimes  hurried  into  the  intes- 
tine. 

Diagnosis. — Leube  insists  that  chronic  gastritis  should  never  be 
diagnosticated  until  cancer,  ulcer  and  functional  disease  have  been 
finally  excluded.  Its  cardinal  points  are  (a)  its  steady,  slow,  chronic 
course;  (b)  the  presence  of  mucus,  and  (c)  decreased  secretion.  (For 
its  differentiation  v.i.  Ulcer.) 

Treatment. — 1.  Prophylaxis. — Recurrence  of  the  trouble  is  pre- 
vented by  treatment  of  the  causal  conditions;  digitalis  is  indicated  in 
gastric  stasis  of  cardiac  origin,  and  iron  in  ansemia. 

2.  Hygiene. — Hygiene  concerns  regularity  in  living,  moderation, 
recreation,  massage,  rational  exercise,  and  avoidance  of  haste  in  eating. 

3.  Diet. — F.A.Hoffman  justly  remarks  that  every  one  "has  the 
stomach  he  deserves."  Slowness  of  eating,  drinking  only  after  the  solid 
part  of  the  meal  is  eaten,  and  thorough  mastication,  are  frequently 
curative  with  no  medicinal  treatment.  The  importance  of  thorough 
insalivation  of  the  food  is  manifest  when  we  remember  that  the  ptyalin 
operates  for  nearly  an  hour  in  the  unchurned  contents  of  the  cardiac 
end  of  the  stomach.  As  Ewald  states,  "die  Diat  der  Magen-Kranker 
fangt  im  Munde  an."  The  teeth  should  receive  such  care  as  the  treat- 
ment of  pyorrhoea,  extraction  of  carious  teeth,  and  fitting  of  proper 
plates.  Food  should  be  taken  in  moderate  amounts,  and  the  stomach 
should  be  given  sufficient  rest,  though  most  dyspeptics  do  not  eat 
enough  (von  Noorden).  Pawlow  has  shown  that  the  relish  of  food 
excites  the  flow  of  the  gastric  juice;  he  names  it  the  "appetite  juice." 

KiXD  OF  Food — The  term  "easily  digestible  food"  is  extremely 
relative,  but  the  kind  of  food  is  less  important  than  careful  mastication 
and  insalivation.  In  severe  or  alcoholic  cases  an  absolute  milk  diet 
may  be  tried,  giving  equal  parts  of  milk  and  Apollinaris  water,  to  which 
grains  x  of  sodium  bicarbonate,  grains  x  of  sodium  chloride,  and  grains 
V  of  magnesia  levis  are  added.  Predigested  milk  and  ]Mosquera's  beef 
jelly  (see  Typhoid)  soon  become  distasteful  to  the  patient,  and  are  in- 
dicated chiefly  in  severe  catarrh  with  much  mucus  formation  or  with 
atrophy.  Generally  speaking,  the  diet  should  be  mixed,  but  proteids 
are  superior  to  carbohydrates,  which  are  prone  to  ferment.  The  pro- 
teids which  may  be  given  are  chopped  lean  meats,  scraped  beef,  boiled 
mutton,  veal,  roasted  steak,  broiled  tenderloin,  pigeon,  chicken,  eggs 
boiled  one  minute,  somatose,  and  nutrose.  Chittenden  has  shown  that 
we  eat  twice  as  much  meat  as  is  necessary.  Beef  tea,  heavy  fresh  beef, 
hard-boiled  eggs,  pork,  game,  fish,  warmed-over  (therefore  hardened) 
meat,  turkey,  goose,  duck,  smoked  or  cured  meat  (possibly  except- 
ing bacon)  and  cheese  must  be  interdicted.  Carbohydrates  are  to 
be  withheld  when  there  is  obstinate  fermentation.  Those  which  may 
be  allowed  are  arrowroot,  well  cooked  sago,  tapioca,  or  rice,  white  bread, 
zwieback,  and  toast;  those  which  may  be  occasionally  allowed  or  tried 
later  are  mealy  potatoes,  spinach,  pea  or  bean  soups;  those  to  be  for- 


.       CHROXIC   GASTRITIS  607 

bidden  are  substances  containing  much  cellulose,  hard  bread,  brown 
bread,  oatmeal,  coarse  vegetables,  uncooked  green  vegetables,  most 
fruits,  pies,  and  pastries.  It  is  interesting  to  note  that  most  of  the  carbo- 
hydrates ingested  usually  reach  a  maximum  amount  in  the  intestine  in 
two  hours  (some  reach  the  bowel  in  ten  minutes),  which  time  is  twice 
the  maximum  time  for  proteids  and  two  and  a  half  that  for  fats.  Carbo- 
hydrates, therefore,  should  be  eaten  before  the  proteids,  that  they  may 
the  earlier  leave  the  stomach.  Fats  are  a  necessary  part  of  the  diet, 
especially  moderate  amounts  of  butter  and  cream.  Von  Noorden  in- 
sisted on  their  use.  Other  forms  of  fat  are  injurious.  Greasy  soups 
are   to   be   avoided. 

Accessories. — No  seasoning  is  necessary,  but  liberal  quantities 
of  salt  may  be  used.  Liebreich  insists  that  condiments  in  moderate 
amounts  are  helpful.  Tea,  coffee  and  alcoholic  beverages  are  usually 
prohibited.     Smoking  should  be  interdicted  or  restricted. 

4.  Gastric  Lavage.— Lavage  is  indicated  when  there  is  formation  of 
mucus,  fermentation,  deficient  secretion,  and  delayed  digestion.  It  is 
generally  considered  the  most  helpful  measure  but  in  the  writer's  experi- 
ence is  seldom  indicated  as  there  is  no  stagnation  of  food.  Morning 
lavage  is  best  for  removal  of  mucus,  and  lavage  before  the  evening  meal 
for  delayed  digestion  or  fermentation.  Warm  water  is  used,  to  which 
sodium  chloride  or  bicarbonate,  two  spoons  to  the  quart,  may  be  added 
to  dissolve  the  mucus,  or  salicylic  acid  (1  to  1,000)  to  modify  fermen- 
tation. The  stomach  should  be  washed  until  the  water  returns  clear. 
When  the  use  of  the  stomach  tube  is  resisted  or  contra-indicated,  as  by 
exceptional  nervousness,  modified  lavage  may  be  employed,  the  patient 
drinking  before  breakfast  two  glasses  of  warm  water  to  which  a 
teaspoonful  each  of  sodium  chloride  and  sodium  bicarbonate  has  been 
added.  This  process  is  essentially  the  same  as  drinking  the  Kissingen, 
Wiesbaden,  and  other  waters.  The  sodium  bicarbonate  acts  locally, 
and  the  sodium  chloride  acts  both  locally  and  systemically,  for  small 
doses  increase  the  hydrochloric  acid  and  large  doses  reduce  it  by  in- 
creasing the  alkalinity  of  the  blood.  Carbonated  waters  may  be  used, 
which  stimulate  secretion  and  absorption  and  neutralize  abnormal 
acids. 

5.  Medical  Treatment. — (a)  The  value  of  hydrochloric  acid  is  disputed. 
Its  first  indication  is  to  convert  pepsinogen  into  pepsin,  whence  it  is  use- 
less in  atrophic  gastritis  save  as  it  stimulates  the  flow  of  bile.  Its  second 
indication  is  as  a  digestant;  many  specialists  deny  that  it  has  this 
action,  maintaining  that  sufficiently  large  amounts  cannot  be  given; 
but  Stewart  in  his  excellent  articles  says  that  he  employs  doses  of  20 
drops  and  gives  them  every  twenty  or  thirty  minutes  until  o  j  to  ij  have 
been  given.  Its  third  indication  is  as  an  antizymotic,  which  Boas  holds  is 
its  sole  indication ;  it  should  not  be  given  until  about  half  an  hour  after 
meals,  during  which  period  the  saliva  is  acting  upon  the  carbohydrates; 
some  writers  incline  to  the  view  that  at  the  best  hydrochloric  acid  is  only 
a  stomachic,  but  Pawlow  has  shown  that  it  increases  the  flow  of  pan- 
creatic juice  and  perhaps  of  bile,    (b)  Boas  takes  the  extreme  view  that 


608  DISEASES  OF  THE  DIGESTIVE  TRACT 

pepsin  is  useless.  It  should  be  given  as  a  powder,  for  solutions  rapidly 
deteriorate  and  are  usually  strongly  alcoholic.  Like  malt  preparations, 
many  forms  offered  on  the  market  are  inert.  Pancreatin  is  very  fre- 
quently ineffective.  Taka-diastase  is  beneficial  in  some  cases,  (c) 
Bitters  are  best  exhibited  before  meals;  though  their  mode  of  action  is 
disputed  and  their  stimulation  of  secretion  has  been  denied,  they  surely 
act  upon  the  appetite  or  on  the  nervous  structures,  and  increase  the 
flow  of  saliva  and  gastric  juice  and  probably  also  the  pancreatic  juice. 
Strychnine  or  nux  vomica  is  the  best  of  this  group  of  drugs  and  is 
especially  valuable  in  alcoholic  cases.  All  bitters  should  be  given  in 
solution,  as  their  bitter  taste  is  their  chief  mode  of  action. 

^  .  . 

Strychninse  sulphatis gr-  j  • 

Acidi  nitrohydrochlorici .    3 j  • 

Tr.  gentianse  comp 5iv. 

M.  et  S. — One  teaspoonful  half  an  hour  after  meals  in  half  a  glass  of  water. 

Condurango  bark  (fluid  extract  5ss)  is  prepared  by  macerating  the 
bark  in  cold  water.  Some  bitters,  as  gentian,  may  irritate  the  stomach 
and  induce  diarrhoea,  (d)  Antizymotics  (antifermentatives),  as  creo- 
sote or  beta-naphthol,  often  cause  irritation.  Carbolic  acid  gr.  j, 
thymol  gr.  ss  to  j,  resorcin  gr.  ij  to  v,  after  meals,  act  on  the  stomach, 
and  salol  gr.  x  and  beta-naphthol  gr.  x  (in  capsule  because  of  its  bitter- 
ness) are  intestinal  antiseptics,  (e)  Gastric  sedatives  are  seldom  in- 
dicated except  in  the  hyperacid  type.  Bartholow's  combination  (see 
Acute  Gastritis)  meets  all  indications.  Silvernitrateissedative,astrin- 
gent,  and  alterative,  but  may  cause  nephritis  or  argyria;  it  is  given  in 
pill  form,  half  an  hour  before  meals,  in  doses  of  one-fourth  of  a  grain 
(perhaps  with  quite  small  doses  of  opium  or  belladonna).  Zinc  oxide,  gr. 
iij  to  v,  given  before  meals,  is  valuable  in  alcoholic  gastritis.  Extract  of 
belladonna  in  one  quarter  of  a  grain  doses  is  helpful  in  pain,  especially 
in  hyperacid  gastritis.  Pyrosis  and  spasm  may  be  considered  under 
this  heading.  In  pyrosis  of  fatty  and  other  organic  acids,  alkalies  may 
be  employed,  though  sparingly;  Trousseau  gave  sodium  bicarbonate 
grains  v,  creta  preparata  grains  x,  and  magnesium  carbonate  grains  v 
after  meals.  Spasm  from  gas  or  overloading  of  the  stomach  is  modified 
by  spirits  of  chloroform  tt^  xx  and  tincture  of  asafoetida  5j;  spasm 
suggests  erosions  near  the  pylorus,  when  extract  of  belladonna  gr.  ^ 
and  subnitrate  of  bismuth  gr.  x  are  distinctly  indicated,  after  meals. 
(/)  Other  measures,  as  faradization,  massage,  and  hydrotherapy,  are 
less  valuable  than  in  gastric  atony  and  sensory  neuroses  of  the  stomach. 
In  constipation  cathartics  should  be  avoided,  as  they  cause  irritation 
and  constipation  recurs.  Hot  water,  gastric  lavage,  colonic  flushings, 
and  perhaps  the  mildest  saline  aperients,  are  indicated. 


ACHYLIA  GASTRICA  609 


Achylia  Gastrica. 

Etiology. ^^The  term  was  introduced  by  Einhorn  in  1892  to  designate 
total  suppression  of  gastric  digestion.  Atrophy  of  the  stomach  was 
first  described  by  Austin  Flint  (1860)  and  by  Fenwick  (1877),  Ewald, 
Quincke,  and  Einhorn.  It  most  frequently  occurs  secondarily  in  can- 
cer of  the  stomach  and  in  toxic  gastritis,  but  also  in  other  gastritides, 
cancer  of  distant  organs  (mammae,  uterus,  intestine,  oesophagus), 
diabetes,  pernicious  anaemia,  tabes,  and  in  neuroses.  In  rare  cases  it 
develops  as  a  seemingly  primary  affection,  possibly  as  a  congenital 
condition  (Martins).  It  occurs  oftenest  in  middle  or  advanced  life, 
though  isolated  cases  are  reported  at  eighteen  to  twenty-five  years  of 
age. 

Pathology. — Pathologically  two  main  forms  exist,  (a)  one  cirrhosis 
ventriculi,  in  which  the  stomach  is  very  small  and  thickened  so  that  its 
walls  may  measure  several  centimeters  in  thiclaiess,  and  (6)  another, 
phthisis  ventriculi,  in  which  the  walls  are  thin  or  "wasted"  and  the 
stomach  is  lax  or  dilated.  In  some  cases  atrophy  has  been  found  in 
Meissner's  and  Auerbach's  plexuses.  The  glandular  structures  are 
wasted  (anadenia). 

Ssnnptoms. — Symptoms  may  be  absent  if  gastric  motihty  is  good 
and  the  intestinal  glands  are  normal  (von  Noorden).  If  the  same  pro- 
cess exists  in  the  gut,  diarrhoea,  marasmus  and  death  result. 

1.  Gastric  Symptoms. — There  are  no  pathognomonic  gastric  symp- 
toms. Pain  is  variable;  it  may  be  absent  or  moderate,  though  in 
some  cases  lancinating  pain  and  other  symptoms  like  those  of  hyper- 
chlorhy dria  may  exist  (Einhorn ) .  The  appetite  is  also  variable.  Vomit- 
ing does  not  always  occur  but  when  present  the  vomitus  always 
contains  coarse,  poorly  digested  particles. 

2.  Test  Meal — The  recovered  food  is  coarse;  the  total  acidity  is 
1  to  4,  corresponding  to  the  amount  in  the  food  ingested.  No  HCl 
is  found  (achlorhydria),  no  pepsin  (therefore  no  peptones),  no  rennet 
(therefore  no  coagulation  of  milk),  no  blood,  and  according  to  most 
writers  no  mucus;  according  to  Riegel  and  Schmidt,  some  mucus  may 
be  present,  due  to  metaplasia  of  the  gastric  mucosa  to  one  resembhng 
that  of  the  intestine,  the  cells  of  which  secrete  mucus;  as  they  in  turn 
atrophy  the  mucus  disappears.  Lactic  acid  is  found  but  rarely. 
The  gastric  motor  power  is  usually  unimpaired,  and  the  stomach  is 
often  emptied  in  less  than  an  hour.  In  the  contracted  cirrhotic  form, 
the  stomach  may  hold  but  a  few  ounces;  in  the  phthisic  form  ectasia 
may  occur.  In  some  scleroses  of  the  stomach  a  sound  is  introduced 
into  the  stomach  with  difficulty,  hydrochloric  acid  is  present,  the 
stomach  cannot  be  distended  with  gas,  and  its  capacity  is  enormously 
decreased. 

3.  Other  Symptoms. — Headache  and  vertigo  are  common.  Con- 
stipation is  the  rule;  in  some  cases  diarrhoea  may  be  the  sole  salient 
symptom,  so  that  it  apparently  indicates  an  intestinal  lesion  (Oppler). 

39 


610  DISEASES  OF  THE  DIGESTIVE  TRACT 

Symptoms  like  those  of  pernicious  anaemia  (Henry  and  Osier)  or  like 
gastric  cancer  (author)  mark  some  cases.  The  acidity  of  the  urine 
which  is  normally  present  at  the  height  of  digestion,  is  naturally  ab- 
sent.   The  test  meal  establishes  a  clear  diagnosis. 

Prolonged  observation  may  be  necessary  in  order  to  exclude  the 
secondary  atrophic  gastritis  of  cancer.  Amyloid  gastric  disease  and 
nervous  achj/lia  are  eliminated  by  consideration  of  other  somatic 
findings  or  symptoms. 

Prognosis. — Life  may  be  prolonged  for  years  by  compensating 
intestinal  digestion,  but  recovery  is  impossible  after  actual  atrophy 
develops. 

Treatment. — Treatment  is  necessarily  palliative.  Thorough  masti- 
cation of  food  is  imperative.  Cellulose  is  to  be  avoided,  and  thick, 
plain,  leguminous  purees  should  be  given.  Butter  is  well  tolerated. 
The  meals  should  be  small  and  frequent  (every  three  or  four  hours). 
HCl  should  be  given  in  full  doses  {rrjixx  to  xxx),  Pawlow  having  demon- 
strated its  stimulating  action  on  the  pancreatic  flow.  Water  relieves 
the  pain,  which  resembles  that  of  hyperchlorhydria  (Einhorn). 


(C).  DILATATION  OF  THE  STOMACH;  MOTOR  INSUFFICIENCY. 

The  nomenclature  of  this  and  allied  conditions  is  a  matter  of  dispute; 
dilatation  of  the  stomach  (gastrectasia)  is  only  a  symptom,  and  is 
understood  as  a  more  or  less  lasting  dilatation  with  motor  insufficiency. 


1.  Acute  Dilatation. 

Acute  dilatation  and  atony  (loss  of  muscular  tone)  are  rare,  but 
have  been  observed  by  Fagge,  Fraenkel,  Hunter,  Osier,  and  Boas. , 

Somewhat  over  50  cases  of  acute  dilatation  are  recorded. 

Etiology. — (1)  Most  cases  follow  abdominal  trauma  or  laparotomy 
(36  per  cent,  according  to  C.  Thompson);  gall-bladder  operations 
are  the  most  frequent  type.  The  two  cases  seen  by  the  writer  were  in 
women  over  fifty  years  of  age  who  had  been  operated  for  fibroids  of 
the  uterus.  (2)  It  may  follow  acute  infections  as  pneumonia  or 
typhoid;  or  (3)  overloading  of  the  stomach;  in  one  of  Kolisko's  autop- 
sies in  Vienna,  the  author  saw  an  enormously  dilated  stomach  in  a 
man  who  had,  on  a  wager,  taken  a  large  number  of  charged  siphons, 
and  died  soon  afterward  from  gastric  distention  and  reflex  paralysis 
of  the  heart.  (4)  Most  cases  occur  between  twenty  and  thirty  years 
of  age.  (5)  Traction  or  obstruction  of  the  superior  mesenteric  vein 
is  the  most  favored  etiological  factor. 

Symptoms. — The  stomach  is  enormously  distended;  there  is  vomit- 
ing of  brown-gray  to  black  material  which  often  runs  out  of  the  mouth, 
may  be  very  copious  and  sometimes  is  offensive.  There  is  usually  no 
free  HCl;  sometimes  there  is  lactic  acid ;   succussion  sounds  are  fairly 


•  CHRONIC  DILATATION  AND  MOTOR  INSUFFICIENCY        611 

frequent.    The  abdomen  is  greatly  distended.    There  is  much  collapse 
and  often  abdominal  pain. 

Prognosis  and  Treatment. — Eighty-five  per  cent,  die,  and  usually 
within  a  weelc.  The  indications  are:  early  gastric  lavage;  rectal  feed- 
ing; strychnine  in  large  doses  and  a  few  doses  of  atropine  (under  which 
the  writer  observed  one  recovery);  salt  solution  under  the  skin,  and 
other  measures  for  shock ;  and  in  appropriate  cases  gastrostomy  or  gas- 
tro-enterostomy. 


2.  Chronic  (Permanent)  Dilatation  and  Motor  Insufficiency. 

In  the  following  discussion  it  must  be  borne  in  mind  that  various 
grades  of  distention  and  atony  may  occur,  that  dilatation  may  be  asso- 
ciated with  increased  power  of  the  gastric  musculature  or  with  atony, 
and  that  motor  insufficiency  (inability  of  the  stomach  to  propel  food 
into  the  intestine)  is  not  necessarily,  though  very  often,  associated 
with  dilatation  of  the  stomach.  Dilatation  and  motor  insufficiency  are 
most  prevalent  in  middle  or  advanced  life. 

Etiology. — 1.  Pyloric  Stenosis. — Its  causes  and  symptomatology  are 
varied.  It  is  most  often  cancerous,  but  may  also  follow  round  or  cor- 
rosive ulcers,  chronic  gastritis  leading  to  hypertrophy  of  the  pyloric 
musculature  (stenosing  gastritis),  benign  tumors  of  the  stomach,  as 
pedunculated  polyps  occluding  the  pylorus,  and  congenital  stenosis,  of 
which  Shaw  and  Elting  (1905)  collected  145  cases;  under  one  year  of 
age  45  cases  of  congenital  hypertrophic  stenosis  are  reported,  most 
of  which  were  less  than  four  months  old.  It  may  also  result  from  con- 
genital duplicature  of  the  pyloric  mucosa,  from  rotation  of  the  stomach 
on  its  axis,  from  angular  bending  of  the  fixed  pylorus  by  sinking  of 
the  stomach  (gastroptosis),  or  from  adhesions  due  to  cholecystitis. 
Ricard  and  Chevrier  collected  nineteen  cases  of  tuberculous  pyloric 
obstruction.  Stenosis  of  the  duodenum  produces  essentially  the  same 
results  as  pyloric  stenosis  and  may  follow  duodenal  ulcer,  diverticulum, 
or  twisting.  The  pylorus  may  suffer  compression  stenosis  from  tumors 
of  the  liver,  colon,  kidney,  or  pancreas.  Temporary  or  permanent 
pyloric  spasm  (v.  Gastric  Neuroses)  from  fissure,  erosion,  ulcer,  or 
hyperchlorhydria  may  cause  the  obstruction.  Payr  in  1904,  collected 
58  cases  in  which  pyloric  stenosis  was  associated  with  intestinal  stenosis 
(chiefly  from  round  ulcer).  The  pathological  sequence  of  pyloric 
stenosis  is  retention  of  food  within  the  stomach  and  hypertrophy  of 
its  musculature  in  attempts,  sometimes  partially  successful  and  at 
other  times  vain,  to  force  the  food  through  the  narrow  or  closed  pylorus. 
The  analogy  is  close  between  this  change  and  that  observed  in  hyper- 
trophied  and  dilated  bladder  from  prostatic  enlargement,  or  hypertrophy 
with  dilatation  of  the  heart  in  obstructive  valvular  disease.  In  all 
three  instances  the  hypertrophied  muscle  eventually  degenerates. 
Dilatation  of  the  stomach  may  be  considered,  then,  as  a  disturbed 
compensation. 


612         DISEASES  OF  THE  DIGESTIVE  TRACT 

2.  Muscular  weakness  (motor  insufficiency,  insufficiency  of  the 
stomach,  hypotony,  atony,  myasthenia  gastrica),  constitutes,  in  con- 
trast with  the  first  group  of  causes,  a  functional  and,  generally  speak- 
ing, a  more  reparable  type,  (a)  Atony  dependent  on  general  causes 
may  occur  in  acute  infections,  hysteria,  neurasthenia,  anaemia,  and 
possibly  in  cerebrospinal  disease.  The  atonic  tendency  may  be  ac- 
quired or  congenital.  Rickets  is  thought  to  cause  certain  juvenile 
cases,  (b)  Atony  may  result  from  gastric  conditions,  as  trauma,  can- 
cer, gastritis,  hypersecretion,  peritoneal  adhesions,  cholecystitis  with 
pyloric  adhesions,  diaphragmatic  pleurisy,  and  diastasis  of  the  musculi 
recti  abdominales.  Overloading  the  stomach  with  heavy  meals,  eat- 
ing indigestible  foods  or  excess  of  vegetables  and  carbohydrates,  beer 
drinking,  milk  in  large  quantities,  much  water  ingested  with  heavy 
meals,  as  in  diabetics,  swallowing  of  foreign  bodies  by  insane  subjects, 
etc.,  may  develop  muscular  insufficiency.  The  stomach  is  usually 
enlarged,  contains  residual  food,  and  shows  a  lax,  often  wasted  and 
thinned  musculature. 

Symptoms. — ^The  symptoms  of  dilatation  (again  emphasized  to  be 
a  symptom  only)  differ  greatly  in  degree,  ranging  from  absolute  pyloric 
stenosis  to  the  least  motor  weakness.  The  symptoms  are  partly  me- 
chanical, partly  chemical. 

1.  Gastric  Symptoms. — (a)  The  condition  of  the  tongue  is  variable; 
it  is  sometimes  coated,  sometimes  clear.  (6)  The  appetite  is  also 
variable,  (c)  There  is  usually  thirst  and  dryness  of  the  throat,  more 
frequently  in  hypersecretion  than  in  cancer,  (d)  Singultus,  pyrosis 
of  fatty  acids,  oppression  over  the  stomach,  a  cramped  feeling  or  one 
of  unrest,  and  eructation  of  various  gases,  are  frequent.  Gases  are 
never  formed  without  motor  insufficiency;  the  kind  of  gas  is  of  more 
scientific  than  clinical  interest,  but  includes  hydrogen  sulphide,  hydro- 
gen, oxygen,  nitrogen,  carbon  dioxide,  and  even  inflammable  gases, 
(e)  Vomiting  is  always  present  in  pyloric  obstruction  and  in  marked 
motor  insufficiency.  It  occurs  easily,  and  is  often  rather  belched  up 
than  vomited.  It  occurs  when  the  stomach  is  full,  frequently  during 
the  night  or  at  intervals  of  days;  five  quarts  may  be  evacuated.  It  is 
acid,  sour,  and  often  greatly  decomposed.  Three  layers  are  noted,  a 
brownish  foam,  a  gray-brown  fluid,  and  a  sediment  of  food,  stones,  and 
seeds,  which  may  have  lain  for  days  in  the  stomach.  Gas  often  bubbles 
up  as  the  vomitus  stands.  If  gastric  juice  only  is  found,  it  indicates 
hypersecretion  with  motor  insufficiency.  Chemically,  butyric  acid, 
peptones,  and,  in  cancer,  lactic  acid,  are  found;  when  the  obstruction 
lies  in  the  duodenum  below  the  papilla  of  the  common  duct,  bile  is 
also  present.  Microscopically  undigested  meat  or  starch,  in  benign 
stenosis  sarcinae,  and  in  cancer  the  Oppler-Boas  (lactic  acid)  bacilli, 
yeast,  and  other  bacteria,  are  found.  HCl.  is  absent  in  cancer.  (/) 
Pain  is  frequent;   it  is  cramp-like,  boring  or  burning. 

2,  Test  Meal,  Motility,  and  Resorption. — (a)  The  chemism  depends 
on  the  causal  affection,  particularly  if  it  is  gastric  (see  Gastritis,  Ulcer, 
Cancer,  Hyperchlorhydria,  Hypersecretion).  Hyperchlorhydria 


CHRONIC  DILATATION  AND  MOTOR  INSUFFICIENCY        613 

and  hypersecretion  (except  in  malignancy)  are  usually  present  and  are 
sequential  rather  than  causative.  (6)  Motility  is  best  tested  by  Leuhe's 
test  dinner,  "consisting  of  13  ounces  (400  c.c.)  beef  soup,  7  ounces 
(200  gm.)  beefsteak,  one  to  two  ounces  (60  gm.)  bread,  and  7  ounces 
(200  c.c.)  water,  which  should  leave  the  stomach  physiologically  in 
not  more  than  seven  hours.  If  food  is  found  somewhat  later,  stagna- 
tion is  present;  if  found  in  the  morning  when  Leube's  meal  has  been 
given  at  night,  there  is  great  stagnation.  The  long  stay  of  food  in  the 
stomach  shows  practically  what  the  vomitus  shows,  i.  e.,  fermentation. 
Fluid  is  not  absorbed  by  the  stomach,  whence  the  measure  of  its  resid- 
ual amount  is  important.  There  is  more  fluid  in  the  stomach  than  was 
ingested,  which  is  accounted  for  by  hypersecretion  of  the  gastric  juice, 
actual  transudation,  mucus  and  perhaps  regurgitation  from  the  intes- 
tine, or  hemorrhage.  Other  tests  are  less  reliable; — the  oil  test  consists 
of  administering  three  ounces  (100  c.c.)  of  olive  oil,  70  to  80  per  cent, 
of  which  should  leave  the  stomach  in  two  hours;  if  more  than  20  to 
30  c.c.  remain  after  this  time,  it  is  indicative  of  motor  insufficiency. 
Salol,  grains  xv,  given  just  after  eating,  should  normally  reach  the 
intestine  within  an  hour,  where  it  is  split  up  into  salicylic  and  carbolic 
acids;  in  testing  the  urine  passed  in  forty-five  to  sixty  minutes  after 
eating,  salicyluric  acid  should  be  found  (reacting  violet  to  tincture  of 
the  chloride  of  iron) ;  salol  is  normally  eliminated  in  twenty-four  hours, 
and  its  presence  in  the  urine  for  a  longer  time  also  indicates  delayed 
absorption  and  dilatation;  two  errors  are  possible  in  this  test,  viz., 
its  possible  decomposition  by  alkaline  mucus  in  the  stomach,  and  its 
failure  to  decompose  in  the  gut  when  there  is  acid  intestinal  fermen- 
tation ,  (Brunner  and  Huber).  Resorption  may  be  tested  by  giving 
five  grains  of  potassium  iodide  after  eating.  It  should  be  absorbed 
and  secreted  by  the  saliva  in  seven  to  fifteen  minutes;  this  is  tested 
by  adding  nitric  acid  to  the  saliva  and  touching  with  starch  paper, 
which  will  show  the  blue  iodine  reaction;  a  possible  error  is  the 
prompt  absorption  of  the  KI  when  food  is  not  absorbed.  In  general 
a  well-worked-up  homogeneous  chyme  means  that  the  motor  function  is 
normal ;  coarse  particles  occur  when  there  is  motor  insufficiency. 

3.  Physical  Signs. — (a)  Inspection  in  a  good  light  is  very  important. 
A  visible  prominence  of  the  dilated  organ  may  be  seen  below  the  navel, 
sometimes  showing  clearly  the  abnormally  low  upper  and  lower  cur- 
vatures, the  upper  curvature  never  being  seen  normally.  In  obstruction 
a  peristaltic  wave  passing  from  left  to  right,  or  an  antiperistaltic 
wave  in  the  opposite  direction,  often  tells  the  whole  story.  "Stiffen- 
ing" of  the  stomach  is  an  infallible  sign  of  pyloric  stenosis.  Peristaltic 
waves  may  be  elicited  by  applying  ether  or  ice  to  the  epigastrium. 
The  a;-rays  show  the  outline  of  the  viscus  after  ingestion  of  consider- 
able bismuth,  (b)  Palpation  confirms  the  above  findings  and  also 
elicits  splashing  (clapotage)  of  gas  and  water  in  the  stomach,  a  sign  on 
which  no  great  reliance  is  placed,  for  splashing  occurs  in  healthy 
stomachs.  The  hand  may  palpate  the  final  gush  of  gastric  contents 
into  the  gut.     (c)  Percussion — The  normal  vertical  dimension  of  the 


614  DISEASES  OF  THE  DIGESTIVE  TRACT 

stomach  is  4  to  5.5  inches  (10  to  14  cm.)  and  its  maximum  capacity- 
three  pints  (1,600  c.c).  Filling  the  stomach  with  water  and  percussing, 
with  the  patient  standing,  outlines  both  the  lesser  and  greater  curvatures, 
which  may  even  reach  to  the  pubes.  Siphoning  the  water  and  then 
distending  the  stomach  vrith  air  pumped  in,  or  T^ith  carbon  dioxide 
gas,  replaces  the  flatness  by  tympany.  (The  carbon  dioxide  is  pro- 
duced by  giving  sodium  bicarbonate  5j  ^o  ij  dissolved  in  water,  fol- 
lowed by  an  equal  amount  of  tartaric  acid  in  water.)  When  doubtful, 
the  colon  may  be  distended  vv-ith  gas  or  fluid.  The  greatest  distention 
is  at  the  fundus.  With  both  gas  and  water  in  the  stomach,  the  note 
changes  with  change  of  posture,  the  fluid  being  in  the  lower  and  the 
gas  in  the  upper  parts,  as  in  ascites;  the  most  experienced  men  ac- 
knowledge that  they  have  confused  enormously  dilated^stomachs  mth 
ascites  and  ovarian  cysts  and  have  introduced  a  trochar;  Jadon  pub- 
lished a  case  in  which  the  stomach  contained  45  quarts.  Leube  was 
the  first  to  palpate  the  lower  end  of  the  stomach  by  means  of  a  rigid 
sound;  this  has  justly  been  practiced  less  frequently  of  late  years; 
the  normal  distance  from  the  upper  teeth  to  the  greater  curvature  is 
23.5  inches  (60  cm.)  which  is  increased  in  dilatation  to  27.5  inches 
(70  cm.)  or  more,  (d)  Auscultation  elicits  the  splashing  which  may 
be  heard  by  the  patient,  and  sometimes  a  fine  crepitation  or  hissing 
noise  as  gas  is  generated,  a  splashing  or  dripping  sound  as  the  patient 
drinks,  or  metallic  heart  tones.  The  rc-rays  and  gastric  illumination 
are  less  certain  and  easy  methods  of  diagnosis. 

4.  Complications. — (a)  Constipation  is  the  rule,  and  the  stools  are 
hard,  because  less  fluid  passes  the  pylorus,  (b)  The  urine  is  often 
alkaline,  its  chlorides  are  lessened,  and  its  amount  is  reduced  to  a 
pint  or  less  as  a  result  of  the  acid  vomiting;  triple  phosphates  are 
common  and  acetone  and  diacetic  acid  are  occasional,  (c)  The  skin  is 
often  dry,  and  (d)  emaciation  is  common,  even  in  benign  stenosis  or 
muscular  insufiiciency,  because  food  is  imperfectly  absorbed;  some  of 
it  is  lost  to  the  organism  by  fermentation  and  tissue-destroying  toxins 
possibly  develop,  (e)  Auto-intoxication  from  fermentation  may  de- 
velop, causing  headache,  vertigo,  drowsiness,  psychoses,  polyneuritis, 
tetany,  slow  pulse,  and  nervous  dyspnoea.  Tetany  (Neumann  and 
Kussmaul)  occurs  oftenest  in  hj^ersecretion  or  stenosis  from  cancer 
or  ulcer;  its  symptoms  are  considered  under  Tetany,  and  it  may  be 
merely  noted  here  that  73  per  cent,  of  cases  die  (101  cases  combined 
from  Riegel,  Albu,  Fraenkel-Hochwart,  etc.). 

Diagnosis. — The  etiology,  vomiting,  impaired  motility  as  showm  by 
Leube's  te.st  dinner,  the  visible  outlines  confirmed  by  percussion,  and 
the  low  lesser  curvature  which  is  not  seen  normally,  distinguish  gastrec- 
tasia  easily;  its  cause  may  be  determined  with  difficulty  only.  The 
stomach  may  be  physiologically  large  (megalogastria) ,  but  then  there 
is  no  motor  insufficiency,  no  vomiting,  and  no  stagnation.  Gastroptosis 
will  be  considered  later.  The  degree  of  stasis  is  determined  by  wash- 
ing out  the  stomach  at  varying  times  after  the  test  dinner.  In  pyloric 
stenosis  there  is  greater  dilatation  than  in  simple  motor  insufficiency 


CHRONIC  DILATATION  AND  MOTOR  INSUFFICIENCY        615 

(or  atony),  and  marked  peristalsis  is  always  indicative  of  obstruction. 
When  a  diagnosis  of  pyloric  obstruction  is  established,  the  benign  must 
be  differentiated  from  the  mahgnant  type;  benign  pyloric  obstruction 
runs  a  more  remittent  longer  course,  of  over  two  years',  even  of  fifteen 
years'  duration ;  HCl  and  the  ferments  are  usually  increased  and  are 
always  present,  sarcinse  are  often  and  lactic  acid  seldom  present;  in 
the  writer's  experience  stenosis  due  to  round  ulcer  is,  in  fully  half  the 
cases,  attended  by  subacidity  or  anacidity;  while  in  cancer  (v.i.)  the 
march  of  symptoms  is  unfortunately  progressive,  and  cachexia,  severe 
anaemia  with  leukocytosis,  hydrops,  pyloric  tumor,  the  Oppler-Boas 
bacillus,  and  metastases,  develop  with  relative  rapidity.  The  spasmodic 
form  runs  an  intermittent  course.  The  prognosis  depends  on  the 
etiology  and  amenability  to  treatment;  spastic  (spasmodic)  types  are 
curable;  relative  stenosis  may  somewhat  improve. 

Treatment. — 1.  Etiological  factors,  especially  those  of  atony,  should 
be  treated. 

2.  General  measures,  tending  to  tone  the  musculature,  are  (a) 
abdominal  massage,  which  should  be  practised  only  when  ulceration 
and  inflammation  are  certainly  excluded;  (6)  drugs,  especially  strych- 
nine, which  is  often  combined  with  atropine  and  the  application  of 
an  ice-bag  to  the  epigastrium;  ergot  and  creosote  are  less  valuable; 
(c)  hydrotherapy;  (d)  faradization  of  the  stomach;  external  applica- 
tion is  seemingly  as  efficacious  and  certainly  less  difficult  than  intra- 
gastric application,  though  opinions  vary  greatly;  and  (e)  abdominal 
binders  or  supports.  These  five  points  in  treatment  avail  only  in 
atony. 

3.'  Gastric  therapy  is  indicated,  (a)  Gastric  lavage  removes  the 
fermenting  contents,  relieves  the  organ  of  pressure  exerted  by  accumu- 
lated food  and  fluid,  cleans  off  the  mucus,  lessens  vomiting  and  auto- 
intoxication, and  may  permanently  help  atony  and  temporarily  mitigate 
the  effects  of  pyloric  stenosis.  The  stomach  should  be  washed  with 
luke-warm  water  until  it  returns  clear  of  food  and  mucus;  salicylic 
acid  and  sodium  bicarbonate  may  be  added,  as  in  chronic  gastritis; 
the  patient  soon  becomes  accustomed  to  the  tube  and  welcomes  the 
relief  afforded;  it  is  generally  said  that  morning  lavage  is  best,  but 
washing  before  the  evening  meal  is  preferable,  as  the  organ  then  suffers 
less  stagnation  through  the  night;  the  stomach  should  rest  for  a  few 
hours  before  food  is  taken.  (6)  The  food  should  be  well  divided, 
nourishing,  and  not  too  voluminous;  it  should  be  given  with  very 
moderate  quantities  of  water,  in  small  amounts  and  at  intervals  of 
three  to  four  hours.  The  average  diet  consists  of  meat,  eggs,  legum- 
inous purees,  very  thoroughly  cooked  rice,  and  small  amounts  of  butter; 
generally  speaking,  fats  and  carbohydrates  are  more  prone  to  fermen- 
tation. P.  Cohnheim  advises  an  ounce  or  two  of  olive  oil  in  pyloro- 
spasm  and  in  moderate  benign  stenosis.  A  dry  diet  was  early  advised 
by  von  Swieten,  but  moderate  amounts  of  fluid  aid  in  propulsion  of 
food  into  the  gut.  Of  course  much  depends  on  the  causal  disease; 
a  fluid  diet  is  indicated  in  great  pyloric  stenosis,  and  when  the  hydro- 


&16  DISEASES   OF  THE  DIGESTIVE  TRACT 

cHoric  acid  is  decreased.  ^leat  should  be  given  if  the  hydrochloric 
acid  is  normal  or  increased  and  the  pylorus  is  not  greatly  stenosed. 
Recently  there  has  been  a  reversion  in  favor  of  one  or  two  fair-sized 
meals  a  day,  thus  giving  the  stomach  ample  time  to  empty  itself  and 
to  rest.  Water  is  not  absorbed  by  the  stomach,  as  proven  by  von 
Mering,  Avho  also  found  that  the  absorption  from  the  stomach  of  sugar, 
peptone,  dextrin,  and  alcohol,  is  attended  by  actual  excretion  of  water 
into  the  stomach.  Riegel  believes  a  small  amount  of  water  is  bene- 
ficial. In  pronounced  cases  peptonized  milk  and  water  are  given  by 
rectum  to  supplement  gastric  feeding.  In  all  cases  careful  indi^'iduali- 
zation  is  indicated;  the  exact  degree  of  insufficiency  should  be  tested 
by  Leube's  meal,  i.  e.,  the  time  required  for  absorption,  and  the  patient 
should  be  fed  accordingly,  (c)  Posture — The  seriously  affected  patient 
should  lie  on  his  right  side  one  to  two  hours  after  eating,  thereby 
relieving  pressure  upon  the  greater  curvature  of  the  stomach  and 
directing  the  food  toward  the  pylorus,  (d)  Gastric  medication — (See 
Chroxic  Gasteitis,  Ulcer,  Cancer, Hyperchlorhtdria).  (e)  Thio- 
sinamin — (See  Intestixal  Obstructiox). 

4.  Surgical  intervention  is  imperative  in  severe  or  malignant  stenosis 
and  when  medical  treatment  fails.  It  embraces  (a)  pylorectomy,  of 
which  Dryendorff  collected  188  cases  with  a  57  per  cent,  mortahty; 
(b)  pyloroplasty  (29  cases  \tdth  a  21  per  cent,  mortality),  (c)  gastro- 
enterostomy (215  cases  with  a  43  per  cent,  mortality).  In  153  opera- 
tions for  benign  stenosis  Moynihan  had  only  two  deaths.  As  shown 
in  ulcer  and  cancer  (v.i.)  the  earlier  recorded  mortality  has  been  much 
reduced.  According  to  Shaw  and  Elting,  in  the  pyloric  stenosis  of 
infancy  the  mortality  under  medical  treatment  is  72  per  cent.,  under 
surgical  56  per  cent.  In  eleven  operations  for  tetany  with  pyloric 
stenosis  (Jonnesco),  eight  cases  recovered. 


(D).  CHANGES  IN  FORM,  SIZE  AND  LOCATION  OF  THE  STOMACH. 

Form. — The  antrum  cardiacum  and  fore-stomach  are  oesophageal 
rather  than  gastric  anomalies.  The  antrum  cardiacum  is  a  congenital 
bulging  of  the  oesophagus  just  below  the  diaphragm,  and  the  fore- 
stomach  is  a  congenital  dilatation  above  the  diaphragm.  There  is  a 
congenital  form  of  narrowness  of  the  pylorus  as  well  as  of  hour-glass 
stomach. 

The  acquired  hour-glass  deformity  is  more  common  and  may  result 
from  spasm  (h}^ertrophic  muscle),  cancer,  ulcer,  or  adhesions  around 
the  middle  of  the  organ,  as  well  as  from  abdominal  tumors,  peritoneal 
tuberculosis,  twisting  of  the  stomach  or  hernia  of  it  through  the  meso- 
colon. Mayo  Robson  (1904)  in  23  cases  found  ulcer  as  the  cause  in  15, 
tumor  in  4  and  perigastritis  in  4.  It  may  co-exist  with  pyloric  stenosis. 
Raadolph  and  Thomas  observed  2  cases  in  one  family. 

Symptoms  may  be  lacking  in  the  lesser  degrees  of  deformity;  in  the 
higher  grades  they  are  those  of  stenosis.     (1)  Only  a  part  of  a  given 


CHANGES  IN  FORM,  SIZE  AND  LOCATION  OF   THE  STOMACH   617 

amount  of  water  introduced  into  the  stomach  may  be  recovered 
(Wolfler's  first  symptom).  (2)  After  the  stomach  has  been  washed 
till  the  water  returns  clear,  the  fluid  may  suddenly  become  clouded 
(Wolfler's  second  symptom).  (3)  The  stomach  is  emptied  by  the 
stomach  tube  and  yet  splashing  is  obtained  (from  the  cavity  nearest 
the  pylorus) ;  Jaboulay  called  this  paradoxical  dilatation.  (4)  Inflation 
by  carbon  dioxide  produces  distention  first  of  the  left  and  later  of 
the  right  half  of  the  epigastrium  (von  Eiselsberg's  first  symptom).  (5) 
Normally  when  the  stomach  is  distended  and  the  gas  passes  through 
the  pylorus  into  the  bowel,  there  is  a  sharp  gurgle  over  the  pylorus; 
in  the  hour-glass  stomach  the  gurgle  is  heard  two  to  four  inches  to 
the  left  of  the  median  line  (von  Eiselsberg's  second  symptom).  (6) 
On  gastric  distention  by  carbon  dioxide  Moynihan  found  tympany 
only  over  the  upper  part  of  the  stomach  and  not  over  its  lower  half. 
(7)  When  the  stomach  is  distended,  a  furrow  may  appear  (Eichhorst 
and  Schmid-Monard) ;  Moynihan  saw  the  furrow  in  10  cases.  (8) 
Filling  the  stomach  with  water  and  illuminating  it  by  a  light  intro- 
duced into  the  stomach,  the  cardiac  portion  appears  translucent  and 
the  pyloric  part  dark  (Ewald).  (9)  A  rubber  balloon  (introduced 
into  the  stomach  and  then  inflated  through  the  stomach  tube)  fills  or 
outlines  a  part  only  of  the  stomach  (Hemmeter). 

Treatment  is  surgical.  ^Moynihan  successfully  operated  on  23  cases; 
he  enumerates  the  surgical  measures  as  follows :  single  or  double  gastro- 
enterostomy, gastroplasty,  gastrogastrostomy,  partial  gastrectomy,  and 
dilatation  of  the  stenosis. 

In  situs  viscerum  inversus  (see  Diseases  of  the  Heart)  the  pylorus 
lies  on  the  left  side. 

Size. — Megalogastria  and  microgastria  are  usually  accidental  find- 
ings if  not  associated  with  other  gastric  disease. 

Location. — The  stomach  at  birth  is  vertical,  and  in  adult  life  is 
generally  held  to  lie  so  that  three-quarters  of  it  is  to  the  left  of  the 
miedian  line.  Rosenfeld  has  recently  insisted  that  the  whole  stomach 
is  disposed  to  the  left  of  the  mid-line,  and  that  the  organ's  physio- 
logical posture  is  vertical. 

Gastroptosis. — (See  Enteroptosis.) 

(E).  ROUND  ULCER  OF  THE   STOMACH. 

Definition. — Ulceration  of  the  stomach  is  characterized  in  the 
majority  of  cases  (a)  etiologically  by  its  occurrence  chiefly  in  young 
women  or  in  chloransemic  subjects;  (6)  pathologically  by  a  "punched 
out"  funnel-Hke  ulcer,  oftenest  near  the  pylorus,  and  (c)  clinically  by 
localized  pain  and  tenderness,  hsematemesis,  and  hyperacidity. 

Frequency.— It  is  found  in  2.5  to  5  per  cent,  of  all  autopsies  (W.  H. 
Welch,  Orth,  and  von  Jaksch).  It  occurs  four  times  less  frequently 
in  America  than  in  Europe. 

Etiology. — The  causes  of  ulcer  are  not  exactly  known,  (a)  Age 
and  sex — ^^Nlost  cases  (70  per  cent.,  Lebert)  occur  between  twenty  and 


618  DISEASES  OF  THE  DIGESTIVE  TRACT 

thirty  years  of  age,  especially  in  women.  Isolated  cases  occur  in  the 
very  young  and  in  the  foetus;  in  children  E.G. Cutler  collected  29 
cases ;  60  per  cent,  occurs  in  women,  in  whom  the  disease  occurs  two 
to  four  times  as  frequently  as  in  men.  Ulcer  develops  most  frequently 
in  men  between  thirty  and  fifty  years  of  age;  the  author  has  seen  five 
cases  in  men  over  sixty,  (b)  Anaemia  and  chlorosis  are  strongly  pre- 
disposing factors.  Anaemia  plus  (c)  hyperacidity  are  usually  held  to 
be  important  factors;  the  writer  believes  Rosenheim  and  Cohnheim  are 
correct  in  stating  that  hyperacidity  is  only  a  result;  73  per  cent,  of 
Leube's  cases  of  chlorosis  showed  hyperacidity,  (d)  Changes  in  the 
vessels  are  of  etiological  importance.  As  a  normal  access  to  the  stomach 
of  arterial  blood  prevents  its  autodigestion,  it  is  thought  by  some  that 
interruption  in  the  local  circulation  is  the  cause  of  ulceration ;  Virchow 
believed  that  embolism  was  causal,  and  Klebs  held  that  arterial  spasm 
was  an  etiological  factor.  Embolism  is  proven  to  follow  bums.  It 
will  be  noted,  however,  that  ulcer  often  occurs  at  an  age  when  arterial 
changes  are  rare,  though  syphilis,  alcoholism,  arteriosclerosis,  cardiac 
and  hepatic  disease  apparently  cause  some  of  the  cases  in  later  life. 
(e)  Occupation  is  a  factor.  Many  cases  occur  in  servant  girls  and  in 
cooks ;  (/)  trauma  in  cooks,  shoemakers,  and  in  tailors,  is  an  accessory 
factor,  for  the  tasting  of  hot  foods  and  pressure  against  the  stomach 
promote  the  development  of  ulcer.  (Some  writers  hold  that  there  are 
two  leading  causes  for  ulcer:  anaemia  and  pressure.)  The  pressure  of 
corsets,  the  swallowing  in  certain  trades  of  particles  of  iron,  porcelain, 
and  glass,  and  imperfectly  masticated  or  improper  food,  may  be  brought 
under  this  caption.  External  trauma  is  a  distinct  factor,  (g)  Other 
alleged  causes  are  heredity;  vomiting,  and  even  hysteria,  have  been 
considered  as  causal.  Letulle  and  Martin  hold  that  (h)  bacterial 
necrosis  causes  ulcer,  which  is  clearly  shown  by  Dieulafoy's  cases  of 
pneumococcic  hemorrhagic  ulceration  of  the  stomach. 

Pathology. — Scars  indicating  healed  ulcers  are  three  times  as  fre- 
quent at  autopsy  as  open  ulcers.  The  ulcer  is  known  as  ulcus  simplex 
(to  distinguish  it  from  malignant,  or  syphilitic  ulceration),  idcu^ 
rotundum,  as  the  smaller  ones  especially  are  round,  ulcu^  pepticum 
and  perforans.  The  peptic  ulcer  occurs  almost  exclusively  in  the 
stomach,  lower  oesophagus,  and  upper  duodenum.  (See  Duodenal 
Ulcer.)  Its  general  morphology  was  first  described  by  Cruveilhier 
(1829)  and  Rokitansky  (1839);  it  has  a  "punched  out,"  clean-cut 
appearance;  in  contour  it  is  round  or  oval  in  small,  and  irregular  in 
large,  ulceration;  it  is  usually  small,  but  sometimes  invades  most  of 
the  surface  of  the  stomach,  and  in  one  case  it  measured  four  by  seven 
and  a  half  inches;  it  is  funnel-shaped  in  old  cases;  its  apex  is  eccentric 
and  is  directed  toward  the  serosa,  its  sides  are  terrace-shaped,  and  its 
floor  is  usually  clean.  In  80  per  cent,  the  ulcer  is  single,  though  a  case 
with  as  many  as  34  ulcers  has  been  reported.  Extension  is  more 
common  in  acute  than  in  chronic  cases  and  is  more  toward  the  peri- 
toneum than  laterally.  Microscopically  there  is  usually  no  infiltration 
with  round  cells.     Its  localization  is  chiefly  near  the  pylorus  on  the 


ROUND   ULCER  OF  THE  STOMACH  619 

posterior  wall  or  lesser  curvature;  its  complications,  as  hemorrhage 
■  and  perforation,  and  its  sequelce,  as  pyloric  stenosis  and  deformations, 
will  be  considered  under  clinical  symptoms. 

Sjniptoms. — The  general  clinical  picture  varies,  cases  being  typical, 
doubtful,  or  entirely  latent. 

In  the  typical  case  the  symptoms  develop  gradually  with  a  sense  of 
epigastric  pressure  after  eating,  which  later  becomes  a  more  violent, 
cutting,  localized  pain;  this  is  observed  less  commonly  directly  after 
eating  than  one-half  to  one  and  a  half  hours  thereafter;  it  lasts  through- 
out the  period  of  digestion  and  ceases  only  with  passage  of  the  food 
into  the  bowel  or  after  vomiting.  The  appetite  is  usually  good ;  hyper- 
acidity is  noted  after  a  test  meal  or  in  the  vomitus;  focal  tenderness 
occurs  over  the  epigastrium,  and  in  fully  half  the  cases  bleeding  from 
the  stomach  or  blood  in  the  stools  is  observed. 

The  typical  triad  of  cardinal  symptoms,  taken  together  or  possibly 
singly,  makes  the  diagnosis  most  easy;  (1)  pain  with  localized  tender- 
ness, (2)  heematemesis,  and  (3)  hyperacidity. 

1.  Pain. — The  most  important,  characteristic  and  constant  symptom 
is  pain,  which  is  usually  paroxysmal,  is  localized,  and  occurs  during 
digestion.  It  is  boring  or  burning,  seldom  lancinating,  and  is  due  to 
irritation  of  the  gastric  nerves  aroused  by  peristalsis,  nerve  erosion,  or 
hyperacidity.  The  diet  affects  the  pain  greatly;  milk,  for  instance,  is 
well  tolerated  in  certain  cases,  but  solid  food  usually  produces  exces- 
sive pain,  and  very  hot  or  very  cold  foods  or  beverages  almost  invariably 
cause  discomfort.  This  disappears  quickly  with  rectal  feeding.  The 
seat  of  the  pain  varies  in  different  patients,  but  is  always  the  same  in  a 
given  case.  In  the  great  majority  of  cases  it  is  epigastric  and  is  very 
often  quite  near  the  ensiform.  Ewald  and  others  describe  it  as  char- 
acteristically cramp-like  in  the  pyloric  region  (in  the  right  mammary 
line  under  the  liver).  Sometimes  there  is  wide  irradiation  toward  the 
sternum,  ribs,  intercostal  spaces,  shoulder,  scapula,  and  more  infre- 
quently even  in  the  brachial  plexus  and  pulmonary  branches  of  the 
vagus,  resembling  that  of  angina  pectoris  (Traube)  or  even  producing 
sympathetic  pain  (Mueller)  in  the  arms  and  legs.  The  pain  varies 
with  change  of  position,  depending  on  the  localization  of  the  ulcer, 
but  there  is  always  pain  when  the  patient  lies  on  the  left  side. 

In  relation  to  eating,  there  is  a  difference  of  opinion.  Sometimes 
the  pain  occurs  two  to  ten  minutes  after  eating,  the  old  "wound  pain," 
supposedly  due  to  contact  of  food  with  the  eroded  nerves  in  the  ulcer. 
Again,  the  pain  occurs  at  the  height  of  digestion,  i.e.,  one-half  to  one 
and  one-half  hours  after  ingestion  of  food;  this  is  caused  by  the  hyper- 
acidity of  the  gastric  juice.  Patients  fear  to  eat  because  of  the  inevit- 
able pain.  Pain  may  occur  after  meals  for  months,  and  disappear 
to  recur  after  months.  (In  some  cases  of  ulcer  there  is  constant 
flow  of  gastric  juice  [v.  Hypersecretion]  which  may  result  in  two 
kinds  of  pain,  one  of  which  is  present  when  the  stomach  is  empty  and 
the  other  at  the  height  of  digestion.)  Pain  may  be  worst  at  the  time 
of  the  menses.    Pain  from  the  scars  or  adhesions  of  an  ulcer  is  infre- 


620         DISEASES   OF  THE  DIGESTIVE  TRACT 

quent,  is  rarely  cramp-like  but  usually  drawing  or  vague,  and  some- 
times continuous.  In  old  ulcers  pain  is  atypical  or  wholly  absent. 
The  time  of  development  of  the  pain  does  not  locate  the  ulcer,  though 
if  it  comes  on  at  once  it  may  suggest  oesophageal  or  cardiac  ulcer;  or, 
if  it  occurs  two  and  a  half  hours  or  more  after  eating,  it  is  suggestive 
of  ulcer  of  the  duodenum. 

Tenderness  is  most  often  found  under  the  ensiform  or  near  the  navel 
(if  there  be  gastroptosis).  It  is  usually  circumscribed  and  is  more  often 
and  more  advantageously  found  on  the  lightest  touch,  rather  than  on 
deep  palpation.  A  diagnosis  from  tenderness  alone  is  somewhat  unsafe. 
Tenderness  in  the  back  (Cruveilhier)  suggests  ulcer  on  the  posterior 
wall  of  the  stomach  and  is  found  in  25  to  33  per  cent,  of  cases  over  an 
area  of  one  or  two  inches  to  the  left  of  the  tenth  to  twelfth  dorsal  or 
upper  lumbar  vertebrae.  The  abdomen,  back,  and  chest,  are  often 
exquisitely  hypersesthetic.  In  a  few  cases  pressure  is  grateful  (Osier). 
Palpation  must  be  guarded,  for  perforation  has  followed  undue  pres- 
sure. 

2.  Haematemesis. — The  second  cardinal  symptom  is  hsematemesis. 
Some  authors  consider  it  the  most  important  and  certain  finding. 
Its  frequency  is  variously  given  at  from  25  to  even  80  per  cent.;  the 
average  figure  is  probably  50  per  cent.  Vomiting  of  blood  in  ulcer  is 
most  frequently  from  ulcer  in  the  pyloric  region  (posterior  wall  and 
lesser  curvature),  or,  less  frequently,  from  ulceration  reaching  the  liver, 
pancreas,  or  spleen.  Hemorrhage  when  small  may  be  overlooked 
(occult  hemorrhage),  or  blood  may  be  found  only  in  the  stools;  meleena 
alone  is  found  in  11  per  cent,  of  cases.  It  is  said  that  the  hemorrhage 
must  amount  to  a  pint  to  turn  the  stools  black.  It  may  be  large  and 
sometimes  prove  fatal;  indeed  it  may  be  so  acute  that  no  blood  is 
vomited  and  the  stomach  and  bowels  are  found  to  be  filled  with  one 
massive  clot.  The  usual  signs  of  internal  hemorrhage  exist,  as  collapse, 
pallor,  moderate  rise  of  temperature,  brain  anaemia,  hsemic  mur- 
murs, amaurosis,  and  rarely,  optic  atrophy  or  hemiplegia.  If  profuse 
it  is  voided  bright  red;  if  slow  and  moderate  the  acid  turns  it  dark, 
"coffee-grounds  vomitus."  If  red  blood  cells  cannot  be  found  in  the 
vomit  because  of  complete  disintegration  of  the  cells,  blood  can  be 
detected  by  treating  it  with  acetic  acid,  extracting  with  ether  and  then 
testing  with  the  guaiac  and  turpentine  reaction,  when  blood  will  be 
shown  (Bial)  even  if  the  spectroscope  shows  nothing.  "  Occult  hemor- 
rhage" occurs  in  25  to  50  per  cent,  of  cases  (see  H^matemesis  and 
Cancer)  ;  it  is  not  as  constantly  present  as  in  gastric  cancer.  J.  Dutton 
Steele  concludes  that  the  tests  for  occult  hemorrhage  are  valuable; 
first,  to  determine  the  length  of  the  various  periods  of  the  medical 
treatment  of  ulcer.  Second,  to  detect  the  tendency  to  bleeding  during 
the  course  of  gastric  ulcer  and  by  appropriate  medical  and  surgical 
measures  to  anticipate  and  prevent  serious  hemorrhage.  Third,,  to 
determine  when  the  medical  treatment  may  be  considered  to  have 
failed  and  surgical  treatment  is  indicated.  Fourth,  perhaps  the  test 
may  prove  helpful  under  certain  circumstances  in  detecting  the  de- 


ROUND   ULCER  OF   THE  STOMACH 


621 


velopment  of  a  cancer  upon  the  floor  of  an  ulcer.  Blood  is  found 
macroscopically  in  the  stomach  washings  less  frequently  than  is  to  be 
inferred  from  text-book  descriptions^  and  apparently  normal  vomitus 
may  show  blood  microscopically  or  chemically.  Profuse  hemorrhage 
usually  indicates  deep  ulceration.  Hemorrhage  is  said  to  complicate 
chronic  more  than  acute  cases,  though  this  does  not  correspond  to 
personal  experience.  The  hemorrhage  is  usually  fairly  profuse  in 
ulcer;  it  may  be  spontaneous  during  sleep  or  rest  or  may  result  from 
excitement,  physical  exertion,  or  improper  diet.  In  a  case  of  "chronic 
dyspepsia"  with  vague  symptoms,  the  writer  inflated  the  stomach 
with  the  usual  amount  of  carbon  dioxide;  the  patient  collapsed  in  the 
oflSce  and  vomited  nearly  a  quart  of  blood. 

3.  Hyperacidity. — This  is  the  third  cardinal  flnding.  Though  it 
has  often  been  stated  to  be  a  constant  finding  by  Riegel  and  others, 
Hemmeter  finds  it  in  90  per  cent,  and  Leube  in  50  per  cent. : 


HCl  according  to 

Normal  acidity. 

Hypochlorhydria. 

Achlorhydria. 

HjTjerchlorhydria. 

Ewald 

57% 
36% 
46% 

9% 
34% 
20% 

23% 

4% 

34% 

Eichhorst 

7% 

30% 

The  variance  noted  in  these  figures  is  due,  in  the  author's  opinion,  to 
combining  old  callous  ulcers  with  the  fresh  chlorotic  ulcers;  in  old 
ulcers  hyperchlorhydria  is  present  in  only  10  per  cent.,  and  they  explain 
most  of  the  cases  of  decreased  acidity;  in  fresh  ulcers,  hyperacidity 
occurs  in  70  per  cent.  Hyperchlorhydria  is  probably  due  to  irritation 
of  the  vagus  (Pawlow).  Complicating  cancer,  hypersecretion  or  catarrh 
may  cause  subacidity. 

Should  a  test  meal  be  given  in  cases  of  ulcer,  to  determine  whether 
an  excess  of  acid  exists  ?  Certainly  not,  when  the  diagnosis  is  deter- 
mined by  the  pain,  tenderness,  and  vomiting  of  blood,  or  when  the 
ulcer  lies  at  the  cardiac  end  of  the  stomach.  The  stomach  tube,  how- 
ever, is  used  by  Riegel,  Boas,  Rosenheim,  Fleiner,  and  others,  not  only 
for  diagnosis  in  atypical  cases,  but  also  to  relieve  the  more  dangerous 
vomiting  and  to  introduce  silver  and  bismuth  into  the  stomach.  Or- 
ganic acids,  as  lactic,  are  absent,  the  carbohydrates  are  poorly  digested, 
and  the  albumins  are  rapidly  converted  into  albumoses  or  peptones. 
The  motiHty  of  the  stomach  is  normal  in  one-quarter  and  slow  in 
three-quarters  of  the  cases.  If  pyloric  obstruction  exists  the  mineral 
acid  is  still  more  increased. 

4.  Other  Symptoms. — Vomiting,  present  in  75  per  cent.,  is  a  less 
valuable  diagnostic  than  pain,  although  they  usually  occur  together. 
Some  cases  never  vomit,  or  do  so  only  several  hours  after  meals.  It 
occurs  at  the  height  of  the  pain,  one,  two  or  three  hours  after  eating, 
whereas  in  dilatation  or  hypersecretion  it  occurs  much  later.  Vomit- 
ing as  well  as  pain  depends  directly  on  the  diet,  heavy  meals  increasing 
and  appropriate  diet  lessening  each.  It  may  be  uncontrollable.  Some 
degree  of  parallelism  exists  between  the  pain  and  vomiting,  the  latter 


622  DISEASES  OF  THE  DIGESTIVE  TRACT 

usually  relieving  the  former.  The  vomitus  usually  consists  of  fine 
particles,  is  sour,  grits  the  teeth,  and  shows  much  acid  and  no  fermen- 
tation. Dyspepsia  occurs  from  catarrhal  gastritis,  dilatation,  or  other 
complications.  The  appetite  is  very  frequently  good  or  even  exag- 
gerated. Acid  eructations  (pyrosis)  may  cause  a  burning  sensation 
back  of  the  sternum  or  between  the  shoulder  blades.  If  there  is  much 
oesophageal  burning  it  indicates  incontinence  of  the  cardiac  orifice. 
Diarrhoea  is  rare.  Constipation  is  due  to  the  anaemia,  diet,  rest, 
vomiting,  possibly  reflex  inhibition  from  the  stomach  upon  the  motor 
nerves  of  the  bowel  or  to  impairment  of  peristalsis  by  scars  and  adhe- 
sions. Dysmenorrhoea  and  amenorrhoea  are  not  infrequent.  Blood 
may  be  found  in  the  stools.  Fever  is  a  complication.  The  nutrition 
varies  and  emaciation  may  be  observed  (cachectic  type).  Anaemia  is 
more  common  in  men  and  may  become  profound.  The  urinary 
findings  are  not  characteristic.  Reduction  of  the  chlorides  cannot  be 
used  to  differentiate  from  carcinoma.  The  urine  is  slightly  acid  or 
even  alkaline,  particularly  when  the  stomach  is  dilated.  The  phos- 
phates are  increased;  with  dilatation,  indican  and  ethereal  sulphates 
are  increased.  Acetonuria  and  diaceturia  sometimes  result  from  inani- 
tion and  from  rectal  feeding. 

Clinical  Forms  of  Lebert. — (a)  The  hemorrhagic  form  may  be  either 
acute  or  chronic;  hemorrhage  may  be  the  first  symptom,  or  the  last 
and  fatal  one.  (6)  In  the  perforative  form  there  may  be  entire  latency 
of  previous  symptoms,  (c)  In  the  dyspeptic  type,  dyspeptic  symptoms 
are  most  prominent;  the  evidences  of  ulcer  are  absent,  or  there  are 
atypical  symptoms,  such  as  pain,  which  is  not  sharp,  vomiting,  which 
is  infrequent,  and  excess  of  hydrochloric  acid,  but  no  increase  in 
mucus,  (d)  The  cachectic  form  is  characterized  by  old  ulcers,  by 
cicatrix  producing  dilatation,  and  by  chronic  hypersecretion;  this 
form  may  be  confused  with  carcinoma,  especially  when  there  is  no 
excess  of  acid.  The  other  types  are  as  follows :  (e)  gastralgic  or  neu- 
ralgic form;  (/)  vomitive  form;  (g)  latent  ulcer  (scars  at  autopsy); 
(h)  a  form  with  tumor;  {i)  recurrent  type;  (y)  stenotic  type;  (Jk)  car- 
cinomatous type. 

Clinical  Course. — ^The  course  is  usually  chronic,  for  ulceration  is 
frequently  long  latent  before  diagnosis  is  possible,  and  probably  lasts 
some  time  after  all  symptoms  have  disappeared.  Pain  usually  indi- 
cates incomplete  cicatrization  or  certain  other  sequences,  but  cessa- 
tion of  pain  is  no  certain  criterion  of  healing.  The  course  may  be 
acute  and  rapid,  especially  under  appropriate  therapy.  The  course 
lasts  from  three  to  five  years  (Lebert)  or  even  twenty  to  thirty-five 
years;  this  is  usually  due  to  such  complications  as  pyloric  obstruction, 
dilatation,  or  adhesions.  Very  large  ulcers  probably  never  heal.  They 
frequently  remit  with  appropriate  therapy,  but  may  recur  with  the 
resumption  of  the  old  diet.  It  is  questionable  when  they  can  be  con- 
sidered cured:  certainly  only  when  all  symptoms  have  been  absent 
for  six  months. 


ROUND   ULCER  OF  THE  STOMACH  623 

Localization. — This  can  rarely  be  determined  accurately  (Riegel 
and  Leube).  According  to  Gerhardt,  tenderness  and  tumor  are  indic- 
ative of  ulcer  on  the  anterior  wall,  but  hemorrhage  and  dorsal  pain 
suggest  posterior  involvement.  Pain  in  a  lateral  decubitus  suggests 
localization  in  the  fundus  or  pylorus;  dilatation,  in  the  pylorus  or 
duodenum;  pain  under  the  ensiform  during  the  act  of  deglutition 
suggests  cardiac  ulcer  and  contra-indicates  the  use  of  the  sound.  Ulcers 
are  palpable  in  only  0.1  per  cent,  of  cases  (Leube).  The  percentage 
of  involvement  of  the  cardia  is  6.3;  of  the  fundus,  3.7;  of  the  lesser 
curvature,  36.3;  of  the  posterior  wall,  29.6;  of  the  pylorus,  12;  of  the 
anterior  wall,  8.7.  "  In  over  80  per  cent,  of  the  cases  it  occurs  in  a  rela- 
tively small  area  about  the  pylorus,  lesser  curvature,  and  posterior  wall." 

Complications  and  Sequelae. — (a)  Perforation  (6  per  cent.)  may 
occur  into  the  peritoneum,  usually  with  symptoms  of  collapse,  peri- 
tonitis, and  cessation  of  vomiting  (Traube),  though  Brunner  finds 
vomiting  in  66  per  cent,  and  Gross  in  33  per  cent,  of  such  cases. 
Perforation  may  be  prevented  by  the  left  lobe  of  the  liver,  pancreas, 
or  spleen,  or  by  omental,  pericardial,  and  pleural  adhesions.  The 
danger  of  perforation  in  ulcer  of  the  anterior  wall  is  seven  times  as 
great  as  in  that  of  other  locations.  Perforation  of  a  latent  ulcer  may  be 
confused  with  rupturing  appendicitis  or  salpingitis.  Perforation  may 
occur  into  the  heart,  colon,  gall-bladder,  portal  vein,  pericardium, 
chest  wall,  or  abdominal  wall;  or  it  may  reach  the  space  between  the 
liver  or  spleen  and  the  diaphragm,  producing  pneumothorax  subphren- 
icus,  which  is  suggested  by  pleurisy,  epigastric  and  hypochondriac 
pain,  stiffness  in  the  back,  painful  eructations  and  swallowing,  singul- 
tus, dorsal  decubitus,  or  local  oedema.  (6)  Simple  peritonitis  (perigas- 
tritis) may  cause  a  friction  murmur  over  the  stomach,  (c)  According 
to  Rosenheim  6  per  cent.,  Liebert  9  per  cent.,  or  Zenger,  the  major- 
ity of  cases  of  cancer  develop  from  ulcer.  Two  years  ago  the  author 
saw  with  Dr.  Harpole  a  case  of  carcinoma  developing  in  an  ulcer  scar 
in  a  girl  twenty-six  years  old.  The  typical  symptoms  of  ulcer  are 
followed  by  loss  of  weight,  and  persistence  of  symptoms,  usually  by 
gradual  lessening  of  hydrochloric  acid  and  other  evidences  of  car- 
cinoma, (d)  Adhesions  about  the  stomach  may  interfere  with  its 
motility,  produce  deformation,  such  as  the  hour-glass  stomach  or 
diverticulum,  neuralgia  which  outlasts  the  ulcer,  and  obstruction  of 
either  orifice  of  the  stomach.  Dilatation  of  the  stomach  usually,  but 
not  always,  indicates  pyloric  stenosis;  it  may  also  indicate  cicatrizing 
ulcer  or  result  from  spasm  of  the  pylorus.  Scars  may,  in  rare  cases, 
produce  intestinal  obstruction.  Troublesome  adhesions  may  be  finally 
so  stretched  as  to  relieve  all  symptoms. 

Diagnosis. — The  diagnosis  is  determined  by  (a)  the  etiological 
factors,  (b)  the  cardinal  symptoms,  and  (c)  the  various  chnical  types 
enumerated.  In  general  the  diagnosis  is  easy  in  the  young,  but  may 
be  difficult  in  anaemic  or  chlorotic  individuals. 

Any  two  of  the  cardinal  features  confirm  the  diagnosis.  Pain  is 
often  the  only  symptom;    if  it  is  atypical,  hyperacidity  may  indicate 


624  DISEASES    OF    THE  DIGESTIVE  TRACT 

ulcer,  though  the  latter  is  often  observed  without  ulcer;  Leube  pro- 
poses for  such  cases  the  therapeutic  test,  although  both  cases  may 
respond  to  the  treatment.  According  to  Riegel  the  chief  difference  is 
that  pain  in  simple  acidity  is  less  regular  than  in  ulcer  and  that  local- 
ized tenderness  is  absent,  though  he  admits  that  these  criteria  may 
fail.  Some  cases  of  seemingly  primary  hj'perchlorhydria  are  found  to 
be  ulcers.  "VSTiere  pain  alone  exists  one  must  always  remember  the 
gastric  crises  of  tabes.  Ewald  has  called  attention  to  the  pain  of  small 
hernias  in  the  linea  alba.  Pain  may  cause  confusion  when  it  occurs 
in  the  transverse  colon,  which  lies  in  close  apposition  to  the  stomach, 
but  it  usually  ceases  on  evacuation  of  the  bowels.  Without  careful 
examination  movable  kidney  may  be  confused  with  ulcer.  The  pain 
in  gall-stones  is  paroxysmal,  but  more  irregular,  and  is  independent  of 
eating.  Icterus  in  gall-stones  is  not  common.  The  gall-bladder  is 
tender,  and  may  be  distended  and  palpable.  The  paroxysm  in  gall- 
stones is  often  attended  by  fever,  which  is  not  present  in  ulcer,  and  by 
a  chill.  The  paroxysm  is  longer.  The  liver  may  be  large,  especially 
the  right  lobe.  The  pain  more  often  radiates  to  the  right  side  and 
to  the  shoulder,  and  the  vomiting  is  not  that  of  ulcer,  though  hyper- 
acidity and  gastric  dilatation  may  follow  cholelithiasis.  Chronic 
poisoning,  as  by  arsenic,  may  be  suspected,  as  in  the  case  of  the 
Duchess  of  Orleans  until  Littre  made  the  diagnosis  of  ulcer. 

Hemorrhagic  erosions  and  fissures  of  the  stomach  present  no  con- 
stant clinical  picture.  After  eating  there  is  a  sense  of  burning  over  the 
entire  stomach,  which  is  not  altered  by  change  of  position.  The 
chemism  and  tender  points  of  ulcer  are  lacking,  though  Cohnheim 
usually  finds  hyperchlorhydria;  he  also  beheves  that  sohd  food  relieves 
the  pain.  Shreds  of  tissue  are  always  found,  according  to  Pariser, 
which  cease  with  cessation  of  pain.    Fatal  hemorrhage  is  recorded. 

In  duodenal  idcer  (as  in  inflammation,  new  growths  of  the  liver, 
perihepatitis,  cysts,  and  chronic  pancreatitis),  hyperacidity  is  absent, 
although  in  some  instances  of  duodenal  ulceration  hyperacidity  has 
been  observed.  Duodenal  ulcer  occurs  mostly  in  men,  in  alcoholics, 
and  after  burns.  Pain  is  often  absent  in  duodenal  ulcer,  but  when 
present  occurs  later  than  in  gastric  ulcer  and  in  the  parasternal  line. 
Vomiting  gives  less  rehef ,  and  the  vomitus  is  usually  alkaline,  contains 
bile,  and  may  digest  fibrin  (Boas).  Icterus  is  not  uncommon,  though 
not  constant  enough  for  diagnostic  reliance.  Hemorrhage  into  the 
bowels  is  more  common  than  in  ulcer.  Its  sudden  appearance  with 
recurrence  and  profound  ansemia  is  most  suggestive. 

Pyloric  spasm,  considered  so  characteristic  of  ulcer  by  most  writers, 
may  also  occur  in  myocarditis,  aneurysm,  coronary  atheroma,  ttenia, 
ascaris,  the  spastic  form  of  intestinal  constipation,  or  chronic  nico- 
tinism (Ageron). 

Differentiation  from  carcinoma  is  not  very  often  necessary,  though 
in  middle-aged  patients  confusion  with  ulcer  may  occur.  In  Kraus* 
clinic,  the  author  saw  two  cases;  one  was  an  old  man  with  cachexia, 
pyloric  tumor,  and  decreased  hydrochloric  acid,  which  was  diagnosti- 


ROUND   ULCER  OF  THE  STOMACH 


625 


cated  cancer;  the  other  was  a  young  girl  with  vomiting  of  blood,  in 
whom  the  diagnosis  of  ulcer  was  made.  The  post-mortem  examination 
showed  that  the  old  man  had  a  round  ulcer  and  the  girl  had  a  cancer. 
The  author  has  seen  five  cases  of  carcinoma  under  the  age  of  thirty. 
The  table  on  page  626  considers  differentiation  from  cancer,  gastritis, 
gastralgia,  and  hyperchlorhydria. 

Prognosis. — ^Though  ulcer  occurs  most  frequently  between  the  ages 
of  twenty  and  forty,  it  is  most  fatal  between  forty  and  sixty.  It  is 
generally  stated  that  the  mortality  ranges  between  6  or  8  and  10  or  13 
per  cent,  of  the  cases,  of  which  about  4  per  cent,  is  due  to  hemor- 
rhage and  6  per  cent,  to  perforation.  Debove  and  Redmond  give  the 
high  death-rate  of  50  per  cent. 


Recovery. 

Death. 

Improvement. 

No  Improvement. 

Eichhorst 

Leube 

Kobler 

85% 
74% 
61% 

8% 

2.4% 

6% 

4% 
22% 
30% 

3% 

1.6% 

3% 

Very  deep  and  old  ulcers  rarely  heal.  The  deeper  the  ulcer  the  greater 
the  danger  of  hemorrhage  and  perforation.  Ulcers  with  coincident 
hypersecretion  give  a  relatively  poor  prognosis.  Carcinoma  must  be 
considered  in  cases  which  do  not  respond  to  treatment.  One  of  the 
author's  cases  died  from  exhaustion,  although  the  autopsy  showed 
that  there  had  been  perfect  healing  of  the  ulcer.  In  over  one  thousand 
cases  the  deaths  from  hemorrhage  and  perforation  (each  1  per  cent.) 
are  about  equally  divided  (Leube). 

Treatment. — l.  Prophylaxis. — Prophylaxis  concerns  care  of  the 
stomach  in  anaemia,  and  chlorosis,  and  with  a  history  of  ulcer,  care  in 
the  diet.    The  mouth  should  be  kept  clean  to  avoid  parotitis. 

2.  Absolute  Rest. — Absolute  rest  in  bed  for  a  month  or  more  was 
first  recommended  by  Cruveilhier,  in  addition  to  which  Leube  recom- 
mends the  frequent  application  of  hot  fomentations  to  the  epigastrium, 
which  relieve  pain  within  a  few  days.  Women  should  remain  in  bed 
during  menstruation,  even  after  recovery  is  seemingly  complete. 

3.  Absolute  Rest  of  the  Stomach. — Though  opinions  differ  some- 
what, it  is  true  that  distention  of  the  stomach  by  even  small  quantities 
of  food  or  water  excites  peristalsis  and  secretion,  distends  the  ulcer, 
and  prevents  granulation.  Rest  permits  the  stomach  to  contract  and 
allows  the  edges  of  the  ulcer  to  come  more  rapidly  and  completely  in 
apposition.  The  more  absolute  the  rest  of  the  stomach  the  more  rapidly 
the  ulcer  granulates  and  cicatrizes.  The  time  for  complete  granu- 
lation varies  with  each  case,  and  chronic  ulcers  show  little  or  no  ten- 
dency to  cicatrize.  An  ice-bag  promotes  contraction  of  the  stomach. 
Rectal  feeding  is  imperative,  and  the  usual  rules  should  be  followed; 
peptonized  milk,  grape  sugar,  baby  foods,  meat  juice,  and  eggs,  should 
be  given,  in  amounts  not  to  exceed  a  total  of  eight  ounces,  and  at  eight- 
hour  intervals;  they  should  be  injected  slowly,  with  the  patient  on 
his  left  side,  and  should  be  given  warm,  which  precautions  obviate 


40 


626 


DISEASES  OF  THE  DIGESTIVE  TRACT 


Gasthaigia.        ^^^^^°^- 

HTDEIA. 

Etiology. 

75%  over  40  years.  75%     under     40          Males.                  Women.                  Males. 
[years — 2-4  times 
i  of  tenerin  women,  j 

Tongue. 
Appetite. 

Heavily  coated.        Usually    clean, Gray-white fiir.  Xormal.                  Clean. 
Usually    anorexia,  and  red.     Good:  Poor.                    Variable.    Some- Good,     often 
only  fears  to  eat.                               times   perverted,  increased. 

Pyrosis. 

Often  pyrosis.           Water  brash.        JFrequent.            None.                       Present. 

belching. 

Usually    f  ce  t  i  d  Usually  absent.    JGopious.             j  Variable.                 Usual. 
belching.                   I                                 | 

Pain. 


The  pain  is  less  in- 
tense, but  more 
constant;  seldom 
free  intermissions, 
during  which  no 
distress  is  felt  in 
gastric  region.  Pain 
not  increased  at 
the  height  of  diges- 
tion. Tenderness 
less  frequent  and 
intense. 


Intense;  appears 
shortly  after 
meals  ;  g  rows 
severer  on  pres- 
sure; disappears 
at  the  end  of  di- 
gesti ve  period; 
perfectlj-  free 
periods  more  fre- 
quent; paroxys- 
mal. 


May  be  present 
but  not  pro- 
nounced and 
rarely  actual 
pain  but  ten- 
derness of  dif- 
fuse charac- 
ter. Lancina- 
ting pains  in 
atrophic  gas- 
tritis onlj-. 


The  pain  appears 
without  regular- 
ity, and  not  de- 
pendent upon 
meals;  may  be 
reheved  by  pres- 
svire;  inter^-als  of 
several  days  free 
from  pain.  Ten- 
derness rare;  con- 
forms to  outUnes 
of  the  stomach. 
Electrical  test 
|(Leube)  during 
digestion;  if  pain 
decreases,  it  isl 
gastralgia;  if  it 
idoes  not,  may  bej 
ulcer  or  gaatral-' 
gia.  i 


The  pain  ap- 
pears about 
one  or  three 
hours  after 
meals,  disap- 
pears after  eat- 
ing, especially 
meat,  milk  or 
eggs,  or  after 
the  administra- 
tion of  bicar- 
bonate of  so- 
dium. Pain  is 
less  regular. 


Vomiting.    Usual.  Hours  after  Freque  nt — at  Frequent;  mu- 
eating    or    once    a  height    of    diges-  cus. 
day     or     alternate  tion — s  mailer 
days,  etc.  Copious,  amount,      finelj', 

I  coarse  mucus ,  f  er-  homogeneous. 

mented.  no  mucus,  acid. 


Rare;  no  mucus.  Much  less  fre- 
quent, then 
acid  and  no 
mucus. 


Hcema-         Frequent  —  small,  F  r  e  q  u  e  n  t — co-  Xone. 
temesis.     dark,     hke     coffee  pious,     bright; 
igrounds,       decom-  may      be      early, 
jposed,  usuaLlj-  late  symptom.  I 

in  disease. 


None. 


Test  :Early  reduction  Hyperchl  o  r-  Decreased  HCl  Xormal   or  vari-' As  in  ulcer. 

Meal.      :  HClknd  later,  total  hydria  often;  fer- (r  a  r  el  y     in- able.     If   HCl  is: 
absence;     ferments  ments  normal  or  creased,  gastri- decreased,  the! 
'decreased     or     ab-  increased;    notis  acida) ;  later  ferments  are  nor- 
Isent;       lactic    acid  lactic  nor  Oppler- may  be     achy- mal. 
ipresent;     impaired  Boas  bacilli;  food  lia. 
motility    and     ab-  well  digested, 
sorption;        abun-  Xo  mucus, 
dant    mucus,    Op- 
pler-Boas   bacillus. 
—  yeast  —  possibly 
tumor     shreds; 
coarse     undigested| 
particles  of  food.  I 


Tumor. 


In  80  per  cent. 


CoUateral 
Symptoms. 


Course. 


!ln   but    one   pro  Xone. 
jmille    (from    py-^ 
iloric  spasm,  hy- 
pertrophy,   cica- 
trix, etc.) 


Cachexia — oedema. 


Part  of  a  year. 


Xone. 


Absent. 


Absent. 

Nerv'ous     s  t  i  g- 
mata  often. 


None     (very 
rarely     from 
pyloric  spasm). 


Absent. 


Longer;      helped  Chronic. 

by     treatment ditto. 

aggravated    by 
arsenic. 


'Arsenic  helps.        Like  ulcer. 


ROUND   ULCER  OF  THE  STOMACH  627 

excessive  peristalsis.  A  piston  syringe  should  never  be  used ;  a  fountain 
syringe  with  a  soft  tube  is  always  used.  Nutrient  rectal  enemata  can 
be  retained  almost  invariably  if  the  technique  is  carefully  carried  out. 
Wine  or  spirits  almost  always  irritate  the  bowel.  Rectal  tenesmus 
is  obviated  by  administering  a  short  time  before  the  enema,  an  opium 
suppository  of  one-half  grain  of  the  extract.  Though  rectal  feeding 
gives  the  patient  but  one-quarter  of  the  food  necessary  to  maintain 
metabolism,  it  is  sufficient,  because  the  patient  is  absolutely  quiet. 
Thirst  should  be  relieved  by  allowing  the  patient  to  rinse  his  mouth 
out,  but  he  should  swallow  nothing,  either  water  or  melted  ice,  and 
by  giving  two  administrations  daily  of  warm  saline  enemata. 

4.  Pain. — Rest  of  the  stomach  relieves  the  pain  in  almost  every 
case;  the  use  of  narcotics  should  be  limited  as  much  as  possible;  small 
doses  of  opium  or  morphine  by  rectum,  or  atropine,  may  be  given. 
There  is,  of  course,  danger  that  the  patient  may  develop  the  opium 
habit. 

5.  Superacidity. — Though  many  physicians  would  begin  the  treat- 
ment of  superacidity  at  once,  the  author  is  convinced  it  should  be 
initiated  ten  days  to  two  weeks  after  commencement  of  treatment, 
during  which  time  the  stomach  has  had  absolute  rest.  Then  Carlsbad 
water  should  be  given;  it  should  be  lukewarm,  because  hot  water 
opens  the  ulcer;  it  should  be  given  in  small  quantities  and  taken  in 
sips.  It  was  formerly  held  that  alkalies  were  incompatible  with 
digestion,  but  Ziemssen,  Leube,  and  others,  have  disproven  this  point. 
Carlsbad  water  consists  of  sodium  sulphate  50  parts,  sodium  bicar- 
bonate 6  parts,  and  sodium  chloride  3  parts;  it  possesses  no  intrinsic 
value  other  than  its  alkalinity;  it  neutralizes  the  acid,  thereby  tending 
to  check  the  ulceration,  to  aid  intestinal  digestion,  and  to  cleanse  the 
stomach.  Ziemssen  administered  half  an  ounce  in  a  pint  of  water; 
this  was  taken  in  quarters  every  ten  minutes,  the  last  dose  being  given 
one-half  hour  before  meals,  Vichy  water  may  be  used.  Roberts 
prescribed  a  lozenge  composed  of  magnesium  carbonate,  grains  3^; 
chalk,  grains  2\;  sodium  chloride  grain  1,  which,  dissolved  slowly  in  the 
mouth,  increased  the  salivary  flow  and  neutralized  the  excess  of  acid. 

6.  Diet. — After  ten  days  of  rectal  feeding,  five  or  six  meals  daily  of 
predigested  milk  with  lime  water  should  be  given  in  small  quantities, 
that  the  edge  of  the  ulcer  may  not  be  distended.  The  saccharate  of 
lime  is  five  times  as  rich  in  lime  as  is  lime  water.  Cooked  milk  is  more 
easily  digested  and  curds  less.  The  casein  both  engages  and  neutral- 
izes the  acid.  If  peptonized  milk  is  distasteful  it  may  be  administered 
as  a  thin  gruel;  this  is  especially  indicated  when  the  stomach  is  very 
irritable  and  painful.  Potato  puree,  arrow-root,  wheat-meal,  baby 
foods,  meat  juice,  and  buttermilk,  may' be  given;  soups  with  meal  and 
alkalies  which  precipitate  the  casein  in  finer  form,  Mosquera's  beef 
meal,  beef  peptone  jelly,  and  ice  cream,  may  also  be  given;  but  it  should 
be  remembered  that  the  milk  diet  recommended  by  Cruveilhier  is 
most  efficacious.  After  the  patient  has  been  on  the  above  mentioned 
diet  for  ten  days,  soups  without  fat,  rice,  sago,  soft-boiled  eggs,  calves* 


628  DISEASES  OF  THE  DIGESTIVE  TRACT 

brains,  and  chicken,  may  be  administered.  Raw  eggs  are  digested 
with  difficulty,  but  shghtly  boiled  or  poached  eggs  are  less  indigestible 
and  may  be  given  with  bread-crumbs  from  the  inside  of  the  loaf. 
Custards  may  be  given.  Tea  and  coffee  should  be  forbidden.  Sugar 
was  considered  deleterious  by  Cruveilhier,  but  Strauss  has  found  that 
it  lessens  the  amount  of  acid  and  he  recommends  that  the  patient 
should  have  a  dram  of  a  20  per  cent,  solution.  After  fifteen  days 
Leube  permits  grated  beef,  and  after  about  another  week,  tender 
roast  beef,  chicken,  and  pigeon,  to  which  others  would  add  lamb,  mac- 
aroni, thymus  gland,  and  bread.  After  the  fifth  week,  roast  veal  and 
souffles  may  be  given.  Cohnheim  gives  olive-oil  freely  at  all  times; 
he  finds  that  it  relieves  spasm  and  inhibits  hyperchlorhydria. 

7.  The  Bowels. — Plain  enemata  may  be  administered  after  the  first 
or  second  week. 

8.  Drugs. — Much  has  been  written  in  regard  to  the  administration 
of  bismuth  and  silver.  Bismuth  may  relieve  pain  and  is  taken  most 
advantageously  in  solution;  the  author  does  not  believe  that  bismuth 
has  any  curative  value;  its  use  is  less  efficacious  than  absolute 
and  prolonged  rest  of  the  stomach.  Fleiner,  Kussmaul,  and  others, 
administer  bismuth  by  means  of  the  stomach  tube.  The  objections 
to  large  doses  are  that  they  may  accumulate  in  the  ulcer,  the  drug 
may  cause  pain,  and  is  expensive.  Chalk  and  talcum  are  no  more 
efficacious  than  bismuth.  Silver  has  been  used,  and  some  writers 
even  wash  the  stomach  of  the  patient  before  meals  with  a  solution  of 
1  to  500  or  to  1,000  (Reichmann).  The  silver  is  readily  precipitated 
by  the  acid  or  the  albuminoids,  and  unless  given  in  capsule  or  pill  or 
by  the  stomach  tube  may  produce  nausea,  burning  in  the  mouth, 
diarrhoea,  and  even  argyria.  Iodide  is  indicated  in  syphilitics,  by 
whom  it  is  well  tolerated. 

9.  Symptomatic  Treatment. — Pain  is  best  relieved  by  rectal  alimen- 
tation, as  is  vomiting,  which  sometimes  may  necessitate  the  adminis- 
tration of  bismuth,  minute  doses  of  carbolic  acid  in  mint  water,  or 
the  use  of  the  ice-bag  or  sinapisms.  Hemorrhage  is  treated  by  absolute 
rest  of  the  stomach,  intestine,  mind,  and  body;  morphine  quiets  peri- 
stalsis and  mental  excitement.  No  styptics  or  astringents  should  be 
given  and  ergot  is  contra-indicated.  Syncope  promotes  spontaneous 
coagulation,  and  stimulation  should  be  avoided  as  long  as  possible. 
In  severe  hemorrhages  the  use  of  saline  transfusions  should  be  con- 
sidered, but  more  than  one  pint  should  seldom  be  given,  for  death  has 
occurred  from  reaction  and  renewal  of  hemorrhage.  Gelatine  injec- 
tions may  be  indicated  for  severe  hemorrhages. 

10.  Surgical  Treatment. — Seventy-five  to  96  per  cent,  of  cases,  ac- 
cording to  Leube,  either  heal '  absolutely  or  improve  greatly  under 
proper  medical  treatment;  this  is  especially  true  of  fresh  ulcers.  Leube 
in  his  widely  quoted  article  gives  the  following  indications  for  surgical 
interference:  (a)  When  the  hemorrhage  is  small  and  repeated,  and 
persists  in  spite  of  rectal  nutrition;  in  single  large  hemorrhages  opera- 
tion is  contra-indicated.    Movnihan  holds  a  similar  view,  and  lost  but 


CANCER  OF  THE  STOMACH  629 

1  out  of  70  cases  of  chronic  hemorrhages,  which  result  he  attributes 
to  his  treating  the  ulcer  instead  of  performing  simple  gastro-enteros- 
tomy.  Savariand  estimates  the  operative  mortality  at  50  and  Rodman 
at  33  per  cent.  Tuffier  (1905)  finds  a  mortality  of  36  per  cent.  (56 
cases).  (6)  Gastro-enterostomy  is  indicated  for  mechanical  difficulties, 
pyloric  obstruction,  persistent  pyloric  spasm,  and  pain;  obstruction  at 
the  cardia,  or  hour-glass  stomach,  also  requires  surgical  treatment. 
Thirty-one  cases  of  jejunal  ulcer  have  followed  operation,  since  Braun's 
first  case;  it  develops  usually  after  a  year  or  more  (ten  days  to  seven 
years).  Mickulicz  in  operations  for  benign  gastric  disease  finds  a  7.5 
per  cent,  mortality  in  his  series  of  1897-1899,  Moynihan  in  15  opera- 
tions for  hour-glass  stomach  had  a  mortality  of  20  per  cent.,  and  in 
100  cases  of  gastro-enterostomy  a  mortality  of  2  per  cent,  (c)  Peri- 
gastric adhesions  or  abscess,  and  collections  of  pus  beneath  the  dia- 
phragm, necessitate  operation,  (d)  In  cases  of  perforation  the  outlook 
is  fairly  good  if  early  operation  is  undertaken  and  is  performed  at 
once  when  the  initial  shock  has  passed.  The  best  figures  are  those  of 
English  and  Graff e  with  50  per  cent.,  of  recoveries;  of  Ferrier  and  Hart- 
mann,  with  47.5  per  cent.;  and,  between  1900  and  1904,  of  H.  A.  Hare, 
with  37  per  cent.  Donati,  of  Florence,  collected  in  1905,  1,041  cases  of 
operation  on  ulcer  cases ;  the  mortality  in  perforation  was  48  per  cent. ; 
in  gastro-enterostomy  the  mortality  with  the  use  of  Murphy's  button 
was  7.5  per  cent.;  with  suture  anastomosis,  14.5  per  cent. 

Surgical  interference  is  necessary  in  a  limited  number  of  cases. 
Sahli  is  opposed  to  excessive  surgical  interference,  and  argues  that 
(i)  reports  only  show  that  many  of  the  patients  stand  an  operation; 
(ii)  gastro-enterostomy  is  indicated  only  for  anatomical  stenosis,  too 
many  cases  of  spasmodic  stenosis  are  called  anatomical,  and  at  opera- 
tion too  many  contracted  pylori  are  called  cicatricial,  (iii)  Gastro- 
enterostomy is  not  proven  beneficial  for  hemorrhage,  diet  being  the 
important  indication.  Cases  operated  on  often  die  from  hemorrhage 
after  the  operation,  (iv)  No  proof  exists  that  ulcers  heal  better  with 
gastro-enterostomy  than  with  medical  treatment,  (v)  Excision  of  the 
ulcer  is  too  radical.  The  writer's  experience  justifies  the  conclusion 
that  (i)  fresh  (chlorotic)  ulcers  always,  and  (ii)  chronic  ulcers  in  half  the 
instances,  belong  to  internal  medicine;  (m)  half  the  inveterate  cases 
respond  to  medical  treatment;  (iv)  most  of  the  cases  "chronic  dyspep- 
sia," and  almost  none  of  the  cases  with  hemorrhage,  call  for  surgical 
interference. 

(F).  CANCER  OF  THE   STOMACH. 

Cancer  of  the  stomach  is  more  frequent  than  cancer  of  any  other 
organ;  it  constitutes  33  to  50  per  cent,  of  all  cancers,  and  is  found  in 

2  per  cent,  of  autopsies. 

Etiology. — This  is  as  obscure  as  in  other  carcinomata.  (a)  Age — 
75  to  80  per  cent,  of  the  cases  occur  in  subjects  after  the  fortieth 
year.    According  to  Lebert  1  per  cent,  occurs  in  persons  under  thirty 


630  DISEASES  OF   THE  DIGESTIVE  TRACT 

years;  18  per  cent,  in  those  between  thirty  and  forty;  61  per  cent, 
in  those  between  forty  and  sixty,  and  20  per  cent,  in  those  over  sixty 
years  of  age.  Welch's  figures  give  2  per  cent,  under  thirty,  13  per  cent, 
between  thirty  and  forty,  54  per  cent,  between  forty  and  sixty,  and  26 
per  cent,  over  sixty  years  of  age.  Every  cHnician  has  observed  a 
number  of  cases  in  persons  under  thirty  years.  The  author  has  seen 
five,  which  leads  him  to  believe  that  many  more  cases  occur  than  is 
indicated  by  Debove's  collection  of  32  cases  under  the  thirtieth  year. 
Rare  congenital  cases  are  recorded  (Wilkinson,  Debove,  Collings- 
worth). Of  late  years  cancer  is  apparently  becoming  more  frequent 
and  more  common  in  relatively  young  persons,  (b)  Sex — It  is  slightly 
more  frequent  in  males  (6  to  5).  (c)  Heredity  is  noted  as  an  etiological 
factor  in  6  to  17  per  cent.,  and  in  some  families  the  number  of  cases 
of  carcinoma  is  astonishing,  (d)  Ulcer  of  the  stomach  is  an  antecedent 
in  at  least  6  per  cent.;  C.  Graham  found  ulcer  in  60  per  cent,  of  his 
cases,  (e)  Other  causes  are  less  definite.  Trauma,  external  pressure, 
as  in  shoemakers,  or  internal  ulceration  by  caustics,  is  noted  in  some 
cases.  Pulmonary  tuberculosis  and  alcoholism  are  slightly  predis- 
posing factors.  Cancer  is  almost  unknowTi  in  certain  tropical  and 
subtropical  localities,  and  in  temperate  zones  a  topical  disposition  is 
occasionally  apparent. 

Pathology. — (a)  In  origin  it  is  an  abnormal  growth  of  the  glandular 
epithelium,  as  was  first  proven  by  Waldeyer,  which  unlike  mere  adenom- 
atous or  papillomatous  proliferations,  extends  beyond  the  mucosa 
into  the  other  coats  of  the  stomach  and  very  often  into  other  organs 
and  tissues.  Cancer  may  develop  in  the  seemingly  normal  mucosa,  in 
an  atrophied  mucosa,  or  in  open  or  cicatrized  ulcers.  (6)  It  is  almost 
always  "primary,  is  very  rarely  metastatic,  or  extends  to  the  stomach 
by  contiguity;  such  secondary  growths  are  usually  from  mammaiy 
or  pancreatic  cancer;  Welch  has  collected  37  cases.  It  is  also  almost 
invariably  single. 

Histology  and  Morphology. — A  tumor,  in  the  clinical  sense,  usually 
develops,  although  in  some  cases  the  cancer  is  infiltrative  and  flat 
{carcinoma  planum).  There  are  three  main  types:  (a)  Carcinoma 
fibrosum  (scirrhus),  the  most  frequent  type,  contains  much  poorly 
vascularized  stroma  and  relatively  little  carcinomatous  tissue;  it  is 
hard,  and,  leading  to  much  induration,  is  prone  to  stenose  the  pylorus, 
where  it  is  especially  frequent,  or  to  stenose  the  cardia;  if  it  is  diffuse 
it  causes  the  stomach  to  shrink  (carcinoma  atrophicans);  its  onset  is 
insidious;  it  grows  slowly  and  ulcerates  less  than  other  types.  (&) 
Carcinoma  medullare  is  next  in  frequency;  the  cell  elements  prepon- 
derate over  the  stroma;  there  is  much  soft,  vascular  tissue,  and  the 
knife  scrapes  out  much  "cancer  juice";  it  may  form  cauliflower-like 
exuberances;  earlv  extensive  degeneration,  ulceration,  and  metastases, 
are  common;  this  type  includes  the  cylindrical  celled  adenocarcin- 
oma, epithelioma,  or  the  very  vascular  fungus  forms,  (c)  Carcinoma 
gelatinosum  (colloides)  is  least  frequent;  it  produces  nodular 
tumors    or  diffuse   infiltrations,    both   of   which  contain  colloid  ma- 


CANCER  OF  THE  STOMACH  631 

terial ;  it  inclines  rather  to  extension  by  contiguity  than  to  metastatic 
deposits. 

The  gastric  mucosa  shows  focal  wasting  of  the  peptic-  and  acid- 
secreting  epithelium  and  substitution  by  cylindrical  epithelium,  round 
cells,  and  connective  tissue.  This  secondary  atrophic  gastritis  explains 
the  chemism  of  gastric  cancer — viz.,  diminution  in  the  secretion  of 
acid,  rennet,  and  pepsin ;  in  some  cases  it  has  regressed  after  surgical 
extirpation  of  the  tumor,  the  secretion  of  acid  and  pepsin  returning.. 

Localization. — Cancer  occurs  (a)  in  the  pylorus  in  about  60  per 
cent.,  (b)  in  the  lesser  curvature  in  nearly  20  per  cent.,  and  (c)  in  the 
cardia  in  10  per  cent,  of  the  cases;  in  round  numbers,  therefore,  about 
90  per  cent,  of  cancer  occurs  in  these  sites;  this  is  explained  by  their 
greater  exposure  to  mechanical  insult,  their  relative  fixation,  and  the 
greater  muscular  activity  of  the  pylorus  and  cardia;  many  tumors, 
apparently  pyloric  in  origin,  really  begin  in  the  lesser  curvature, 
whence,  in  other  words,  a  palpable  pyloric  tumor  often  means  one  of 
considerable  extension;   this  is  an  important  surgical  point. 

Complications. — (a)  Ulceration,  which  is  really  more  a  part  than  a 
complication  of  cancer,  results  from  inadequate  vascularization;  it  is 
usually  central  and  does  not  necessarily  depend  on  the  size  of  the 
tumor.  In  some  cases  the  tumor  may  ulcerate  almost  completely,  and 
Ziegler  has  observed  total  disappearance,  though  metastases  declared 
the  nature  of  the  scar.  (6)  Hemorrhage  or  slow  seeping  of  blood  is 
caused  by  ulceration,  as  is  also  (c)  'perforation  (3  per  cent.)  into  the 
peritoneum,  or,  by  adhesions,  into  adjacent  abdominal  organs  or  vessels, 
into  the  lung,  pleura,  or  pericardium,  or  into  the  abdominal  wall,  of 
which  latter  22  cases  are  recorded;  perforation  is  not  more  coinmon 
because  adhesions  often  prevent  perforation,  (d)  Stenosis  of  the  cardia 
or  pylorus  is  common,  sometimes  causing  hypertrophy  of  the  muscle 
fibers,  which  appear  on  section  of  the  stomach  as  red  lines,  (e)  Dila- 
tation of  the  stomach  follows  pyloric  obstruction,  atrophy  is  observed 
in  cardiac  localization  or  in  carcinoma  atrophicans  (diffuse  cancer),  and 
hour-glass  deformation  may  result  when  an  annular  scirrhus  develops 
in  the  mid-stomach.  (/)  Local  extension  by  contiguity  occurs  by  the 
submucous  lymphatics,  and  there  is  early  involvement  of  the  lymph 
nodes  along  the  lesser  curvature;  other  lymphatics  are  soon  invaded; 
the  peritoneum  is  quite  often  involved,  and  less  often  there  is  exten- 
sion into  the  portal  vein,  (g)  Metastases  occur  in  50  per  cent.;  they 
are  distributed  as  follows:  the  liver  is  involved  in  28  per  cent.,  the 
peritoneum  in  37  per  cent.,  the  lymphatics  in  23  per  cent.,  the  pancreas 
in  20  per  cent.,  and  the  lungs  in  8  per  cent. 

Symptoms. — General  Clinical  Picture. — Anorexia,  distaste  for  meats, 
mild  dyspepsia,  gastric  oppression,  and  eructations  after  eating,  usually 
mark  the  insidious  onset.  Much  less  frequently  the  disease  begins 
acutely  or  follows  closely  on  symptoms  of  gastric  ulcer.  Vomiting 
occurs  and  then  symptoms  of  gastric  distress  after  eating  solid  food, 
and  of  mechanical  or  secretory  insufficiency  develop.  There  is  gradual 
loss  of  weight  together  with  loss  of  strength  and  endurance.    Exami- 


632  DISEASES  OF  THE  DIGESTIVE  TRACT 

nation  reveals  anaemia,  cachexia,  emaciation,  lax  skin,  jBabby  muscles, 
and  often  a  tumor  near  the  pylorus.  A  test  meal  shows  absence  of  free 
hydrochloric  acid  and  imperfectly  digested  food.  The  symptoms  pro- 
gress steadily,  or  remissions  occur,  especially  early  in  the  disease.  The 
ankles  become  puffy  and  the  prostration  is  profound.  Ulceration  may 
relieve  pyloric  or  cardiac  stenosis,  but  gradually  within  a  year  after 
the  first  marked  symptoms  death  results,  from  the  exhaustion  due  to 
pain  or  vomiting,  from  local  complications,  or  intercurrent  disease. 

1.  General  Digestive  Symptoms. — (a)  The  tongue  is  almost  always 
heavily  coated,  not  being  cleaned  by  mastication,  and  there  is  gen- 
erally a  bad  taste  in  the  mouth.  The  appetite  is  decreased  or  absent 
in  85  per  cent,  and  there  is  a  special  distaste  for  meat  and  fats;  the 
appetite  is  very  rarely  excessive;  a  normal  appetite  may  be  retained 
when  the  motor  power  is  good  and  cancer  develops  on  an  ulcer.  (&) 
Pain  is  present  in  90  per  cent.  It  is  usually  diffuse,  dull,  oppressive, 
and  less  severe  than  in  ulcer.  It  is  increased  several  hours  after  eat- 
ing, or  in  the  night,  but  is  not  wholly  relieved  by  vomiting.  Localized 
pain  and  tenderness  are  suggestive  of  circumscribed  peritonitis.  Pain 
may  be  reflected  up  the  sternum,  between  the  shoulders,  and  to  the 
acromion,  (c)  Vomiting  (in  85  per  cent.)  is  an  obstinate  and  rather 
advanced  symptom,  resulting  chiefly  from  pyloric  stenosis,  with  which 
it  runs  more  or  less  parallel,  and  also  from  coincident  gastritis.  It 
appears  late  in  the  day  or  in  the  night,  and  may  occur  only  on  alternate 
days.  There  may  be  no  vomiting  in  cancer  of  the  curvatures,  in  diffuse 
cancerous  infiltration  involving  the  muscularis,  or  in  pyloric  cancer 
when  ulceration  is  marked.  The  vomitus  contains  much  mucus, 
poorly  digested  food,  little  or  no  free  hydrochloric  acid,  much  lactic 
acid,  and  often  blood,  which  may  be  obvious  or  occult.  Fsecal  vomit- 
ing usually  but  not  always  indicates  gastrocolic  fistula  (of  which  70 
cases  are  recorded),  (d)  Hoematemesis,  present  in  over  50  per  cent, 
of  cases,  is  due  to  parenchymatous  oozing,  and  is  therefore  moderate 
in  amount;  it  is  dark  in  color,  as  the  blood  is  retained  long  in  the 
stomach  and  is  converted  from  oxyhaemoglobin  to  hsematin.  It  seldom 
reaches  the  stools  because  of  pyloric  stenosis.  The  author  has  seen 
four  cases  with  fatal,  profuse,  bright  hsematemesis.  (e)  Constipation 
is  present  in  75  per  cent.,  diarrhoea  in  20  per  cent.,  and  normal  move- 
ments in  5  per  cent,  of  the  cases  (Hemmeter) ;  in  two  cases  the  writer 
has  seen  ichorous  stools  resulting  from  necrosis  of  the  lower  jejunum 
and  of  the  ileum. 

2.  Special  Gastric  Symptoms. — (a)  Tumor  is  felt  in  80  per  cent, 
and  seen  in  40  per  cent,  of  the  cases,  but  is  not  an  early  symptom.  It 
is  most  often  missed  in  persons  with  a  wide  thorax  and  rigid  abdom- 
inal muscles.  In  most  instances  it  occupies  the  right  epigastric  area, 
as  a  round,  ovoid,  irregular  mass;  this  is  best  determined  when  the 
knees  are  drawn  uj)  and  the  mouth  is  open,  after  the  bowels  have  been 
flushed  out  and  the  stomach  distended;  in  some  cases  the  tumor  may 
be  felt  lower  or  even  on  the  left  side.  Examination  should  be  made 
with  the  patient  in  several  postures,  as  on  the  side,  on  the  face,  genu- 


CANCER  OF  THE  STOMACH  633 

pectoral  position,  etc.  Anaesthesia  may  facilitate  detection.  The 
tumor  may  be  palpable  one  day  and  not  to  be  found  on  the  next.  Dis- 
tention of -the  stomach  by  gas  (von  Frerichs)  brings  forward  tumors  of 
the  anterior  wall  and  greater  curvature,  obliterates  tumors  of  the  pos- 
terior wall  and  lesser  curvature,  and  pushes  downward  and  to  the 
right  tumors  of  the  pylorus;  motility  on  distention  excludes  adhesions. 
If  the  pylorus  is  incontinent  from  ulceration  or  infiltration,  the  gas 
escapes  rapidly  into  the  gut  (Ebstein).  The  a^-rays  outline  the  stomach 
after  administration  of  bismuth.  With  or  without  distention,  a  visible 
peristaltic  wave  suggests  pyloric  obstruction.  Percussion  is  wholly 
subordinate  to  palpation  and  inspection,  but  auscultation  occasionally 
elicits  friction  or  a  stenotic  murmur  over  the  abdominal  aorta.  Respir- 
atory excursion,  though  generally  stated  to  be  absent  if  the  stomach 
is  not  adherent  to  the  liver,  is  often  present,  though  less  in  degree, 
than  the  excursion  of  the  liver  or  spleen ;  if  adherent  to  the  omentum, 
there  is  no  excursion.  The  possibility  of  expiratory  fixation  is  more 
important;  if  nonadherent  tumors  of  the  stomach,  intestine,  and 
omentum,  are  grasped  at  the  height  of  inspiration,  their  ascent  upward 
during  expiration  can  be  prevented  (Minkowski's  expiratory  fixation) ; 
on  the  other  hand,  tumors  of  the  liver  and  spleen,  or  tumors  of  the 
stomach,  if  adherent  to  the  liver,  must  ascend  during  expiration;  i.e., 
they  cannot  be  retained  where  they  were  grasped  and  felt  during 
inspiration,  (b)  Chemism — (i)  Bird  (1842)  found  the  hydrochloric 
acid  reduced,  but  Van  der  Velden  (1879)  showed  the  especial  frequency 
of  achlorhydria  in  gastric  carcinoma.  Absence  or  decrease  of  hydro- 
chloric acid  is  not  pathognomonic,  as  it  is  also  absent,  permanently 
or  temporarily,  in  numerous  other  conditions,  as  nervous  dyspepsia, 
fevers,  cardiac,  renal  or  hepatic  disease,  pernicious  anaemia,  cachectic 
states,  gastric  atrophy,  amyloid  degeneration,  and  toxic  gastritis.  Ben- 
jamin Moore  states  that  the  hydrochloric  acid  is  absent  in  66  per  cent, 
and  decreased  in  33  per  cent,  of  carcinoma  involving  other  organs  than 
the  stomach;  the  writer  has  repeatedly  seen  cases  of  rectal  cancer  in 
which  digestive  symptoms  and  achlorhydria  have  led  to  an  erroneous 
diagnosis  of  gastric  cancer.  In  cancer  it  is,  as  stated,  due  to  the  second- 
ary atrophic  gastritis.  After  administration  of  an  Ewald  test  breakfast 
of  a  slice  of  stale  bread  and  a  cup  of  weak  tea  without  cream  or  sugar, 
the  food  is  withdrawn  in  an  hour  and  tested  as  described  under  chronic 
gastritis.  If  there  is  no  stagnation  the  total  acidity  ranges  from  6  to  8; 
in  stagnation  it  is  higher  from  lactic  and  other  acids.  The  absence  of 
free  hydrochloric  acid  is  often  observed  early,  but  is  especially  marked 
in  the  advanced  stages.  In  very  exceptional  cases  free  acid  may  per- 
sist, both  in  those  cases  which  develop  from  peptic  ulcer  and  in  those 
without  this  antecedent,  (ii)  The  pepsin  and  rennet  are  decreased  in 
66  per  cent,  of  cases  (v.  Chronic  Gastritis),  (iii)  Lactic  acid,  which 
is  always  pathological  in  appreciable  quantities,  is  present  in  70  to  80 
per  cent,  of  cases,  and  though  present  in  other  conditions,  as  in  atony, 
gastritis,  and  pyloric  obstruction,  85  to  90  per  cent,  of  the  cases  in 
which  it  is  found  are  gastric  cancer.    Boas,  who  developed  this  topic. 


634  DISEASES  OF  THE  DIGESTIVE  TRACT 

considers  it  a  very  early  finding;  while  others,  as  Riegel,  hold  that  it 
does  not  develop  until  later.  The  factors  involved  in  its  formation 
are  somewhat  disputed,  but  depend  to  a  great  degree  on  (a)  the 
reduced  hydrochloric  acid;  (/?)  motor  insufficiency,  stagnation, 
pyloric  obstruction;  (y)  slow  absorption;  in  the  normal  stomach  it 
is  absorbed  as  fast  as  formed  (Sticker) ;  (8)  probably  also  poor  diges- 
tion of  proteids.  As  a  test  meal  Boas  employs  1.5  per  cent,  oatmeal  to 
100  parts  of  water;  the  Uffelmann  method  is  employed  as  modified 
by  Strauss  for  phosphates,  alcohol,  and  sugar  also  give  the  reaction; 
5  c.c.  of  the  gastric  filtrate  are  added  to  25  c.c.  of  ether  and  shaken 
in  a  burette,  which  is  provided  with  a  cock  at  its  lowest  part;  the 
lower  25  c.c.  are  drained  away  and  25  c.c.  of  distilled  water  are  added 
to  what  remains  (the  etherial  extract)  in  the  burette.  Two  drops  of  a 
10  per  cent,  solution  of  ferric  chloride  and  20  c.c.  of  water  are  added; 
the  blue  solution  turns  to  canary  yellow  if  lactic  acid  is  present,  (c) 
Microscopically,  the  long,  thread-like  Oppler-Boas  bacilli  (Plate  XII) 
are  found,  which  are  probably  one,  though  not  the  only,  source  of  lactic 
acid  formation;  the  bacilli  stain  brown  with  the  Gram  stain  and  are 
called  Gram-positive.  The}-  may  be  confused  with  other  morphologic- 
ally similar  organisms,  such  as  the  Leptothrix  buccalis,  which  however 
stains  blue  by  Gram.  The  Oppler-Boas  bacilli  are  also  found  in  the 
faeces  in  gastric  cancer;  the  bacilli  point  very  strongly  to  the  existence 
of  gastric  cancer,  but  may  rarely  occur,  as  in  the  writer's  experience,  in 
gastric  ulcer  and  atrophic  gastritis  (with  hypertrophy  of  the  pyloric 
musculature).  Small  particles  of  tumor  are  seen  in  rare  cases,  showing 
carcinoma  structure  and  irregular  mitoses.  Sarcinse  are  rarely  ob- 
served. Occult  hemorrhage  (v.  H^matemesis),  i.  e.,  blood  which  can 
be  seen  only  with  the  microscope  or  detected  chemically  or  spectro- 
scopically,  has  the  same  significance  as  in  gastric  ulcer,  (d)  Motility — 
if  the  stomach  is  washed  out  four  to  six  hours  or  more  after  eating, 
there  are  evidences  of  stagnation  in  the  undigested  food,  particularly 
in  pyloric  localization;  disturbed  motility  may  appear  very  early  in 
the  disease.  The  stomach  is  usually  much  dilated  in  patients  whose 
appetites  persist  and  little  dilated  in  those  with  anorexia.  If  the  stom- 
ach is  empty  after  six  hours,  good  motility  alone  is  proven,  not  good 
digestion.  Every  case  of  stagnation  should  arouse  suspicion  of  car- 
cinoma. 

3.  Other  Symptoms  and  Complications. — (a)  Cachexia  results  from 
malnutrition  but  is  something  more  than  malnutrition;  it  is  probably 
the  result  of  toxins  which  break  down  the  proteids.  The  body  weight 
is  usually  greatly  reduced;  in  exceptional  cases  it  may  temporarily 
increase,  as  in  cases  of  pyloric  stenosis;  it  may  increase  from  hope,  as 
in  a  case  of  Keen  and  Stewart,  who  gained  70  pounds  after  operation; 
or  when  the  intestine  digests  what  the  stomach  could  not.  The  skin 
itches  and  is  ancemic  or  clay-colored,  somewhat  resembling  the  tint 
it  assumes  in  pernicious  anaemia,  though  distinguished  (i)  by  its  later 
appearance,  (ii)  by  its  association  with  loss  of  weight,  (iii)  by  the  red 
cells  being  seldom  lower  than  two  million  and  the  haemoglobin  seldom 


PLATE  XII. 


/  V 


M- 


h 


-^ 


X     « 


/ 


fj/JN 


■'/ 


Oppler-Boas  Bacillus  in  Vomitus.      (Musser.) 


CANCER  OF  THE  STOMACH  635 

below  40  per  cent.,  though  an  apparently  good  count  sometimes  results 
from  thickening  of  the  blood  which  is  due  to  lack  of  absorption  ;  and 
(iv)  by  the -leukocytosis  (see  Pernicious  Anjsmia).  Schneyer  has 
described  the  absence  of  the  digestive  leukocytosis;  it  occurs  in  about 
half  the  cases.  As  in  nephritis  or  chlorosis  (rubra),  the  face  may  not 
show  the  real  anaemia.  The  wrinkling  and  wasting  of  the  hands  may 
be  far  more  significant.  (6)  The  urine  is  decreased  from  poor  absorp- 
tion and  vomiting,  the  physiological  change  in  the  acidity-curve  after 
eating  is  absent,  the  urea  is  increased  from  increased  toxsemic  catabo- 
lism,  albuminuria  is  present  in  35  per  cent,  of  cases,  and  indicanuria 
is  common,  (c)  Several  ioxcemic  symptoms  may  occur,  (i)  Fever 
of  a  low,  irregular  or  intermittent  type  results  from  the  cancer  products, 
from  septic  absorption  through  the  ulcer,  or  from  complications  as 
pleurisy  or  peritonitis,  (ii)  A  coma  closely  resembling  coma  diabeticum 
may  result  from  the  cancer  toxins  or  the  breaking  down  of  the  proteids ; 
acetonuria  has  been  noted,  (iii)  Phlebitis  and  the  less  common  multiple 
neuritis,  tetany,  and  amaurosis,  are  probably  toxsemic.  {d)  Metas- 
tases or  extension  by  contiguity  may  occur.  Enlargement  of  the  supra- 
clavicular glands  may  result  from  any  abdominal  carcinoma,  but  50 
per  cent,  are  due  to  cancer  of  the  stomach  (Troisier).  Liver  deposits 
may  appear  before  any  suggestive  stomach  symptoms.  Icterus  occurs 
in  5  per  cent.  (For  other  metastases  v.  Pathology.)  ie)  Ascites 
results  (i)  from  the  cachexia  and,  like  the  swelling  of  the  ankles,  appears 
late  in  the  malady,  (ii)  Some  cases  are  due  to  carcinomatous  peri- 
tonitis, the  fluid  often  showing  blood  and  cancer  cells,  with  mitoses, 
(Dock),  and  (iii)  others  result  from  glands  or  tumor  compressing 
the  porta  hepatis.     (/)  Perforation  (v.  Pathology)  may  occur. 

Cancer  of  the  cardia  presents  symptoms  more  like  those  of  oesoph- 
ageal cancer  (q.v.).  The  symptoms  may  be  few  or  absent.  The 
stomach  is  never  distended.  There  may  be  tenderness  under  the 
xiphoid.  The  tumor  when  advanced  may  be  palpated  as  well  as  the 
perigastric  lymph  nodes. 

Diagnosis. — Diagnosis  is  easy  in  the  typical  case  outlined  in  the 
general  clinical  picture.  No  single  finding,  as  achlorhydria,  or  even 
tumor,  is  pathognomonic ;  only  the  grouping  of  symptoms  and  signs  is 
final.  Single  analyses  of  the  stomach  contents  are  often  deceptive; 
they  should  be  repeated  constantly  and  considered  in  connection  with 
other  findings.  Vomiting  in  middle  or  advanced  life  is  suspicious 
when  accompanied  by  emaciation,  ansemia,  pruritus,  and  insomnia. 
With  absence  of  hydrochloric  acid  and  the  ferments,  the  findings  of 
tumor,  blood,  lactic  acid,  Oppler-Boas  bacilli,  dilated  stomach,  and  per- 
haps of  cancer  tissue,  are  positive.  The  diagnosis  may  be  doubtful,  even 
in  the  presence  of  pyloric  tumor,  emaciation,  and  gastric  dilatation, 
when  hydrochloric  acid  is  present;  the  tumor  may  then  be  peptic 
ulcer,  hypertrophy  of  the  pyloric  musculature,  or  pyloric  spasm  due 
to  hyperchlorhydria ;  in  the  last  instance  the  tumor  is  alternately 
hard  and  then  soft,  and  often  the  chyme  may  be  felt  or  heard  as  it 
intermittently  squirts  through  the  pylorus.     The  diagnosis  between 


636  DISEASES  OF  THE  DIGESTIVE  TRACT 

beginning  cancer,  nervous  dyspepsia  and  atrophic  gastritis  must  be 
reserved  for  a  time.  Atrophic  gastritis  is  more  chronic,  often  lasting 
•  years  without  emaciation.  Age  is  of  no  diagnostic  value.  Youth  and 
adolescence  do  not  exclude  cancer;  in  the  young,  gastric  cancer  is 
more  rapid  in  evolution,  and  hydrops  and  peritonitis  are  more  com- 
mon.   Ulcer  (q.  v.). 

The  so-called  latent,  dyspeptic,  gastralgic,  anasarcous,  ascitic,  and 
anaemic  forms  of  cancer,  and  those  causing  early  metastases  (for 
example,  in  the  liver)  and  intestinal  obstruction,  show  in  what  direc- 
tion error  may  occur,  without  due  balancing  of  the  individual  and 
combined  symptoms. 

Differentiation. — (a)  Pancreatic  tumors  (q.v.)  are  deep,  fixed,  im- 
mobile, and  disappear  on  gaseous  inflation  of  the  stomach.  They 
may  be  accompanied  by  fatty  stools,  and  by  glycosuria.  It  must  be 
recalled  that  the  normal  pancreas  is  sometimes  palpable  in  meagre 
subjects,  (b)  Cancer  of  the  gall-bladder  has  respiratory  excursion  but 
neither  expiratory  fixation  nor  lateral  movement;  the  digestive  symp- 
toms, chemism,  ectasia,  and  changes  on  infiation,  of  gastric  cancer  are 
lacking,  (c)  Duodenal  carcinoma  is  hard  to  separate,  though  the 
gastric  chemism  is  usually  lacking;  passage  of  blood  in  the  faeces,  and 
icterus,  are  suggestive,  (d)  Cancer  of  the  colon  is  usually  distinguished 
by  the  presence  of  intestinal  signs  and  the  absence  of  stomach  symp- 
toms or  chemism.  (e)  Enlarged  aortic  glands  are  distinguished  by 
lack  of  altered  chemism,  and  abdominal  aneurysm  by  absence  of  cancer 
chemism  and  presence  of  expansile  pulsation;  (/)  omental  and  peri- 
toneal tumors  are  more  diffuse,  (g)  Hypertrophy  of  the  pyloric  muscle 
(v.  s.),  felt  as  a  tumor,  is  less  common  than  is  usually  assumed;  it  is 
usually  associated  with  the  findings  of  ulcer  or  of  hyperacidity;  (h) 
foreign  bodies  (hair  tumors),  subserous  lipoma,  fibroma,  myxoma,  and 
other  benign  gastric  tumors,  and  palpable  round  ulcers,  are  much 
rarer  sources  of  error.  Of  sarcoma  59  cases  are  reported  by  Lecene 
and  Petit;   of  these  a  dozen  were  successfully  operated  on. 

Prognosis. — The  prognosis  unhappily  is  determined  by  the  diag- 
nosis, an  error  in  which  is  the  only  hope.  The  average  duration  is  one 
or  two  years  (three  months  to  three  years).  Death  results  from  exhaus- 
tion by  pain  or  vomiting,  hemorrhage,  gangrene,  perforation,  portal 
pressure,  intercurrent  pneumonia,  nephritis,  and  tuberculosis. 

Treatment. — 1.  Medical  or  Palliative. — (a)  Condurango  bark 
(Friedreich)  seems  for  a  time  to  increase  the  appetite  and  strength. 
(6)  Vomiting  is  treated  as  in  gastritis,  dilatation,  and  simple  ulcer,  but 
with  less  success;  lavage  is  indicated  in  pyloric  stenosis;  boric  or 
salicylic  acid  or  resorcin  may  be  added  for  fermentation;  narcotics 
by  rectum,  rectal  feeding,  champagne,  and  carbolic  acid,  as  outlined 
before,  are  also  useful,  (c)  Hemorrhage  is  rarely  profuse  and  usually 
subsides  on  rectal  feeding;    iron,  ergot,  and  lead,  should  be  avoided. 

(d)  The  achylia  is  seldom  helped  by  hydrochloric  acid  or  pepsin. 

(e)  Pain  necessitates  the  use  of  fomentations,  lavage,  chloroform  (3 
to  5  drops)  with  ice,  and  as  a  last  resort  atropine  or  opium  by  rectum. 


H^MATEMESIS  637 

(/)  For  constipation,  cathartics  are  inferior  to  warm  colonic  flushings 
or  salts,  glycerine  or  olive  oil  by  rectum,  (g)  Diarrhcea  is  lessened  by 
lavage;  when  due  to  pj-loric  insufficiency,  salol,  beta-naphthol  (  aa  gr. 
x)  and  opiates  are  indicated,  (h)  Stenosis  of  the  cardia  may  yield  to 
dilatation,  (i)  Motor  insufficiency,  evidenced  by  food  in  the  stomach 
from  five  to  seven  hours  after  a  test  meal,  necessitates  lavage,  which 
should  be  practised  before  supper,  (j)  The  diet  should  be  soft  and 
small  in  bulk.  IMeats  and  fats  are  digested  with  difficulty.  Vegetables, 
cereals,  small  quantities  of  milk,  koumyss,  honey,  pastries  (not  too 
rich),  tea,  coffee,  diluted  wine,  peptones,  albuminoses,  baby  foods, 
somatose,  and  nutrose,  may  be  tolerated,  but  the  stomach  finally  rebels 
at  all  food. 

2.  Surgical  or  Radical  Treatment. — Cases  having  good  surgical 
prospects  are  few,  but  operation  only  can  cure.  When  a  tumor  is 
found  it  usually  has  a  rather  wide  extension;  pyloric  tumors,  for  in- 
stance, have  often  reached  the  pylorus  from  the  lesser  curvature 
(Israel).  For  resection  of  the  cancer  the  cases  should  reach  the 
surgeon,  if  possible,  before  the  tumor  is  palpable,  a  condition  possible 
only  in  private  practice,  for  hospital  cases  are  always  advanced. 
Metastases,  peritonitis  and  [glandular  invasion  are  contra-indications 
to  operation.  Pylorectomy  results  in  an  immediate  mortality  of  15.6 
per  cent,  as  against  the  original  death  rate  of  56  per  cent,  in  the  time 
of  Billroth,  who  did  the  first  operation  (1878).  The  ultimate  outlook 
is  very  doubtful,  recurrence  having  been  noted  after  five  years.  The 
Mayos,  in  1906,  reported  100  resections  of  gastric  cancer,  with  a  mor- 
tality of  14  per  cent.;  in  one  group  of  25  cases  only  one  case  died; 
27.7  per  cent,  of  their  cases  were  living  three  years  after  operation,  and 
22  per  cent,  were  well  over  three  years  after  resection.  The  Mayo 
brothers  logically  plead  for  an  early  diagnosis  (by  exploratory  laparot- 
omy) and  for  early  resection.  Gastrostomy  is  indicated  in  cardiac 
cancer,  and  gastro-enterostomy  for  pyloric  obstruction. 


(G).   HAMATE  ME  SIS. 

Definition. — Hsematemesis  is  not  absolutely  synonymous  with  gastric 
hemorrhage;  it  is  the  vomiting  of  blood,  which  may  come  directly 
from  the  stomach  or  may  reach  it  from  the  gums,  nose,  larynx,  hmgs, 
oesophagus,  or  even  regurgitate  backward  from  the  intestine.  Gastror- 
rhagia  designates  profuse  hemorrhage  from  the  stomach.  It  may  be 
arterial,  venous,  or  capillary. 

Etiology.— (a)  Various  forms  of  ulceration, as  simple  ulcer,  carci- 
nomatous, tuberculous  (of  which  Letorey  [1895]  found  only  21  cases), 
diphtheritic,  typhoid,  syphilitic,  ursemic,  or  phlegmonous  ulcers,  hemor- 
rhagic erosions,  and  perforations  into  the  stomach  from  without,  as 
gall-stones,  or  aneurysm  dissecting  down  from  the  arch  of  the  aorta 
(Minkowski),  are  etiological  factors.  Parrot  described  superficial  ulcers 
in  the  gastritis  of  the  new-born.     Dieulafoy  describes  a  pneumococcic 


638  DISEASES  OF  THE  DIGESTIVE  TRACT 

hemorrhagic  gastritis.  Chiari  and  Murchison,  but  especially  Dieulafoy, 
have  described  very  small  simple  ulcers  causing  profuse,  often  repeated 
and  fatal  hemorrhage;  their  diagnosis  seems  probable  when  they  de- 
velop in  perfect  health  and  with  no  previous  stomach  symptoms ;  they 
are  easily  overlooked  at  operation  or  autopsy  because  they  involve 
only  the  mucosa  or  perhaps  some  of  the  muscularis;  some  regard  this 
form  as  the  beginning  of  round  ulcer,  (b)  Trauma,  such  as  external 
violence,  or  internal  trauma,  as  from  foreign  bodies,  thermal  and 
chemical  injury,  and  violent  vomiting,  as  sea-sickness  and  hyper- 
emesis,  may  be  causal,  (c)  The  cause  may  be  vascular,  such  as 
amyloid  degeneration  which  may  sometimes  involve  the  stomach  and 
bowels  alone ;  large  or  miliary  aneurysm,  arterial  hypersemia,  embolism, 
vicarious  congestion  from  suppression  of  hemorrhoids  or  menstruation, 
passive  congestion  of  cardiac  or  hepatic  origin ;  and  oesophageal  varix, 
though  it  should  be  remembered  that  when  due  to  cirrhosis  of  the 
liver  there  is  in  33  per  cent,  of  cases  no  other  evidence  of  cirrhosis; 
Welch  and  Powell  have  found  varices  in  the  floor  of  peptic  ulcers; 
malarial  deposits  in  the  liver;  acute  pylethrombosis,  causing  profuse 
hemorrhage;  and  parenchymatous  oozing,  where  no  postmortem, 
changes  are  found,  (d)  Nervous  causes  are  injuries  to  the  central 
nervous  system,  vasomotor  influences,  and  hysteria  (aside  from  simu- 
lation and  artifices),  in  which  the  blood  is  small  in  amount  and  occurs 
usually  in  the  morning  vomit;  tabetic  crises;  and  general  paralysis. 
(e)  Acute  infections  may  be  etiological  factors,  as  malaria,  hemorrhagic 
exanthemata,  yellow  fever,  sepsis,  embolism  after  operations  (von 
Eiselsberg),  appendicitis  (Dieulafoy),  and  genito-urinary  sepsis  (Guyon) ; 
Busse  (1905)  collected  96  cases  following  operations;  they  result  from 
direct  embolism  (of  which  35  per  cent,  are  in  the  mesentery  or  omen- 
tum) or  retrograde  embolism;  the  hemorrhage  occurred  in  the  stomach 
or  bowels;  55  per  cent.  die.  (/)  Blood  diseases,  as  pernicious  anaemia, 
leukaemia,  haemophilia,  purpura,  scurvy,  and  splenic  anaemia,  may 
be  causal,  {g)  Poisons,  which  early  erode  and  later  ulcerate,  as  acids 
and  caustics,  those  causing  fatty  degeneration  of  the  vessels  as  arsenic 
and  phosphorus,  and  uraemia  or  cholaemia,  may  cause  haematemesis. 

Most  cases  occur  in  women  between  fifteen  and  forty  years  of  age. 
Of  all  causes,  round  ulcer  and  liver  cirrhosis  are  the  first  to  suggest 
themselves.  At  autopsy  it  may  be  impossible  to  find  the  point  of  issue 
of  blood. 

Symptoms. — ^The  symptoms  are  (a)  those  of  the  antecedent  disease, 
(b)  In  some  cases  no  blood  may  be  vomited  up,  and  the  incident  then 
remains  undiscovered,  unless  the  stools  are  examined.  In  vomitvs 
cruentus  gastric  uneasiness  is  common.  The  amount  vomited  varies 
from  microscopic  quantities  to  those  sufficiently  large  to  cause  death. 
The  occurrence  of  "occult  hemorrhage"  has  been  particularly  em- 
phasized by  Boas;  blood  can  be  detected  microscopically  or  chemically 
when  not  visible  to  the  eye,  in  over  25  per  cent,  of  the  cases  of  ulcer 
and  cancer;  in  microscopic  examination  the  diet  for  days  previously 
should  contain  no  meat,  blood,  iron,  or  chlorophyll,  but  should  consist 


SECRETORY  NEUROSES  OF  THE  STOMACH  639 

solely  of  eggs,  fruit,  flour,  or  fat.  In  profuse  gastrorrhagia  the  blood 
is  bright  red,  if  it  remains  in  the  stomach  only  a  short  while,  as  it  does 
in  most  cg,ses  of  peptic  ulcer.  In  smaller  hemorrhages  it  is  black  or 
rust-colored,  as  in  cancer,  uraemia,  cholsemia,  various  poisonings,  and 
perhaps  in  peptic  ulcer  from  action  of  the  hydrochloric  acid;  rust- 
colored  blood  may  become  bright  on  the  edges  or  surface  when  it  has 
stood  for  some  time.  Blood  may  issue  in  the  fluid  form,  or  as  clots, 
in  which  case  it  is  suggestive  of  valvular  disease,  vascular  diseases  or 
the  dangerous  hsematemesis  which  occurs  in  cirrhosis.  In  a  fatal 
typhoid  hemorrhage,  which  occurred  in  one  of  the  author's  students, 
enormous  clots  were  vomited;  the  author  has  seen  large  clots  vomited 
by  patients  having  carcinoma  of  the  stomach,  (c)  Meloena  may 
render  the  stools  black,  tarry,  and  offensive,  (d)  Systemic  signs  may 
occur.  A  gradual  or  sudden  intense  ancemia  may  be  noted,  with  all 
the  usual  signs  of  anaemia  (q.v.),  with  vertigo,  syncope,  tinnitus, 
spots  before  the  eyes,  rapid  heart  action,  and  some  dyspnoea.  Later 
there  may  be  amaurosis,  slight  febrile  movements,  dicrotic  pulse, 
hsemic  murmurs,  moderate  oedema  about  the  ankles,  albuminuria,  and 
sometimes  hemiplegia  or  convulsions. 

Diagnosis. — Differentiation  from  haemoptysis  (q.v.),  from  the  swal- 
lowing of  blood  from  the  nipples  in  nurslings  or  from  the  vagina  in 
the  new-born,  from  fracture  of  the  skull,  from  oesophageal  or  throat 
disease,  and  from  simulation  of  blood  in  the  stools  from  ingestion  of 
bismuth,  coffee,  tea,  claret,  iron,  or  blueberries,  does  not  need  par- 
ticular elaboration,  as  the  microscopic,  chemical  and  spectroscopic 
examination  determines  doubtful  cases.  Weber's  test  for  blood  is 
made  by  adding  to  15  c.c,  of  the  vomitus  or  faeces,  5  c.c.  of  glacial 
acetic  acid,  and  agitating  with  20  c.c.  of  ether;  the  ether  becomes 
brownish-red  in  the  presence  of  blood,  the  brown  acetate  of  haematin 
being  formed.  Treatment  is  identical  with  that  of  the  haematemesis 
which  occurs  in  round  ulcer. 


(H).  NEUROSES  OF  THE   STOMACH. 

The  neuroses  of  the  stomach  occur  in  nervous  individuals,  either  as 
a  part  of  a  neurosis  or  as  a  rather  isolated  nervous  symptom.  Their 
relations  will  also  be  considered  under  neurasthenia  and  hysteria. 
They  sometimes  occur  reflexly,  as  in  gall  or  renal  stones,  or  in  uterine 
disease.  Though  their  varieties  will  be  considered  as  (I)  secretory, 
(II)  motor,  and  (III)  sensory,  combinations  of  symptoms  are  more 
frequent  than  single  symptoms. 


(I).   SECRETORY  NEUROSES. 

These  have  been  described  especially  by  Reichmann,  Rossbach, 
Sahli,  and  Riegel. 


640  DISEASES  OF  THE  DIGESTIVE  TRACT 

1.  Hyperchlorhydria  (Hyperaciditas  Hydrochlorica). — This  is  a 
qualitative  anomaly  of  gastric  secretion  in  which  the  free  hydrochloric 
acid  is  increased;  it  is  not  solely  a  neurosis,  though  conveniently 
classified  as  such;  it  is  attended  by  no  known  anatomical  lesion;  it  is  an 
excessive  secretion  of  hydrochloric  acid  during  the  height  of  digestion. 

Etiology. — (a)  General  etiological  factors  are  as  follows:  (i)  It  is 
most  frequent  in  young  and  middle-aged  persons;  (ii)  in  the  better 
situated  classes,  (iii)  in  Polish  Jews,  and  (iv)  in  brain-workers;  (v) 
it  is  somewhat  more  common  in  women  than  in  men;  (vi)  a  neurotic 
or  psychopathic  tendency  is  a  predisposing  factor,  as  is  also  (vii) 
chlorosis,  in  which  hyperchlorhydria  is  found  in  85  to  95  per  cent,  of 
cases,  (b)  Local  causes  are  (i)  rapid  eating  and  cold  drinks;  (ii)  condi- 
ments; (iii)  smoking;  (iv)  certain  foods  and  coffee;  (v)  gall-stones, 
or  possibly  renal  stones,  which  induce  hyperchlorhydria  by  irritating 
the  stomach;   and  (vi)  habitual  constipation. 

Symptoms. — Symptoms  are  quite  often  absent.  The  clinical  picture 
varies  much,  and  no  single  symptom  is  pathognomonic,  (a)  Pain 
is  the  chief  symptom;  it  varies  from  a  sense  of  pressure  or  discomfort 
in  mild  cases  to  extreme  gastralgia  in  severe  cases.  It  develops  at  the 
height  of  gastric  digestion — i.e.,  one  to  two  hours  after  eating — and  is 
due  to  the  excess  of  free  hydrochloric  acid;  it  depends  on  the  kind 
and  amount  of  food  ingested;  the  more  food,  especially  meat,  ingested, 
the  later  is  the  pain,  for  the  food  engages  the  free  acid  longer.  Carbo- 
hydrates cause  increased  pain,  as  they  do  not  engage  the  acid,  and 
amylolysis  is  decreased,  perhaps  suspended;  in  exceptional  cases  the 
patient  tolerates  small  and  frequent  meals  better  than  larger  ones.  The 
patient  is  often  aware  of  the  increased  peristalsis  and  feels  a  cramping 
or  spasm  of  the  pylorus.  Pain  lasts  one-half  to  several  hours.  It  is 
relieved  by  vomiting,  and  unless  it  has  become  quite  severe  is  also 
relieved  by  ingestion  of  more  food  or  of  alkalies.  (6)  Belching  and 
pyrosis  are  frequent,  and  the  eructated  hyperacid  fluid  causes  a  burn- 
ing in  the  oesophagus — i.e.,  along  the  spine,  (c)  Vomiting  of  a  sour 
fluid,  which  causes  a  burning  sensation,  is  not  frequent,  save  in  severe 
cases,  (d)  The  appetite  is  usually  good,  and  most  patients  desire 
food  frequently,  though  in  small  amounts;  occasionally  it  is  ravenous, 
(e)  Tenderness  over  the  stomach  is  usually  diffuse,  moderate  in  degree 
and  coincident  with  the  pain;  it  is  sometimes  pyloric,  and  is  associated 
with  some  epigastric  distention.  (/)  Stomach  tests  show  that  the  total 
acidity  is  increased  to  100,  even  to  150  or  160;  the  digestive  power  is 
shown  to  be  increased  by  the  egg-disk  test,  the  proteids  are  well  sub- 
divided, the  amylolysis  delayed,  motility  and  absorption  normal  or 
increased  in  uncomplicated  cases,  and  no  lactic  acid,  no  fermentation 
and  no  gas  are  present,  (g)  Other  symptoms  are  as  follows:  The 
bowels  are  irregular,  constipation  being  more  frequent  than  diarrhoea; 
headache  is  common,  and  migraine  or  neurasthenic  symptoms  may 
develop;  the  gums  may  retract  (Herter);  in  the  urine  the  chlorides 
are  decreased,  the  acidity  lessened  during  digestion,  and  frequently 
an  alkaline  reaction  and  phosphaturia  are  present. 


SECRETORY  NEUROSES  OF  THE  STOMACH  641 

Diagnosis. — The  diagnosis  is  determined  by  the  presence  of  hyper- 
chlorhydria  in  the  vomitus  and  in  the  test  meal,  by  the  rehef  of  the 
chemical  pain  by  vomiting  or  ingestion  of  more  food  or  alkalies,  and 
by  negative  physical  findings. 

Differentiation. — (a)  Ulcer  (q.v.  table)  is  marked  by  well-localized 
tenderness  and  hsematemesis  or  occult  bleeding,  and  its  symptoms  are 
much  more  regular  than  in  hyperchlorhydria,  in  which  bleeding 
rarely  results  from  erosions,  (b)  Gastritis  is  characterized  by  mucus 
formation  and  decreased  secretion,  save  in  gastritis  acida,  in  which 
the  hydrochloric  acid  rarely  exceeds  50.  (c)  Gastrosuccorrhoea  or 
continuous  secretion  (v.i.).  (d)  Gastr ectasia  and  gastroptosis  are  ex- 
cluded by  percussion  and  by  inflation,  (e)  Gall-stones,  in  which  pain 
has  no  relation  to  eating,  occur  at  longer  irregular  intervals  and  are 
associated  with  turgidity  and  tenderness  of  the  gall-bladder. 

Course  and  Prognosis. — The  disease  begins  slowly  and  may  dis- 
appear, to  recur  after  a  few  days,  weeks,  or  months,  from  irregular 
living,  nervous  strain,  excesses,  certain  articles  of  diet,  or  sometimes 
without  obvious  cause.  The  nutrition  is  usually  fairly  well  maintained. 
The  outlook  is  generally  good  if  early  treatment  is  instituted ;  compli- 
cations, as  continuous  secretion,  gall-stones,  or  gastric  atony,  modify 
the  prognosis. 

Treatment. — 1.  Peophylaxis. — Nervous  factors,  smoking,  haste  in 
eating,  chlorosis,  etc.,  should  receive  appropriate  treatment. 

2.  Diet. — (a)  A  proteid  diet  is  most  beneficial,  for  it  takes  up  the 
largest  amount  of  hydrochloric  acid,  which  is  not  essentially  increased 
by  proteids,  as  has  been  maintained;  veal,  beefsteak,  mutton,  and 
ham,  absorb  twice  as  much  hydrochloric  acid  as  equal  weights  of  other 
proteids  (Fleischer);  fish  fat  is  particularly  to  be  avoided;  milk  and 
some  kinds  of  cheese  may  be  given,  (b)  Carbohydrates  should  be 
restricted,  because  the  early  amylolytic  gastric  digestion  by  the  ptyalin 
is  delayed  or  arrested;  a  slice  or  two  of  stale  bread,  biscuits,  toast,  and 
zwieback,  or  purees  of  aleuronat  meal,  which  contains  much  nitrog- 
enous matter,  may  be  given;  Strauss  allows  six  to  nine  ounces  of 
2  per  cent,  grape  sugar  solution,  unless  there  is  a  complicating  motor 
insufficiency.  Potatoes,  salads,  and  most  uncooked  vegetables,  should 
be  interdicted,  (c)  Fats  may  be  given  in  limited  quantities,  including 
small  amounts  of  cream  or  unsalted  butter  (one  ounce);  one  or  two 
drams  of  olive  oil  an  hour  after  meals  inhibit  the  secretion  of  acid. 
(d)  Condiments,  such  as  mustard,  pepper,  vinegar,  spices,  horseradish, 
coffee,  alcohol,  cold  foods  and  drinks,  should  be  forbidden  because  of 
their  irritating  action.  Weak  tea,  cocoa  or  milk  may  be  given,  (e) 
Thorough  mastication  must  be  insisted  upon.  (/)  Small  meals,  given 
at  frequent  intervals,  are  generally  most  efficacious,  though  Bouveret's 
three  meals  may  sometimes  be  given  if  the  patient's  appetite  is  good. 

3.  Medication. — (a)  Alkalies,  as  sodium  bicarbonate  and  mag- 
nesia usta,  aa  gr.  xv  to  xxx,  should  be  given  at  the  height  of  digestion, 
to  neutralize  the  hyperchlorhydria  and  relieve  its  symptoms;  Pawlow 
maintains  that  alkalies  do  not  only  act  chemically  but  inhibit  secretion 

41 


642  DISEASES  OF  THE  DIGESTIVE  TRACT 

by  action  on  the  glandular  cells.  The  charged  alkaline  waters  dilute 
the  gastric  juice,  neutralize  the  acidity,  and  are  sedative,  (b)  Extract 
of  belladonna,  i  to  ^  grain,  given  at  meal-time,  lessens  secretion  and 
mitigates  pain;  opiates  are  seldom  indicated  and  should  be  avoided. 
(c)  Lavage  with  silver  nitrate  (1  to  1,000)  solution  is  useful  in  obsti- 
nate cases. 

2.  Gastrosuccorrhoea  (H3T)ersecretion,  Parasecretion,  Continuous 
Secretion). — ^This  is  a  quantitative  perversion  of  gastric  secretion,  in 
which  a  fairly  abundant  secretion  is  found  in  the  fasting  stomach; 
i.e.,  it  occurs  without  the  stimulus  of  food,  and  when  the  stomach 
should  be  empty.  In  the  lightest  forms  it  only  occurs  when  food  is 
ingested  (alimentary  form);  in  the  severest  forms  it  occurs  without 
ingestion  of  food.  It  is  not  denied  that  some  gastric  juice  may  be 
found  in  the  normal  stomach,  due  to  secretion  initiated  by  swallowed 
saliva  or  mucus,  but  if  this  exceeds  one-half  to  one  ounce  it  is  rarely 
physiological.  Two  forms  are  distinguished,  the  continuous  (Reich- 
mann,  1882)  and  the  intermittent  form  (Sahli,  1885).  (a)  The  inter- 
mittent form  occurs  in  attacks  which  last  a  day  or  two,  is  often  called 
acute  or  nervous  dyspepsia,  and  is  found  in  about  the  same  class  of 
patients  in  which  hyperchlorhydria  develops;  it  has  been  observed 
during  tabetic  crises.  Colic-like  pain  develops,  iisually  at  night, 
followed  by  sour  eructations  and  repeated  vomiting,  first  of  food,  then 
of  three  ounces  or  more  of  yellow-green  fluid  which  contains  hydro- 
chloric acid  and  ferments.  The  first  vomitus  may  contain  considerable 
hydrochloric  acid  and  no  more  mucus  than  the  small  amount  which 
the  normal  stomach  contains;  there  is  seldom  blood.  During  the 
attack  the  pulse  is  small  and  rapid,  the  skin  clammy,  the  urine  scanty 
and  alkaline,  and  headache  is  frequent.  Thirst  is  great  and  drinking 
may  give  temporary  relief,  but  is  followed  by  increased  vomiting. 
Between  attacks  the  acidity  is  normal,  and  the  appetite  and  general 
health  are  usually  good;  occasionally  there  is  a  constant  sense  of 
gastric  discomfort.  (&)  The  second  form  is  continuous  gastrosuccor- 
rhoea. Its  etiology  is  similar  to  that  of  hyperchlorhydria  {-mXh.  which 
it  may  co-exist),  but  rather  less  clearly  established. 

Symptoms. — (a)  Pain  is  more  marked  than  in  hyperchlorhydria, 
develops  later  after  eating,  and  very  often  at  night  (11  p.  m.  to  2  a.  m.); 
it  may  occur  before  meals,  for  the  gastric  secretion  is  constant,  or  in 
severe  cases  it  may  be  present  both  during  the  day  and  night;  it  is 
relieved  by  eating  and  by  vomiting.  There  may  be  some  local  or 
diffuse  tenderness,  (b)  Vomiting  closely  follows  the  pain,  and  may 
occur  at  its  height,  or  during  the  night;  the  quantity  of  the  vomitus 
varies;  it  is  large  when  there  is  dilatation  (a  frequent  complication 
and  a  common  cause  of  this  type).  It  contains  hydrochloric  acid, 
ferments,  and  a  small  quantity  of  mucus;  vomiting  may  be  absent  in 
light  cases,  (c)  There  may  be  other  digestive  symptoms.  The  condition 
of  the  tongue  varies,  being  often  red  and  clean,  but  sometimes  coated. 
The  teeth  are  often  carious.  The  appetite  is  usually  good,  sometimes 
ravenous,  or  in  advanced  cases  may  be  poor.     The  thirst  is  marked, 


SECRETORY  NEUROSES  OF  THE  STOMACH  643 

and  is  sometimes  suggestive  of  diabetes.     The  bowels  are  sluggish. 

(d)  The  results  of  the  test  meal  and  lavage  show  that  the  total  acidity 
ranges  up  ta90  or  100,  and  free  hydrochloric  acid  to  50  or  60.  After 
a  test  dinner,  the  fluid,  when  removed,  separates  into  three  layers; 
the  upper  one  is  foamy,  the  middle  one  consists  of  yellowish  fluid,  and 
the  lower  one  of  sediment  of  fine  undigested  carbohydrates;  the  pro- 
teids  are  found  to  have  been  converted  into  peptones.  When  the 
stomach  is  washed  out  thoroughly  at  night  to  remove  all  fluid  and 
food,  examination  on  the  next  morning,  of  the  fasting  stomach  reveals 
one  to  ten  ounces  of  gastric  juice  (hydrochloric  acid  and  ferments) — 
i.e.,  secretion  without  the  stimulus  of  food;  if  the  fasting  stomach  is 
washed  out  one,  two  or  three  hours  later,  gastric  juice  is  again  found — 
i.e., [there  is  continuous  secretion,  when  the  stomach  should  be  empty. 

(e)  Other  symptoms.  The  urine  is  the  same  as  in  hyperchlorhydria. 
Old  cases  show  marked  emaciation  which  may  resemble  cachexia, 
particularly  because  of  the  frequently  lax  muscles  and  dry,  inelastic 
skin* 

Course  and  Prognosis. — The  onset  is  slow  and  the  course  is  pro- 
tracted; it  may  last  for  years.  The  nutrition  suffers  and  death  from 
exhaustion  may  result  in  untreated  cases.  Complications  are  frequent, 
especially  (a)  dilatation  (atony,  motor  insufficiency),  for  the  stomach 
is  never  empty;  the  hydrochloric  acid  does  not  inhibit  the  growth  of 
sarcinse  or  yeast,  and  gases  may  generate.  The  dilatation  may  be 
primary  but  is  most  often  secondary;  it  is  differentiated  by  thoroughly 
washing  out  the  stomach  at  night,  and  when  the  tube  is  introduced 
the  next  morning  it  should  show  nothing  in  simple  dilatation.  Dilata- 
tion may  also  result  from  (h)  pyloric  spasm.  Pawlow  has  shown  that 
in  health  the  pylorus  relaxes  intermittently  and  allows  the  acid  chyme . 
to  reach  the  duodenum;  the  pylorus  is  reflexly  contracted  by  the  acid 
fluid  in  the  duodenum  until  this  is  neutralized,  when  the  pylorus  again 
relaxes.  When  the  secretion  is  continuous,  the  passage  of  acid  fluid 
into  the  duodenum  constantly  contracts  the  pylorus  (hypertonic  spasm) 
which  sometimes  may  be  felt  as  a  tumor.  In  this  case  cancer  may  be 
suggested,  especially  when  there  is  emaciation,  or  blood  in  the  stomach, 
until  the  constant  flow  of  gastric  ferments  and  hydrochloric  acid  is 
found,  (c)  There  is  some  tendency  toward  gastric  ulcer,  (d)  Tetany 
is  a  rare  complication  of  pyloric  obstruction. 

Diagnosis. — The  diagnostic  features  are  (a)  the  pain  at  night;  (6) 
vomiting,  and  (c)  thirst,  both  of  which  are  more  common  than  in 
hyperchlorhydria;  (d)  continuous  secretion  after  washing  out  the 
stomach  and  during  fasting. 

Treatment. — Treatment  is  in  general  (a)  that  of  hyperchlorhydria 
as  to  prophylaxis,  diet,  mastication,  and  stimulants.  (6)  Rectal  feeding 
is  a  valuable  accessory;  water,  too,  may  be  given  by  rectum  to  quench 
the  raging  thirst,  (c)  Oral  feeding  is  allowed  at  long  intervals; 
overloading  of  the  stomach  with  fluids  is  carefully  to  be  avoided,  id) 
Lavage  relieves  pain  and  hypersecretion.  Reichmann  employs  irri- 
gation with  silver  nitrate  (1  to  500  or  1,000).     {e)   Olive  oil  lessens 


644  DISEASES  OF  THE  DIGESTIVE  TRACT 

hyperchlorhydria  (Riegel).  (/)  Alkalies  and  belladonna  are  indicated 
as  in  hyperchlorhydria.  (g)  Treatment  of  coincident  dilatation;  mas- 
sage or  gastro-enterostomy  (which,  however,  is  only  indicated  by  pyloric 
obstruction,  never  for  hypersecretion  per  se),  may  be  indicated. 

3.  Hyposecretion. — Hypacidity  (hypochlorhydria  or  subacidity)  and 
an  acidity  (achlorhydria)  refer  respectively  to  reduction  or  absence  of 
hydrochloric  acid,  which  may  occur  from  nervous  as  well  as  from 
organic  causes  (see  Gastritis;  Achylia).  When  the  ferments  and 
hydrochloric  acid  are  absent,  achylia  gastrica  nervosa  is  a  more  appro- 
priate term ;  the  condition  may  be  transient  or  enduring,  and  Einhorn 
reported  a  case  in  which  secretion  returned  after  an  absence  of  five 
years.  Suppressed  secretion  may  occur  in  hysteria,  tabetic  crises,  or, 
less  often,  in  other  affections  of  the  cord. 


II.  Motor  Neuroses  of  the  Stomach. 

These  may  be  irritative  (increased  motility)  or  depressive  (decreased 
motility). 

1.  Irritative  Ts^pes. — (a)  Hyperhinesis  or  hypermotility  hurries  the 
food  into  the  intestine,  so  that  it  disappears  in  three  to  five  hours  or 
even  less.  It  exists  by  itself  as  a  neurosis,  but  may  occur  in  the  hasty 
digestion  caused  by  hyperchlorhydria,  and  in  gastric  atrophy,  appar- 
ently in  order  that  the  intestines  may  earlier  digest  the  unaltered 
food.  (6)  Peristaltic  unrest  (Kussmaul)  or  tormina  ventriculi  nervosa 
occurs  in  functional  affections,  particularly  neurasthenia,  and  in  or- 
ganic pyloric  stenosis.  In  some  cases  the  unrest  may  be  wholly  sub- 
jective, the  patient  experiencing  a  rolling  or  cramping  sensation.  In 
others,  both  neurotic  and  organic,  the  peristaltic  movements  from  left 
to  right  may  be  seen,  as  well  as  antiperistalsis  in  the  opposite  direc- 
tion. The  treatment  of  hyperkinesis  and  peristaltic  unrest  is  that  of 
the  underlying  neurasthenia  and  hysteria,  (c)  Pyloric  spasm  occurs 
very  frequently  as  a  secondary  disorder,  but  very  seldom,  if  ever,  as  an 
independent  neurosis;  it  occurs  usually  in  connection  with  ulcer,  hyper- 
acidity, hypersecretion,  fissures,  erosions,  chronic  stenosing  gastritis, 
sometimes  with  cancer  of  the  stomach,  and  with  poor  mastication  of 
food  and  drinking  of  cold  fluids.  Its  relation  to  dilatation  has  been 
discussed,  {d)  Spasm  of  the  cardia  occurs  in  organic  disease  of  the 
oesophagus  and  stomach  (ulcer,  cancer,  erosions,  hyperchlorhydria),  or 
in  neuroses;  it  is  the  cause  of  idiopathic  dilatation  of  the  oesophagus 
(q.v.),  and  the  spasm  in  tetanus  and  hydrophobia.  It  makes  vomiting 
diflacult  and  is  differentiated  from  organic  stricture  by  the  fact  that 
in  cardiospasm  a  large  sound  passes  more  easily  than  a  small  one,  and 
that  spasm  is  often — not  always — intermittent.  The  treatment  of 
pyloric  spasm  is  that  of  the  cause  (almost  invariably  gastric);  the 
treatment  of  cardiospasm  is  discussed  under  idiopathic  oesophageal  dil- 
atation, (e)  Nervous  eructations  (Bouveret,  Mathieu,  Follet,  Stern)  occur 
in  various  neuroses  and  psychoses.    They  are  said  to  occur  especially  in 


MOTOR  NEUROSES  OF  THE  STOMACH  645 

sexual  neuroses.  The  odorless  ructiis  does  not  result  from  fermentation, 
but  from  swallowing  of  air  (aerophagia),  which  constitutes  a  most  intrac- 
table habit/  The  mechanism  by  which  air  is  swallowed  is  disputed; 
Bouveret  correctly  thinks  it  is  forced  down  by  pharyngeal  contractions, 
but  Oser  holds  that  the  stomach  aspirates  air.  It  is  often  swallowed 
unconsciously,  or,  again,  it  enters  during  what  Matthieu  terms  false 
eructations,  in  which  the  patient,  in  attempting  to  raise  gas,  swallows 
air.  The  ructus  can  be  caused  only  by  aerophagia,  as  such  large 
quantities  could  never  generate  in  the  stomach;  Bardet  estimated 
that  one  patient  raised  twenty  quarts  in  an  afternoon.  Coincident 
cardiac  and  pyloric  spasm  causes  distention  (pneumatosis).  Treat- 
ment lies  in  the  use  of  the  sound,  suggestive  therapy,  and  in  the  diffi- 
cult task  of  breaking  the  habit.  (/)  Nervous  vomiting  occurs  (i)  only 
in  the  neuroses,  as  hysteria,  neurasthenia,  migraine,  and  exophthalmic 
goitre;  but  under  this  caption  we  may  also  bring  for  differential  purposes 
(ii)  cerebrospinal  conditions,  as  anaemia  of  the  brain,  compression, 
meningitis,  tumor,  tabes,  general  paralysis,  disseminated  sclerosis  and 
myelitis;  toxic  conditions,  as  uraemia  or  cholaemia,  may  cause  cerebral 
vomiting,  (iii)  Most  cases  sue  reflex  in  origin;  they  may  originate  in 
the  nose,  as  nausea  from  disagreeable  odors;  in  the  respiratory  tract; 
in  pelvic  or  abdominal  conditions,  as  pregnancy,  menstruation,  gall- 
stones, renal  calculi,  and  peritonitis.  The  symptoms  may  present 
many  incompatible  elements;  thus  the  patient  may  vomit  without 
nausea,  almost  without  effort,  so  that  the  vomiting  is  rather  an  eruc- 
tation ;  it  often  occurs  without  pain  or  without  reference  to  the  fulness 
or  emptiness  of  the  stomach;  even  though  it  is  frequent,  the  nutrition 
may  be  remarkably  good,  the  tongue  clean,  and  the  appetite  good. 
Periodical  or  cyclical  vomiting,  described  by  Leyden,  has  some  resem- 
blance to  tabetic  crises;  Edsall  considers  it  an  acidosis,  for  which 
3ss  to  ij  of  sodium  bicarbonate  is  indicated.  Robert's  conclusions 
are  as  follows: 

1.  Vomiting  of  a  chronic  type,  following  a  gradually  developed 
epigastralgia,  from  one-half  to  three  hours  after  the  ingestion  of  food, 
is  attributable  to  peptic  ulcer,  gastric  or  duodenal. 

2.  Chronic  vomiting  that  occurs  from  ten  to  fifteen  minutes  after 
food  ingestion  is  attributable  to  stenosis  of  the  cardia,  nervous  abnor- 
mality, cerebral  lesion  (occasional  rather  than  chronic),  or  to  protracted 
acute  gastritis. 

3.  Copious  vomiting  ten  or  more  hours  after  food  ingestion  indi- 
cates a  muscular  insufficiency;  frequent  repetition  indicates  a  per- 
manent lesion  in  the  nature  of  a  mechanical  interference  with  the 
exit  of  food. 

4.  Vomiting  in  the  night  is  particularly  liable  to  occur  in  chole- 
lithiasis, periodic  hypersecretion,  muscular  insufficiency,  and  nervous 
abnormality. 

5.  Vomiting  attempts  when  the  stomach  is  empty  indicate  a  cause 
other  than  a  gastric  lesion,  either  a  reflex  cause,  a  toxemia,  a  cerebral 
lesion,  or  a  nervous  abnormality. 


646  DISEASES  OF  THE  DIGESTIVE  TRACT 

6.  Morning  nausea  and  retching  indicate  either  a  beginning  of  preg- 
nancy, alcohohsm,  pharyngitis,  nephritis,  or  a  nervous  abnormahty. 

7.  Periodic  vomiting  of  clear  gastric  juice  of  normal  or  supernormal 
acidity  in  any  considerable  amounts  indicates  a  secretory  neurosis  or 
an  ulcerative  lesion. 

8.  Vomiting  as  a  sequel  of  headache,  accompanied  by  severe  nausea, 
but  no  gastric  or  abdominal  symptoms,  characterizes  attacks  of  mi- 
graine; in  a  majority  of  cases  eyestrain  is  the  underlying  cause. 

9.  Attacks  of  vomiting  of  sudden  onset,  with  tinnitus,  deafness,  and 
vertigo,  are  attributable  to  disturbances  of  pressure  in  the  internal  or 
middle  ear. 

10.  Periodic  attacks  of  vomiting  of  sudden  onset,  associated  with 
more  or  less  severe  gastric  pain  and  nausea,  retraction  of  the  abdomen, 
obstinate  constipation  during  but  not  preceding  the  attack,  and  free- 
dom from  abdominal  tenderness,  are  suggestive  of  the  spinal  crises, 
idiopathic  nervous  vomiting,  and  lead-poisoning. 

11.  Periodic  attacks  of  vomiting  after  abdominal  colic  and  consti- 
pation, with  localized  or  general  tympany,  are  suggestive  of  chronic 
intestinal  stenosis. 

2.  Depressive  Motor  Neuroses  (from  Lessened  Motility). — There 
are  three  types:  (a)  Atony,  which  has  been  considered  under  dilata- 
tion; (b)  pyloric  insujficiency  (Sere  and  Ebstein),  which  is  seldom 
a  neurotic  condition,  as  compared  with  its  frequency  in  cancer,  ulcer, 
and  dilatation  of  the  pylorus  from  duodenal  obstruction.  Its  presence 
is  determined  by  inflating  the  stomach  with  carbon  dioxide,  which 
rapidly  passes  into  the  intestine  with  a  gurgling  gush,  (c)  The  third 
type,  insufficiency  of  the  cardia,  causes  regurgitation  of  food  and  fluid 
and  rumination  (merycismus) ,  which  is  a  regurgitation  in  which  the 
food  is  again  chewed  and  reswallowed.  These  are  generally  involun- 
tary processes,  but  some  subjects  can  regurgitate  at  will.  The  patients 
are  nearly  always  neurotic  males,  psychopaths,  or  idiots.  The  affection 
is  either  hereditary  or  (which  is  more  likely)  imitative  when  it  occurs  in 
several  members  of  a  family.  Its  mechanism  is  a  matter  of  theory; 
congenital  weakness  of  the  cardia,  stimulation  of  the  vagus,  and 
aspiration  into  the  oesophagus  by  the  inspiratory  act,  are  considered 
causal.  It  should  be  treated  by  giving  small  meals  at  frequent  intervals ; 
these  should  be  well  masticated;  intragastric  electrical  applications 
and  suggestive  measures  are  indicated. 

III.  Sensory  Neuroses  of  the  Stomach. 

1.  Hypersesthesia  may  give  the  sensation  of  burning  in  the  stomach, 
or  a  sense  of  weight;  this  usually  occurs  when  the  organ  is  full,  but 
at  times  also  when  it  is  empty.  Certain  kinds  of  food,  as  carbohydrates, 
fats  or  spices  may  induce  the  condition.  Silver  nitrate,  gr.  \  to  \,  ac. 
carbolicum  gr.  i  to  j,  or  extr.  gelsemii  fl.  TTjjij,  given  on  the  empty  stom- 
ach, often  afford  relief,  besides  which  the  basic  neurasthenia  should 
receive  treatment,  and  perhaps  also  the  anaemia  or  constipation. 


SENSORY  NEUROSES  OF  THE  STOMACH  647 

2.  Gastralgia  (gastrodynia  or  cardialgia,  which  is  a  poorly  selected 
but  widely  used  term)  does  not  strictly  include  the  gastric  pain  due  to 
ulcer,  hyperacidity,  or  hypersecretion.  Rosenthal's  etiological  classi- 
fication is  as  follows:  (i)  Cerebrospinal  causes,  including  various  brain, 
cord  (tabes),  peripheral,  and  functional  nervous  affections,  (ii)  Con- 
stitutional causes,  including  chlorosis  and  debility,  (iii)  Toxic  causes, 
resulting  from  gout,  rheumatism,  malaria,  and  from  nicotine  and  con- 
stipation, (iv)  Reflex  causes,  from  the  genito-urinary  and  alimentary 
tracts;  for  example,  from  floating  kidney,  intermittent  hydronephrosis, 
splanchnoptosis,  uterine  or  ovarian  disease,  or  masturbation.  Fliess 
holds  that  many  cases  of  both  dysmenorrhoea  and  gastralgia  arise 
from  disease  of  the  lower  nasal  turbinates.  Most  cases  occur  in  women 
between  fifteen  and  forty-five  years  of  age. 

Symptoms. — As  the  term  implies,  the  affection  occurs  with  severe 
gastric  pain  which  begins  suddenly,  often  at  night,  lasts  for  a  few 
minutes  to  an  hour  or  so,  and  subsides  usually  to  recur  after  a  variable 
interval.  The  pain  is  epigastric  and  may  radiate  widely.  It  bears  no 
relation  to  eating,  though  food  sometimes  relieves  it.  Diffuse  super- 
ficial tenderness  or  hypersesthesia  over  the  stomach  is  not  infrequent, 
but  deeper  pressure  usually  affords  some  relief.  Vomiting  is  rather 
uncommon.  Hiccough,  hunger,  headache,  depression, polyuria, clammy 
sweats,  small  rapid  pulse,  or  even  collapse,  may  attend  the  seizure. 

Diagnosis. — A  diagnosis  is  made  only  by  exclusion  and  usually  after 
the  seizure  is  over.  Rheumatic  myalgia  is  more  constant.  A  tabetic 
crisis  is  at  once  recognized  by  the  Argyll-Robertson  pupil,  and  the 
absent  knee-jerks.  Intercostal  neuralgia  gives  Valleix's  three  tender 
points,  which,  however,  are  quite  frequent  in  neurotic  subjects.  In 
ulcer  (q.  v.)  or  circumscribed  peritonitis,  the  pain  is  associated  with 
localized  tenderness.  Hyperacidity  and  hypersecretion  should  be 
excluded.  Biliary  colic  (q.v.)  is  more  diflicult  to  differentiate,  and  it 
is  well  to  remember  that  icterus  is  absent  in  the  majority  of  cases  of 
gall-stones,  but  a  sharp  thrust  over  the  gall-bladder  during  deep  inspir- 
ation nearly  always  elicits  well-localized  tenderness. 

Treatment. — Treatment  is  that  of  (a)  the  etiology,  especially  the 
neurasthenic  condition,  anaemia,  and  constipation.  Fowler's  solution 
TTj^ij  before  meals  is  excellent,  (b)  The  attack  must  be  treated.  Mor- 
phine hypodermatically  affords  the  only  certain  immediate  relief,  but 
in  these  very  cases  may  establish  the  habit.  If  given  at  all,  it  should 
be  given  by  mouth  without  the  patient's  knowledge.  Heat  and  sinap- 
isms may  relieve  or  aggravate  the  attack.  Silver,  carbolic  acid,  or 
gelsemium  employed  in  hypersesthesia  often  give  relief,  as  may  extract 
of  belladonna  h  grain,  cocain  -|  grain,  charged  waters,  chloroform  and 
Hoffmann's  anodyne  aa  rr^xx  to  xxx,  and  galvanization  with  the  anode 
to  the  epigastrium  and  cathode  to  the  spine,  though  the  attack  is  often 
over  before  application  is  possible. 

3.  Disturbances  may  occur  in  the  sense  of  hunger  and  appetite. 
Loss  of  appetite  {anorexia)  may  be  purely  nervous,  though  it  is  more 
commonly  due  to  gastric  affections,  fevers,  tuberculosis,  or  toxins.    As 


648^  DISEASES  OF  THE  DIGESTIVE  TRACT 

described  under  Hysteria,  anorexia  nervosa  may  be  absolute  and  cause 
profound  emaciation,  as  described  in  the  extreme  cases  of  Lasegue, 
Wallet,  and  Brissaud.  Parorexia  is  perversion  of  the  appetite,  in 
which  the  patient  craves  for  unusual  kinds  of  food.  In  polyphagia 
the  appetite  is  enormous,  but  is  capable  of  satiation;  in  boulimia 
(Jiyperorexia)  the  intense  craving  for  large  quantities  of  food  comes 
on  paroxysmally,  sometimes  with  vertigo,  palpitation,  and  other  neu- 
rotic manifestations;  polyphagia  and  boulimia  are  most  frequent  in 
hyperchlorhydria,  hypersecretion,  and  hypermotility,  but  also  occur  in 
diabetes,  focal  brain  disease  or  tumors,  intestinal  parasites,  or  from 
certain  drugs  as  quinine,  orexin,  or  even  opium.  Acoria  is  loss  of  the 
sense  of  satiation.  These  anomalies  are  central  and  probably  result 
from  organic  or  functional  changes  in  the  bulbar  hunger  centre.  The 
treatment  of  the  neurotic  forms  is  that  of  the  causal  neurasthenia  or 
hysteria. 

IV.  Mixed  Neuroses  of  the  Stomach. 

Mixed  neuroses,  dyspepsia  nervosa  (Leube),  neurasthenia  gastrica 
(Ewald),  or  pseudodyspepsia,  is  marked  by  no  stereotyped  symptoms. 
It  may  occur  alone  as  a  species  of  local  neurosis;  it  is  sometimes  reflex 
from  other  organs,  but  is  much  oftener  a  part  of  the  neurasthenic 
symptom-complex.  Leube's  original  contention  that  digestion  itself 
is  normal  must  be  modified,  as  the  hydrochloric  acid  may  be  increased, 
normal,  or  decreased.  In  many  cases  and  perhaps  in  the  majority  the 
gastric  functions  are  nearly  or  quite  normal.  Two  main  groups  of 
symptoms  prevail;  (a)  the  centric,  neurasthenic,  or  hysteric  apathy, 
irritability,  and  vertigo;  (6)  the  gastric  eructations,  variations  in  appe- 
tite, oppression,  and  diffuse  tenderness,  which  are  probably  also  centric 
(cerebral)  in  origin.  The  symptoms  vary  greatly  in  degree,  often 
change  their  form  with  considerable  rapidity,  and  the  general  nutrition 
is  generally  good.  Organic  disease  must  be  carefully  excluded  by 
repeated  examinations  of  the  secretions  and  motility  of  the  stomach, 
for  nervous  dyspepsia  is  too  often  "a  collective  term  to  cover  incorrect 
diagnoses."  The  treatment  is  that  of  the  neurotic  basis;  rest,  regula- 
tion of  worry  and  strain,  self-control,  and  suggestion,  are  important. 


DISEASES  OF  THE  INTESTINES. 

(A).  ACUTE  ENTERITIS. 

It  is  diflScult  to  draw  a  close  distinction  between  acute  catarrhal 
enteritis,  intestinal  dyspepsia,  and  simple  diarrhoea.  Catarrhal  enteritis 
is  the  most  common  intestinal  disease. 


ACUTE  ENTERITIS  649 

Etiology. — 1.  Primary  Forms. — (a)  Errors  in  diet,  and  the  inges- 
tion of  spoiled  food  containing  ptomaines,  unripe  fruit,  and  impure 
water,  are. common  causes,  (b)  Disturbance  in  intestinal  secretion 
may  possibly  occasion  acute  enteritis,  though  little  is  known  of  the 
succus  entericus.  (c)  Cold,  trauma,  foreign  bodies,  particularly  fsecal 
retention,  and  toxins  eliminated  from  the  blood,  may  initiate  inflam- 
mation, (d)  Some  cases  are  infectious,  though  our  knowledge  of  them 
is  still  imperfect.  Bacteria  are  undoubtedly  an  important  factor;  it  is 
stated  that  one-third  of  the  weight  of  the  normal  stool  is  caused  by 
bacteria,  of  which  48  species  are  normally  present ;  acute  inflammation 
may  arise  from  pathogenic  organisms  or  from  virulence  attained  by 
some  inhabitant  of  the  intestine;  the  Bacterium  coli  is  the  most  impor- 
tant, and  Gaertner's  Bacillus  enteridis  is  probably  one  of  its  manifold 
forms.  In  a  milk  diet  the  Bacterium  lactis  aerogenes,  and  in  a  meat  diet 
the  Proteus  vulgaris,  may  be  possible  factors. 

2.  Symptomatic  Forms. — (a)  Enteritis  is  constant  in  some  in- 
fections, from  the  action  of  microorganisms  or  their  toxins,  as  in 
typhoid;  it  is  frequent  in  others,  as  in  sepsis,  or  influenza;  and  rare  in 
others,  as  in  measles,  scarlatina,  rheumatism,  or  malaria,  (h)  General 
diseases,  as  nephritis;  (c)  burns;  {d)  local  intestinal  diseases,  as 
intestinal  parasites,  ulcers,  or  tumors ;  and  (e)  metallic  or  other  poisons 
are  etiological  factors;  (/)  stasis  is  usually  listed  as  a  factor,  but  is 
rarely  by  itself  a  potent  cause. 

Pathology. — The  pathology  is  that  of  other  inflammations  of  the 
mucous  membranes;  viz.,  redness,  swelling,  increased  mucus  secretion, 
parenchymatous  degeneration,  and  some  interstitial  infiltration  with 
leukocytes.  In  the  few  cases  coming  to  autopsy  these  changes  may  not 
be  at  all  conspicuous,  as  they  regress  soon  after  death.  In  some  cases 
follicular  swelling  or  even  ulceration  may  be  observed  as  well  as 
punctate  ecchymoses,  catarrhal  erosions,  or  slight  swelling  of  the 
mesenteric  glands. 

Symptoms. — The  chief  symptom  is  diarrhoea,  due  to  increased 
peristalsis,  increased  secretion,  or  actual  inflammatory  exudation. 
The  stools  number  two  to  fifteen  daily,  contain  more  or  less  mucus,  and 
are  variously  colored;  they  may  be  brown-yellow  with  moderately 
frequent,  or  colorless  and  odorless  with  very  frequent  evacuations; 
their  reaction  is  commonly  alkaline  or  neutral;  they  contair^  triple 
phosphates,  calcium  phosphate,  and  oxalate  crystals,  sometimes 
cholestearin  and  Charcot-Leyden's  crystals,  but  rarely  leukocytes  in 
any  considerable  number.  There  may  be  concomitant  acute  gastritis. 
Thirst,  dryness  of  the  mouth,  colic  pains,  borborygmus,  visible  peris- 
taltic movements,  tympany,  and  slopping  or  gurgling  in  the  intestine, 
are  frequent.  Fever  is  unusual,  though  febrile  forms  with  acute  splenic 
tumor  are  recorded,  which  may  at  first  resemble  typhoid.  Albumin- 
uria, cylindruria,  or  even  acute  nephritis,  may  develop  in  exceptional 
cases;  the  urine  is  scanty  in  proportion  to  the  amount  of  fluid  lost  by 
the  bowel;  indican,  etherial  sulphates,  and  acetone,  may  be  present. 
In  some  few  cases  herpes  or  muscle  and  joint  pains  occur.     Collapse 


650  DISEASES  OF  THE  DIGESTIVE  TRACT 

is  rare  in  adults,  though  cases  occur  which  bear  a  close  resemblance  to 
cholera.  In  the  vast  majority  of  cases  convalescence  is  established  in  a 
few  days. 

Diagnosis. — (a)  Duodenitis  can  seldom,  he  diagnostica^ted;  pain  and 
tenderness  over  the  duodenum  are  of  most  uncertain,  and  catarrhal 
icterus  is  of  somewhat  presumptive  value  in  diagnosis.  (6)  Jejuno- 
ileitis  seldom  exists  alone;  diarrhoea  is  absent  if  the  colon  is  not 
affected;  the  stools  contain  intimately  mixed  mucus,  which  often  appears 
as  small  hyaline  globules  under  the  microscope  (Nothnagel).  (c)  In 
enterocolitis,  the  bile  is  decomposed  below  the  small  intestine;  when  it 
is  present  in  the  stools  it  signifies  increased  peristalsis  which  moves  the 
bile  along  before  it  can  be  disintegrated,  and  indicates  acute  entero- 
colitis; bile  may  be  found  only  in  the  small  globules  of  mucus  and  not 
in  the  fluid  evacuation.  Many  undigested  food  'particles  (lientery)  are 
found,  and  this  is  rather  significant  if  fever,  biliary  or  pancreatic  ob- 
struction, and  gastric  atrophy,  are  excluded;  they  consist  of  undigested 
meat,  starch  granules  (which  are  more  significant  than  muscle  fibers), 
and  fat  particles,  {d)  Colitis  is  characterized  by  the  absence  of  bile  and 
lientery,  by  thin  stools,  and  by  more  or  less  mucus,  which  is  obtained 
especially  on  washing  out  the  bowel  immediately  after  a  movement 
(Boas),  (e)  Proctitis  is  marked  by  much  tenesmus,  dysuria,  evacu- 
ation of  mucus  alone,  and  the  passage  of  bloody  mucus  covering  but  not 
mixed  with  the  solid  stools ;  it  is  also  diagnosticated  by  the  local  exami- 
nation with  the  finger  or  speculum. 

Treatment. — (a)  In  the  early  stage,  evacuation  of  the  causal  irritant 
is  indicated,  to  which  end  fractional  doses  of  calomel  should  be  given, 
followed  by  castor  oil ;  the  stronger  evacuants,  which  may  of  themselves 
irritate  or  inflame  the  intestine,  should  be  avoided.  Colonic  flushings 
with  pure  water,  or  injections  of  olive  oil,  may  be  added.  (6)  Absolute 
rest  in  bed  is  always  indicated,  (c)  The  diet  should  be  restricted  to 
barley  water,  or  no  food  should  be  given  for  a  day  or  two.  {d)  Heat 
should  be  apphed  to  the  abdomen,  (e)  A  dram  each  of  paregoric 
and  bismuth  should  be  given  after  each  bowel  movement  until  their 
number  is  controlled.  A  quarter  of  a  grain  of  extract  of  belladonna 
relieves  colic.  The  following  preparation  is  excellent;  the  amount  for 
a  child  being  given  in  the  first  and  the  amount  for  an  adult  in  the  second 
column : 

Phenylis  salicylatis  (salol)       gr.  xx.  3j. 

Sodii  bicarbonatis 3ss.  3j- 

Cretge  preparatse 3ss.  5iss. 

Bismuthi  subnitratis 3j-  §]• 

M.  et  divide  in  pulveres  X. 
S. — One  powder  in  milk  or  thin  arrowroot  solution  every  three  hours. 

Lack  of  tone  is  reheved  by  gambir  (catechu),  colic  by  belladonna 
and  flatulency  by  ammonia  and  ginger: 


y 

CHRONIC  ENTERITIS  651 

Tmcturse  gambir  compositse .    .  oj- 

Fluidextracti  belladonnae gtt.  xij. 

Spiritus  ammoniae  aromatici oij- 

Tincturse  kino oj- 

Syrupi  zingiberis oss. 

Misturse  cretse q.s.  ad  §iv. 

M.  et  S. — A  tablespoonful  every  two  or  three  hours. 

Other  astringents  and  intestinal  antiseptics,  as  beta-naphthol  gr.  x  p. 
c.  in  capsules,  or  10  to  15  grains  of  tannigen  (a  compound  of  acetic  acid 
and  tannin),  every  two  or  three  hours,  are  seldom  indicated.  (/)  No 
laxatives  should  be  given  for  the  constipation  resulting  from  this  treat- 
ment. {())  Opium  suppositories  (see  Dysentery)  relieve  tenesmus. 
Qi)  The  diet  may  be  increased  in  a  few  days  to  bouillon  with  raw  egg, 
hashed  beef  or  chicken,  toast,  zwieback,  roast  beef,  and  milk  with  equal 
parts  of  carbonated  water;  fruits  and  vegetables  even  when  cooked 
should  be  given  still  later,  and  only  with  extreme  caution,  because 
recurrence  readily  predisposes  to  chronic  enteritis.  {i)  Cramps, 
collapse,  and  other  choleraic  symptoms,  are  treated  as  in  cholera  (q.v.). 


(B).   CHRONIC  ENTERITIS. 

Etiology  and  Pathology. — The  etiology  is  essentially  that  of  acute 
enteritis,  from  repeated  attacks  of  which,  or  of  "acute  indigestion," 
the  chronic  type  may  develop. 

Chronic  enteritis  always  suggests  a  causative  chronic  gastritis,  though 
both  affections  may  result  from  a  common  cause,  particularly  over- 
eating and  drinking.  Chronic  enteritis  may  follow  chronic  gastritis, 
achylia  gastrica,  and  other  gastric  conditions;  or  intestinal  catarrh  may 
cause  anorexia,  eructations,  abdominal  distention,  and  kindred 
symptoms.  Hyperchlorhydria  may  disturb  the  intestines  by  the  escape 
into  them  of  more  acid  than  they  can  neutralize;  on  the  other  hand 
hypo-  or  achlorhydria  readily  initiates  bowel  trouble  because  hydro- 
chloric acid  bears  an  important  relation  to  the  intestinal  and  pancrea- 
tic secretions. 

The  pylorus  remains  closed  until  the  food  in  the  stomach  is  ready  for 
the  intestinal  juices  and  then  it  relaxes;  the  hydrochloric  acid,  reaching 
the  duodenum,  provokes  a  flow  of  bile  (which  arrests  the  action  of  the 
pepsin),  and  the  acid  also  provokes  the  pancreatic  secretion  (which 
neutralizes  the  hydrochloric  acid)  by  acting  upon  the  duodenal  mucosa, 
which  gives  off  a  substance  known  as  "secretin,"  into  the  blood; 
secretin  acting  upon  the  pancreas  causes  it  to  secrete  (Bayliss  and 
Starling).  When  these  ends  are  accomplished,  the  pylorus  again  re- 
laxes. When  the  pancreatic  juice  is  poured  out,  it  contains  no  active 
proteolytic  ferment,  but  in  the  succus  entericus  there  is  an  "activating" 
ferment  (enterokinase)  which  converts  trypsinogen  into  trypsin ;  i.  e.,  the 
intestinal  juice  "activates"  the  trypsinogen  (Pawlow). 


652  DISEASES  OF  THE  DIGESTIVE  TRACT 

The  bile  doubtless  also  increases  the  activity  of  the  pancreatic 
enzymes  or  ferments;  the  action  of  the  fat-splitting  pancreatic  ferment 
is  enlivened  threefold. 

The  pathology  of  chronic  enteritis  is  also  similar  to  that  of  the  acute 
type.  In  color  the  mucous  membranes  is  brownish-red  or  slaty-gray. 
The  mucosa  and  submucosa  are  often  thickened,  and  the  muscularis  is 
sometimes  hypertrophied.  Polypoid  hyperplasia  and  cystic  degeneration 
of  the  intestinal  glands  as  well  as  atrophic  changes  may  result.  Catarrhal 
erosions  and  follicular  ulcers  may  occur  as  described  under  the  last 
type  of  dysentery  (q.v.). 

Sjmiptoms. — Generally  speaking,  constipation  is  more  frequent  than 
diarrhoea;  in  comparatively  few  cases,  a  single  soft  morning  evacua- 
tion is  noted,  or  perhaps  several;  in  others  constipation  is  observed 
most  of  the  time,  broken  occasionally  by  short  attacks  of  colic  and 
diarrhoea;  continuous  diarrhoea  indicates  inflammation  of  both  the 
large  and  small  gut.  Constipation  is  due  to  alteration  of  the  nervous 
fibers  in  the  gut  or  to  inflammation  in  the  muscular  coat.  A  sense  of 
abdominal  tension  or  colic  may  be  present  and  is  distinguished  from 
gastric  discomfort  and  pyloric  spasm  in  that  it  occurs  independently 
of  ingestion  of  food.  Diarrhoea  results  from  decomposition  and  fsecal 
irritation.  There  may  be  pain,  flatulency,  borborygmus,  or  occasion- 
ally tenderness  over  the  bowels,  which  may  occur  together  or  at  inter- 
vals; but  the  sole  diagnostic  criterion  is  the  presence  of  mucus  in  the 
passages;  an  intimate  mixture  with  the  stool  indicates  inflammation 
in  the  small  gut;  a  mere  coating  of  the  passages  with  mucus  indicates 
colitis,  and  evacuations  of  mucopus  alone,  proctitis.  Mucus  may  be 
seen  as  small  sago-like  globules,  which  are  often  vegetable  matter. 
These  globules  when  bile-stained  indicate  inflammation  of  the  small 
gut,  as  do  shreds  of  bile-stained  mucus.  Small  homogeneous  denucle- 
ated  epithelial  cells  may  be  found  in  the  mucus  adhering  to  scybala. 
Pus  cells  are  rare  except  in  proctitis.  The  presence  of  mu^us  is  always 
indicative  of  enteritis  and  never  occurs  from  ulceration  or  carcinoma 
alone  (a  slight  coating  of  mucus  over  hard  faeces  is  not  significant). 
Blood  always  indicates  a  complication,  such  as  piles,  ulceration,  or 
cancer.    The  stools  may  contain  much  undigested  Tneat,  starch,  or  fat. 

Schmidt  and  Strasburger  have  proposed  the  functional  examination 
of  the  f iaeces ;  while  their  method  does  not  give  us  as  exact  information 
as  does  the  examination  of  the  stomach,  valuable  facts  may  be  deter- 
mined. Schmidt's  test  diet  includes  1,500  c.c.  (3  pints)  of  milk,  100  gm. 
(3  ounces)  of  zwieback  or  toast,  two  eggs,  50  gm.  (1.6  ounces)  of 
butter,  125  gm.  (one  quarter  pound)  of  rare  tender  steak,  190  gm.  (6 
ounces)  of  boiled  potatoes,  60  gm.  (2  ounces)  of  oat-meal,  and  20  gm. 
(two-thirds  of  an  ounce)  of  sugar;  this  total  is  variously  distributed 
among  the  three  meals.  With  the  first  meal  a  capsule  of  five  grains  of 
charcoal  or  carmine  is  given,  and  the  first  examination  is  not  made  until 
the  stools  become  colored  black  or  red.  In  this  way  (i)  the  "period  of 
passage"  is  established,  the  normal  time  being  ten  to  twenty  hours, 
(n)  Mucus  is  detected,  microscopically,  by  mixing  a  piece  of  faeces  as 


CHRONIC  ENTERITIS  653 

large  as  a  walnut  with  a  small  amount  of  water;  it  appears  as  trans- 
lucent, sago-like,  and  often  bile-stained  flakes,  which  must  not  be 
confused  with  starch  particles.  (Hi)  Much  connective  tissue,  recog- 
nized by  its  yellow-white  color  and  its  toughness,  indicates  reduction  of 
the  hydrochloric  acid,  (iv)  Muscle  fibers,  appearing  as  reddish 
threads  or  lumps,  may  indicate  achylia  gastrica,  lack  of  trypsin,  lack 
of  the  activating  enterokinase,  or  very  active  peristalsis,  (v)  Free 
starch  granules  always  indicate  intestinal  catarrh;  normally  only 
starch  enveloped  in  cellulose  is  present,  (vi)  The  normal  stool  shows 
hydrobilirubin,  detected  by  mixing  a  small  amount  of  the  fluid  fseces 
with  an  equal  amount  of  a  5  per  cent,  solution  of  bichloride  of  mercury, 
which  mixture  turns  yellow-red  after  twenty-four  hours;  bilirubin, 
recognized  by  a  green  color  in  the  above  test,  always  indicates  catarrh 
of  the  small  bowel  (except  in  young  children),  (vii)  The  fermentation 
test  is  made  by  mixing  a  dram  of  the  faeces  with  sterile  water  in.  a 
bottle  which  is  connected  above  with  a  tube  containing  water;  almost 
no  gas  results  in  normal  cases;  if  the  reaction  becomes  acid  with  a 
pathological  fermentation,  it  is  due  to  carbohydrate  fermentation;  if 
it  becomes  alkaline  and  foul  in  odor,  it  is  due  to  proteid  fermentation. 
(viii)  With  a  little  experience  with  the  amount  of  fat  normally  found 
it  can  be  readily  determined  whether  the  fat  is  pathologically  increased. 

The  appetite  is  usually  good.  The  general  nutrition  is  good  in  some 
cases,  though  in  others,  pallor,  emaciation,  slow  pulse,  and  cold  extrem- 
ities, may  be  noted.  Attacks  of  diarrhoea,  together  with  undigested 
food  in  the  stools,  should  lead  the  physician  to  look  for  achylia  gastrica 
(Einhorn,  Oppler). 

Prognosis. — The  prognosis,  save  in  either  extreme  of  age,  is  good  as 
to  life  itself,  but  is  always  doubtful  at  any  age  as  to  complete  recovery. 
Improvement  is  at  the  best  tardy  and  too  often  transient.  Intestinal 
atrophy  may  develop,  though  this  is  less  frequent  than  in  puerile  forms. 

Treatment. — -(a)  Moderate  exercise  and  an  hygienic  conduct  of  life 
are  most  essential.  A  flannel  band  should  be  worn  over  the  abdo- 
men, (b)  The  diet  must  be  carefully  supervised.  Though  it  is  im- 
possible to  give  here  a  complete  dietary,  salads,  beer,  wine,  fruits  and 
vegetables  of  nearly  every  description,  either  raw  or  cooked,  sweets, 
pickles,  and  acids,  are  among  the  forbidden  foods,  and  the  articles 
which  may  be  given  include  eggs,  fresh  butter,  lean  meats,  stale  bread, 
rusks,  thoroughly  cooked  rice  or  sago,  and  potato  purde;  i.  e.,  simple 
foods,  in  small  amounts  and  at  frequent  intervals,  controlled  by  frequent 
examination  of  the  f  seces.  (c)  Regulation  of  the  bowels  is  necessary.  For 
constipation,  purgatives  should  be  avoided  and  the  bowels  moved  by 
enemata  of  olive  oil.  Constipation  is  often  due  to  the  careful  diet,  which 
does  not  provoke  peristalsis.  For  diarrhoea,  bismuth  in  dram  doses 
and  tannigen  or  tannalbin  (5  to  15  grains)  are  most  efficacious  (see 
Acute  Enteritis).  Calcium  carbonate  and  salicylate  are  recom- 
mended by  Boas  and  Javorski  (aa  5ss  to  a  quart  of  charged  water;  one- 
half  glass  q.  i.  d.).  (d)  Flatulency — Some  flatus  is  not  pathological. 
As  it  results  not  from  fsecal  stagnation  alone,  but  from  stagnation  plus 


654  DISEASES  OF  THE  DIGESTIVE  TRACT 

catarrh  (chiefly  in  the  ileum,  caecum,  and  ascending  colon),  the  first 
indication  is  that  of  the  catarrhal  enteritis;  the  second  is  the  restriction 
of  foods  which  ferment  (v.  s.);  and  the  third  is  the  administration  of 
aromatic  remedies  (see  Therapy  of  Acute  Enteritis). 

Menthol oss. 

Phenylis  salicylatis o  iij  • 

Extract!  belladonnge gr.  iv. 

M.  et  ft.  capsulge  XX. 
S. — One  after  meals. 

(e)  Colitis  may  be  treated  by  medicated  rectal  flushings,  1  to  1,000  or 
2,000  silver  nitrate,  borax,  salicylic  acid,  or  ichthyol.  (See  Treatment 
OF  Dysentery.) 


(C).  ENTERITIS   (COLITIS)    MUCOSA  OR   MEMBRANACEA. 

This  disease  was  first  described  by  Mason  Good  (1825),  though  the 
first  classical  description  was  Da  Costa's  in  1871.  The  name  implies 
that  the  malady  is  an  inflammation,  but  in  reality  most  cases  are  neither 
enteritis  nor  colitis.  Nothnagel  proposed  the  name  colica  miicosa  for 
the  non-inflammatory  variety,  which  is  a  secretory  neurosis. 

Etiology. — (a)  Eighty  to  90  per  cent,  occurs  in  nervous  or  hysterical 
women  between  twenty  and  forty  years  old,  40  per  cent,  of  whom  have 
uterine  troubles;  males  who  are  affected  are  usually  nervous  or  hypo- 
chondriacal; a  few  cases  have  been  seen  in  nervous  children.  (6) 
Nearly  all  cases  suffer  from  years  of  previous  constipation.  Its  pathol- 
ogy is  unknown;  in  some  autopsies  no  anatomical  alteration  is  noted, 
in  others  that  of  enteritis. 

Symptoms. — (a)  Mucus  casts  of  the  bowels,  shreds  or  lumps,  are 
voided  periodically;  the  mucus  may  resemble  a  huge  diphtheritic  cast, 
is  usually  evacuated  in  large  amounts,  which  often  constitutes  the 
entire  bowel  movement,  and  contains  very  few  leukocytes  or  other 
signs  of  inflammation;  it  is  rarely  simulated  by  curds  of  milk.  (6) 
There  is  usually,  but  not  always,  colic  or  pain  and  tenderness  with  the 
attack,  which  frequently  occurs  over  the  splenic  flexure  of  the  colon,  is 
sometimes  diffuse,  and  occasionally  radiates,  as  into  the  leg.  If  the 
mucus  is  firmly  adherent  to  the  bowel  wall  the  pain  is  particularly 
severe,  and  obstruction  of  the  bowels  may  be  simulated  very  closely. 
Tenesmus  in  voiding  the  mucus  is  usual,  as  are  formation  of  gas,  and 
increase  of  the  original  nervous  symptoms,  as  palpitation,  tremor,  or 
vertigo.  There  may  also  be  coincident  diarrhoea,  achylia  gastrica,  and 
a  periodic  sand  formation  (Dieulafoy).  (c)  Constipation,  abdominal 
distention  or  pressure  and  anorexia  exist  between  the  paroxysms, 
which  last  a  day  or  even  a  week,  and  are  separated  by  intervals  of  weeks 
or  months.    It  is  said  that  death  may  occur  during  an  attack. 

Treatment. — Treatment  concerns  (a)  the  jundamental  neurosis. 
As  a  rule,  the  less  the  neurotic  symptoms  are  in  evidence,  the  better 


DUODENAL  PEPTIC   ULCER  655 

are  the  results  of  therapy;  education,  the  rest  cure,  and  other  measures 
outHned  in  the  treatment  of  hysteria  and  neurasthenia  (q.v.),  are  in- 
dicated. (i>)  Constipation  (v.  i.)  is  treated  in  the  usual  way,  and  an 
appropriate  diet  is  essential.  It  has  been  maintained  by  von  Noorden 
that  the  diet  usually  given  in  spastic  constipation  is  not  appropriate; 
he  advises  the  use  of  graham  bread,  leguminous  vegetables,  including 
the  husks,  vegetables  with  much  cellulose — which  seems  to  be  the 
most  important  element — fruits  with  small  seeds  and  thick  skins,  as 
gooseberries,  currants,  or  grapes,  large  amounts  of  cream,  butter  and 
bacon,  and  olive  oil.  Von  Noorden's  results  with  this  diet  are:  79  per 
cent,  cured  (15.8  per  cent,  partially  cured,  50  per  cent,  permanently 
cured,  13  per  cent,  relapsed),  15.8  per  cent,  unknown  result,  and  5.2 
per  cent,  failure.  In  "White's  series  50  per  cent,  recovered,  13  per  cent- 
improved,  and  37  per  cent,  were  not  improved,  (c)  Local  measures 
include  colonic  flushings  with  normal  salt  solution,  or  half  a  pint  of 
olive  oil  left  in  the  rectum  over  night  (Kussmaul).  (d)  Narcotics,  pur- 
gatives,irrigsition  with  alum,  tannin,  and  silver  solutions,  and  operations 
are  distinctly  contra-indicated.  The  morphine  habit  may  be  readily 
contracted ;  if  given  at  all,  morphine  is  exhibited  with  belladonna  as  a 
suppository.  The  patient  in  an  attack  is  kept  in  bed  and  heat  is  applied 
to  the  abdomen. 


(D).   DIPHTHERITIC,  CROUPOUS,  AND  PHLEGMONOUS 
ENTERITIS. 

True  diphtheria,  due  to  the  Klebs-Loeffler  bacillus,  is  very  rarely 
encountered,  and  practically  all  membranous  enteritis  is  diphtheroid; 
it  develops  in  various  acute  infections,  in  uraemia,  and  in  metallic 
poisoning,  and  has  been  described  under  the  third  form  of  dysentery. 

Phlegmonous  or  purulent  enteritis  is  likewise  extremely  rare  and 
chiefly  of  anatomical  interest.  Most  cases  develop  in  the  duodenum. 
The  affection  may  be  primary,  but  more  often  is  secondary  to  intestinal 
ulceration,  carcinoma,  or  intussusception.  Maragliano  described  a 
form  probably  due  to  the  colon  bacillus,  in  which  multiple  purulent 
foci  are  found  in  the  intestinal  wall,  which  frequently  cause  perforation. 

(E).   INTESTINAL  ULCERATION. 
I.  Duodenal  Peptic  Ulcer. 

This  is  almost  identical  in  etiology,  pathology,  and  treatment,  with 
the  peptic  gastric  ulcer. 

Etiology. —  (a)  Gastric  ulcer  is  10  to  40  times  as  frequent  as  duodenal 
ulcer,  whose  frequency  Kinnicutt  estimates  at  i*o  per  cent,  in  30,000 
autopsies.  In  121  duodenal  ulcers  collected  by  Oppenheimer,  gastric 
ulcer  was  present  in  about  6  per  cent.,  and  in  Lebert's  series  of  237 


656  DISEASES  OF  THE  DIGESTIVE  TRACT 

stomach  ulcers,  duodenal  ulcer  was  present  in  about  10  per  cent. 
Moynihan  found  gastric  ulcer  in  about  50  per  cent,  and  Mayo  in  22 
per  cent.  Thirty-one  cases  of  intestinal  ulcer  are  reported  after  gastro- 
enterostomy for  round  ulcer  of  the  stomach  (q.  v.);  ulceration  may  be 
obviated  by  alkalies  after  operation.  (&)  Seventy-nine  percent,  occurs 
in  males  as  a  result  of  alcohol  and  tobacco,  (c)  In  Collin's  series  of 
279  cases,  two-thirds  occurred  between  twenty  and  sixty  years  of  age, 
being  about  equally  frequent  in  each  decade,  (d)  Other  etiological 
factors  are:  (i)  in  extensive  burns  (Curling,  1842)  acute  ulcers  develop 
in  one  to  two  weeks,  rarely  earlier  or  later;  Holmes  found  them  in 
13  per  cent,  of  125  fatal  burns;  their  cause  is  probably  vascular  ob- 
struction, though  the  precise  factors  are  not  yet  established  (fibrin- 
ferment,  toxins  absorbed  from  the  skin,  aggregation  of  blood  plaques), 
(ii)  Nephritis,  which  occurs  in  17  per  cent,  of  the  cases,  is  suggested 
as  a  cause  by  Perry  and  Shaw,  (iii)  It  may  result  from  embolism 
and  thrombosis.  Endocarditis  and  sepsis  occasionally  cause  duodenal 
ulcer.  Thrombosis  of  the  umbilical  and  other  veins  produces  the  cases 
seen  in  the  new-born  (Landau).  It  has  also  followed  trauma,  multiple 
neuritis,  periarteritis  nodosa,  and  foreign  bodies  such  as  gall-stones. 
Pathologically  the  resemblance  to  gastric  ulcer  is  marked  in  all  details. 
It  is  single  in  84  per  cent.,  is  located  in  'the  upper  horizontal  part  in 
87  per  cent,  of  cases,  and  is  almost  always  above  the  papilla. 

Symptoms. — Symptoms  are  absent  in  30  to  60  per  cent.,  at  least 
until  hemorrhage  or  perforation  occurs.  This  clinical  latency  is  ex- 
plained by  absence  of  gastric  hyperacidity,  motor  insufficiency,  and 
peritonitis,  (a)  It  is  generally  stated  that  gastric  symptoms  are  absent 
in  the  great  majority  of  cases.  C.  Graham,  in  an  analysis  of  46  cases 
operated  by  Mayo,  found  stomach  symptoms,  especially  vomiting  and 
gas  formation,  in  about  70  per  cent.  The  appetite  is  usually  good. 
It  is  usually  stated  that  the  hydrochloric  acid  is  not  increased ;  Graham 
found  superacidity  in  about  half  the  cases.  It  must  be  remembered 
that  associated  gastric  ulcer  is  quite  frequent.  The  writer's  views 
regarding  the  value  of  hyperacidity  in  gastric  ulcer  {q.v.)  have  been 
given.  In  one  of  his  cases  of  gastric  ulcer  in  which  there  was  anacidity, 
Murphy  found  at  operation  a  gastric  ulcer  and  also  a  greatly  dilated 
duodenum;  in  the  jejunum  there  was  marked  stenosis  due  to  a  healed 
round  ulcer,  as  shown  by  microscopic  examination.  This  case  is,  as 
far  as  we  know,  quite  unique;  Tobiesen  reports  a  jejunal  ulcer  follow- 
ing burns.  (6)  Pain  often  occurs  three  to  six  hours  after  eating,  and  is 
located  over  the  duodenum,  and  is  sometimes  accompanied  by  tender- 
ness. Both  pain  and  tenderness  may  be  peritonitic.  (c)  Hemorrhage 
from  the  bowels  occurs  in  33  per  cent,  of  cases.  Darras  estimates  it  at 
75  per  cent.  The  stools  are  usually  tarry,  but  are  sometimes  bright 
red  from  copious  bleeding.  "Occult"  hemorrhage  (small  or  micro- 
scopic hemorrhage)  is  even  more  common,  and  is  as  important  as  in 
gastric  ulcer  or  cancer.  Intestinal  hemorrhage  is  often  fatal  from 
erosion  of  the  pancreatico-  or  gastro-duodenal  arteries,  less  often  of 
the  aorta  or  cava.    Hsematemesis  is  infrequent,  though  it  has  been  said 


OTHER  INTESTINAL   ULCERS  657 

to  occur  in  a  quarter  of  the  cases  where  there  is  intestinal  hemorrhage; 
hsematemesis  usually  indicates  duodenal  stenosis,  in  which  the  blood 
passes  more  readily  upward  than  downward.    Constipation  is  frequent. 

Complications  and  Issue. — (i)  Spontaneous  healing  is  infrequent, 
and  the  clinical  course  is  often  long  (five  to  thirty  years),  (ii)  Per- 
foration, total  with  peritonitis,  or  partial  (chronic)  with  gall-bladder  or 
pancreas  symptoms,  is  very  frequent  (50  per  cent.,  Perry  and  Shaw), 
and  is  even  thought  to  be  as  high  as  69  per  cent,  (iii)  Gastric  dilata- 
tion occurs  in  7  per  cent,  and  duodenal  dilatation  in  nearly  2  per  cent. ; 
both  result  from  duodenal  stenosis,  (iv)  Icterus  occurs  in  less  than 
3  per  cent.;    (v)  duodenal  cancer  is  an  infrequent  sequel. 

Diagnosis. — Leube  holds  that  a  certain  differentiation  from  gastric 
ulcer  is  never  possible,  and  one  is  impressed  with  the  frequency  of 
symptoms  of  gastric  ulcer  in  many  reported  cases.  Von  Wyl  holds 
that  differentiation  from  gastric  ulcer  is  possible  in  but  10  per  cent. 
of  cases.  The  other  chief  cause  of  error  is  disease  of  the  gall-bladder. 
As  Graham  states,  "There  will  always  remain  a  certain  proportion 
of  cases  that  will  mislead  the  careful  physician.  Those  cases  of  gall- 
stones in  which  the  stomach  symptoms  of  gas,  distress,  sour  belching 
and  dilatation  predominate,  and  pain  is  only  of  a  dull  character,  will 
usually  be  diagnosticated  as  ulcer;  but  the  duodenal  case,  of  which 
the  chief  symptom  is  the  sudden,  sharp,  intense  pain  of  perforative 
peritonitis,  and  in  which,  with  no  obstruction  or  hyperacidity,  the  other 
stomach  symptoms  are  in  abeyance,  will  be  diagnosticated  cholelithi- 
asis. Both  conditions  are  purely  surgical,  and  the  differentiation  in 
many  cases  must  be  made  on  the  operating  table."  Acute  pancreatitis 
(g.  v.),  intestinal  obstruction,  and  appendicitis,  must  be  considered  in 
the  diagnosis. 

Treatment. — The  treatment  is  that  of  peptic  ulcer  of  the  stomach 
{q.  v.),  including  its  surgical  indications.  The  operative  mortality 
ranges  from  70  to  85  per  cent.  Moynihan  in  52  operations  (1905) 
obtained  these  results:  in  7  perforations,  71  per  cent,  recovered;  in 
22  chronic  ulcers,  95.5  per  cent,  recovered;  in  22  ulcers  associated 
with  gastric  ulcer,  95.5  per  cent,  recovered. 


II.  Other  Intestinal  Ulcers. 

Ulceration  in  acute  infections,  as  typhoid,  dysentery,  anthrax,  and 
diphtheria,  has  been  described.  In  exceptional  cases  ulceration  may 
occur  in  erysipelas,  variola,  and  sepsis.  Chronic  infections  may  cause 
ulcers,  as  syphilitic,  tuberculous,  and  actinomycotic  lesions;  these  are 
considered  under  general  infections.  Very  rare  cases  of  ulceration 
have  been  observed  from  favus  and  mucor,corymbifer.  Inflammatory 
ulcers,  as  the  catarrhal  and  follicular,  usually  occur  in  the  colon ;  they 
may  be  simple  or  (so-called)  dysenteric  (q.v.)  and  may  develop  from 
the  epithelial  layer;  they  are  seen  in  enteritis,  infantile  diarrhoeas, 
and  fevers.     Stercoral  (decubital)  ulcers  develop  from  the  pressure  of 

42 


658  DISEASES  OF  THE  DIGESTIVE  TRACT 

retained  hard  fseces  or  foreign  bodies,  and  occur  in  the  dilated  pouches 
of  the  colon  or  above  an  intestinal  stenosis.  Constitutional  affections 
are  occasionally  causes,  as  leukaemia,  scurvy,  gout,  and  amyloidosis. 
Toxic  ulcers  may  develop  in  uraemia  (q.  v.),  and  in  mercurial  and 
arsenical  poisoning. 

Symptoms. — The  symptoms  are  rarely  distinctive  without  suggestive 
etiological  factors;  most  ulcerations  occur  without  symptoms  or  with 
ambiguous  symptoms,  (a)  i)wr^cga  is  frequent,  particularly  in  ulcer- 
ation of  the  large  gut;  it  is  often  absent  with  lesions  in  the  small  gut 
or  in  the  upper  colon.  Diarrhoea  results  from  decreased  absorption 
and  from  increased  peristalsis,  due  to  exposure  of  the  intestinal  nerves. 
(b)  Blood  in  the  stools  is  mixed  with  them  in  lesions  of  the  small  gut, 
sometimes  covers  them  in  lesions  of  the  large  gut,  and  is  voided  inde- 
pendently of  the  fseces  in  rectal  lesions.  It  is  more  often  dark  and 
tarry,  especially  in  tuberculosis,  than  bright,  except  in  low-situated 
lesions  and  in  some  profuse  typhoid,  dysenteric,  or  duodenal  hemor- 
rhao'es.  It  is  not  common  in  nontoxic  enteritis.  Blood  is  common  in 
other  diseases  than  ulceration,  as  in  cancer,  piles,  stasis,  and  blood 
diseases,  (c)  Pus  is  seen  more  frequently  in  colonic  than  in  ileac 
ulceration;  it  is  common  in  cancer,  proctitis,  and  croupous  enteritis. 
Pure  pus  in  considerable  amounts  is  rather  indicative  of  rupture  of 
extra-intestinal  pockets  into  the  intestine,  as  appendicitic  and  sal- 
pingitic  abscesses,  (d)  The  presence  of  mucus  has  no  special  signifi- 
cance, as  it  indicates  enteritis  only,  which  of  course  may  complicate 
ulceration,  (e)  Shreds  of  tissue  are  very  rare,  save  in  dysentery.  (/) 
Local  sym'ptoms  are  likewise  ambiguous,  as  tenderness,  pain,  and  tym- 
panites, {g)  General  symptoms  depend  on  the  basic  disease;  fever  is 
most  frequent  in  cancerous,  dysenteric,  or  tuberculous  ulcer,  (h) 
Rupture  causes  peritonitic  adhesions,  diffuse  peritonitis,  retroperito- 
neal cellulitis,  or  subphrenic  pneumopyothorax. 

Treatment. — Treatment  is  that  of  enteritis  or  coHtis.  Of  chronic 
ulcerative  colitis  Mehrkorh  has  published  38  cases  in  which  colostomy 
resulted  favorably. 


(F).   INTESTINAL  DISORDERS  IN  INFANTS. 

Etiology. — Classification  of  the  etiological  factors  is  extremely  diffi- 
cult because  of  the  numerous  species  of  bacteria  in  the  intestine  and 
the  impossibility  of  drawing  any  absolute  line  between  chemical  and 
bacterial  factors  and  between  functional  and  organic  changes.  Most 
cases  occur  in  children  between  six  and  eighteen  months  old,  in 
the  summer  months,  July  especially,  and  in  the  poorer  classes.  It 
occurs  largely  in  infants  who  are  7iot  fed  at  the  breast,  and  for  two 
main  reasons;  (a)  cow's  milk  is  prone  to  disturb  digestion  (see 
Treatment),  and  (6)  there  is  a  greater  chance  for  bacterial  infection. 
Bacteria  operate  in  several  ways.  Vaughan  and  Fluegge  have  demon- 
strated that  toxins  may  form  in  milk.    This  factor  is  especially  potent 


INTESTINAL  DISORDERS  IN  INFANTS  659 

when  milk  is  long  in  transit,  particularly  in  hot  weather.  Bacteria 
may  cause  inflammation  of  the  intestines;  the  Bacterium  lactis  a'erogenes 
causes  inflammation  in  the  small  and  the  Bacterium  coli  in  the  large 
intestine;  the  proteus,  pyocyaneus,  pyogenic  cocci,  and,  since  1897, 
Shiga's  Bacillus  dysenteriae,  are  also  factors,  but  their  relative  import- 
ance is  not  yet  clearly  defined.  Escherich,  Booker,  and  Favel  describe 
a  streptococcus  enteritis,  which,  however,  can  hardly  be  considered  as 
a  distinct  type;  Baginsky  considers  the  saprophytes  of  the  intestine 
and  of  cow's  milk  causative,  and  Czerny  holds  that  toxins  may  develop 
in  the  liver.  The  distinction  between  intoxication  and  infection  is 
maintained  with  difficulty;  intoxication  causes  such  symptoms  as 
erythema,  hemorrhagic  diathesis,  anaemia,  nervous  disturbances,  and 
dyspnoea;  and  infection  produces  certain  complications  as  lobular 
pneumonia,  nephritis,  encephalitis,  phlegmon,  arthritis,  purulent 
pleurisy,  and  necroses  in  the  liver.  In  some  institutional  epidemics, 
infection  may  be  carried  from  one  individual  to  another  by  fsecal  con- 
taminations.    Insects  may  also  convey  infection. 

Symptoms. — (1)  The  symptoms  of  the  acute  dyspeptic  or  fermental 
form  cannot  be  sharply  distinguished  from  those  of  the  other  severer 
forms,  though  possibly  caused  by  the  same  microorganisms.  The 
pathological  findings  are  often,  as  in  adult  forms,  remarkably  insignifi- 
cant. The  temperature  usually  rises  suddenly  to  103  or  104  degrees, 
remains  high  for  a  few  days,  and  falls  rather  suddenly.  The  tongue  is 
dry,  the  face  red,  the  pulse  rapid,  and  the  breathing  sometimes  dys- 
pnoeic  (Czerny).  There  is  considerable  restlessness — sometimes  initial 
convulsions — anorexia,  and  vomiting.  The  stools  in  infants  are  nor- 
mally yellow  from  bilirubin,  which  is  not  decomposed,  are  thick,  and 
slightly  acid  in  reaction ;  they  become  greenish  from  bacterial  action  or 
reduction  of  the  bilirubin  into  biliverdin,  react  alkaline  from  albumin- 
ous decomposition  or  acid  from  acid  fermentation,  and  become  thin 
and  offensive;  the  evacuations  become  frequent  (6  to  10  daily).  The 
microscopic  findings  are  those  of  acute  enteritis  in  adults,  as  mucus, 
leukocytes,  triple  phosphates  in  the  alkaline  stools,  or  cholestearin  in 
the  acid  stools;  blood  in  any  quantity  is  uncommon.  Involvement  of 
the  small  intestine  is  attended  by  considerable  formation  of  gas,  some 
cramping,  large  movements,  and  slight  tenderness  and  tenesmus.  In 
severe  cases  the  nervous  symptoms  may  become  conspicuous  and  con- 
siderable emaciation  may  result.  Albuminuria  occurs  in  about  20  per 
cent,  and  in  many  cases  is  attended  by  cylindruria.  The  author  has 
seen  two  cases  of  extensive  oedema  follow  dyspeptic  diarrhoea  without 
albumin  or  casts.  Recovery  is  usual  and  prompt  after  thorough 
intestinal  evacuation,  though  some  few  cases  run  a  subacute  or  chronic 
course. 

2.  Cholera  infantum  occurs  in  the  severest  cases  and  usually  in 
children  already  suffering  from  some  intestinal  disorder.  According 
to  Holt,  it  constitutes  but  2  to  3  per  cent,  of  summer  diarrhoeas.  The 
howel  movements  are  copious,  alkaline,  and  contain  flocculi;  though  at 
first  they  contain  food  and  are  perhaps  offensive,  they  become  watery 


660 


DISEASES  OF  THE  DIGESTIVE  TRACT 


and  odorless.  Both  the  stools  and  the  general  clinical  aspect  resemble 
the  picture  of  cholera  Asiatica  and  cholera  nostras  (q.v.).  Though 
there  is  fever,  the  extremities  are  algid  and  cyanotic,  the  pulse  small, 
the  heart  tones  weak,  and  all  the  symptoms  of  collapse  are  present; 
the  eyes  are  sunken,  and  there  is  the  pinched  pallid  fades  cholerica, 
the  thirst,  and  the  incoercible  vomiting.  The  skin  is  rigid,  as  though 
the  fatty  tissue  had  hardened  (scleroedema  or  sclerema  adiposum),  and 
nephritis  is  almost  invariably  present.  These  symptoms  result  not 
only  from  loss  of  great  quantities  of  fluid  by  purging  and  vomiting, 
but  also  from  intoxication  which  produces  the  convulsions,  irregular 
and  Cheyne-Stokes  breathing,  retraction  of  the  neck,  stupor,  and  other 
symptoms  grouped  by  Marshall  Hall  under  the  term  "  hydrencephalic 
state,"  and  explained  by  him  as  due  to  oedema  of  the  brain  {q.  v.), 
though  better  explained  by  intoxication.  Oestreich  thinks  that  hypo- 
stasis, resulting  from  compression  of  the  lungs  by  the  tympany,  causes 
more  deaths  than  does  the  toxaemia. 

3.  Acute  enterocolitis  (ileocolitis)  may  follow  the  dyspeptic  form  or 
the  various  specific  infections  in  children,  or  may  begin  as  an  inde- 
pendent form.  Pathologically  it  includes  types  which  cannot  be  sepa- 
rated clinically,  as  (a)  simple  enterocolitis,  (6)  follicular  ulceration,  and 
(c)  diphtheroid  enteritis.  The  growing  importance  of  Shiga's  Bacillus 
dysenterise  in  infantile  enterocolitis  is  established  by  the  recent  work 
in  this  country  of  Vedder,  Duval,  Flexner,  Bassett,  Knox,  Park,  Za- 
horsky,  Dunham,  WoUstein, and  Rotch.  In  some  epidemics  the  bacillus 
which  is  found  produces  acid  in  mannit  media,  which  Shiga's  bacillus 
does  not  produce.  In  Rotch's  cases  of  infantile  diarrhoea  the  Bacillus 
dysenterise  was  found  in  16  per  cent.;  it  was  sometimes  found  in  the 
dyspeptic  or  fermental  type,  but  most  often  in  the  ileocolitic  type 
(78  per  cent.).  In  one  collection  of  412  cases  Shiga's  bacillus  was 
found  in  63  per  cent. ;  Geo.  Weaver  never  found  it,  though  the  Flexner- 
Harris  type  occurred  in  25  per  cent.  {v.  Bacillary  Dysentery). 

The  symptoms  rather  closely  resemble  those  of  dysentery  in  the 
adult.  The  stools  are  small,  yellow,  green,  or  brown,  are  very  frequent, 
are  attended  by  tenesmus  and  void  mucus,  blood,  pus,  and  sometimes 
shreds  of  tissue  or  membrane.  Blood  may  be  present  from  congestion 
or  acute  ulceration.  Rotch  tabulates  the  differential  features  as 
follows : 


Acute  Fermental  Diarrhcea. 


Acute  Ileocolitis. 


(a)  Small  intestine,  mostly. 

(b)  10  to  12  discharges;   often  large. 

(c)  No  or  little  blood. 

(d)  Mucus. 

(e)  No  tenesmus. 

(/)  Not  much  abdominal  tenderness  and  pain. 

(g)  No  or  slight  lesions. 

(h)  Temperature  high — 104°  F.  for  one  or  two 
days,  and  then  falling  sharply  by  crisis. 


Large  intestine,  mostly. 

10,  15,  to  50  discharges,  usually  small. 

Blood  and  sometimes  shreds  of  tissue  or  mem- 
brane. 

Mucus. 

Tenesmus. 

Abdominal  tenderness  and  pain. 

Lesions  marked. 

Temperature  may  be  high  at  first  (103°7F.''to 
104°  F.)  but  usually  soon  moderates  (99°Ito 
101°  F.)  and  falls  gradually  by  lysis  to  normal 
after  some  weeks. 


INTESTINAL  DISORDERS  IN  INFANTS  661 

The  severity  of  the  symptoms  varies  greatly;  the  catarrhal  form 
may  cause  mild  symptoms  or  result  in  death,  with  or  without  gastric 
symptoms.  -  The  ulcerative  and  diphtheroid  types  are  less  often  at- 
tended by  vomiting,  but  run  a  fatal  course  of  days  or  weeks. 

4.  Chronic  dyspeptic  disturbances  often  occur  with  gastric  dilata- 
tion. The  onset  is  gradual  or  it  may  directly  follow  the  acute  forms. 
The  stools  are  green  or  gray,  contain  mucus,  gas,  and  sometimes  pus 
and  tissue  shreds.  Food  and  fluid  are  not  absorbed,  or  absorbed  in 
part  only;  undigested  food  particles  and  fatty  stools  are  observed; 
mucus  is  not  common  in  marked  cases  of  intestinal  atrophy.  Vomiting 
is  rather  frequent.  There  is  usually  but  little  general  disturbance,  no 
fever,  and  little  or  no  colic.  The  scales  show  marked  loss  in  weight 
and  in  some  cases  the  emaciation  may  become  extreme  (psediatrophy, 
athrepsia),  the  muscles  becoming  weak,  the  voice  faint,  the  eyes  luster- 
less,  the  face  of  the  "Voltaire  type,"  and  the  abdomen  distended. 
Death  results  from  marasmus  or  intercurrent  infections. 

Preventive  Treatment. — Children  should  if  possible  be  taken  to 
the  country  in  the  hot  months.    Excessive  swaddling  is  to  be  avoided. 

Diet. — (a)  Human  milk  is  superior  to  all  others,  and  if  the  mother 
cannot  nurse  her  child,  a  wet-nurse  should  be  procured  if  possible,  as 
few  cases  of  stomach  and  bowel  disease  occur  in  breast-fed  infants. 
The  wet-nurse  must  be  carefully  examined  for  syphilis  and  tubercu- 
losis. The  milk  from  the  breast  should  spurt  freely  in  several  streams. 
A  weak  child  may  become  dyspeptic  even  at  the  breast,  and  a  fraction 
of  a  grain  of  calomel  and  magnesium  carbonate  give  the  most  rapid 
relief.  Other  children  thrive,  even  when  the  stools  are  green,  for  which 
Heubner  blames  the  digestion  of  the  infant.  Sometimes  colic  and 
dyspepsia  in  the  child  are  due  to  menstruation,  beginning  of  pregnancy, 
excitement,  lack  of  exercise,  or  alcoholic  indulgence  in  the  nurse  or 
mother.  If  a  wet-nurse  cannot  be  obtained,  (6)  cow's  milk  or  some 
prepared  food  must  be  used,  but  most  of  the  latter  are  objectionable 
because  their  carbohydrates  are  not  dextrinized,  as  shown  by  the  iodine 
test.  Cow's  milk  differs  from  human  milk  in  many  details;  its  con- 
tamination is  far  more  likely,  whence  the  importance  of  pure  milk  and 
sterilized  nipples  and  bottles.  Human  milk  contains  about  1  per  cent, 
of  proteids,  4  per  cent,  fats,  and  7  per  cent,  of  milk  sugar,  but  in  cow's 
milk  the  percentages  are  respectively,  about  3.5,  3.5  and  5  per  cent. ; 
in  cow's  milk  the  casein  constitutes  80  per  cent,  of  the  proteids,  which 
are  physically  and  chemically  different  in  mother's  milk;  e.g.,  they 
contain  more  whey  proteid  and  more  of  certain  relatively  uninvesti- 
gated substances,  as  nucleon.  In  cow's  milk  the  ferments  and  fats 
are  different  and  the  mineral  salts,  especially  phosphates,  are  increased 
which,  as  Blauberg  has  shown,  increases  the  difficulty  of  digestion. 
The  first  objection  is  the  high  percentage  of  proteid  (casein),  which 
must  be  predigested,  or  otherwise  the  milk  must  be  diluted.  Simple 
dilution,  however,  necessitates  giving  too  much  water  or  reducing  the 
fat  and  milk-sugar,  fat  being  essential  not  only  as  a  food  but  as  an 
energizer,  and  milk-sugar  being  important  because  the  Bacillus  lactis 


662 


DISEASES  OF  THE  DIGESTIVE  TRACT 


aerogenes,  operating  upon  it,  produces  lactic  acid,  which  is  inimical 
to  pathogenic  bacteria  in  the  bowel.  In  modification  of  milk  or  in 
substitute  feeding,  then,  the  proteid  of  cow's  milk  must  he  reduced,  fat 
added  in  the  form  of  cream,  and  milk-sugar  added  to  attain  the  normal 
percentage.  The  milk  may  be  diluted  with  thin  oatmeal  water,  as  a 
diastase  ferment  is  present  earher  and  in  larger  amounts  than  pre- 
viously admitted,  though  nature  doubtless  has  her  designs  in  with- 
holding carbohydrates  from  mother's  milk.  The  fats  of  Holstein, 
Durham,  Devon,  and  common  breeds,  can  be  better  emulsified  than 
those  of  Jerseys  and  Guernseys,  which  contain  more  volatile  glycerides. 

Theoketical  Basis  for  Feeding  A  Healthy  Infant. 
(According  to  Rotch). 


Fat. 

Sugar. 

Pro- 

teids. 

Proteids  if 
split. 

Amount  at 

each  feeding, 

in — 

b.  0)  ™ 

a 
Sag 

Age. 

1 

•2^-S 

Whej 
pro- 

Case- 

Ounces. 

C.c. 

teids 

inogen. 

!2; 

Premature 

1.00 
1.50 
2.00 
2.50 

4.00 
4.50 
5.00 
5.50 

0.25 
0.25 
0.50 
0.50 

0.2S 
0.5C 
0.5C 
0.5C 

0.25 
0.25 
0.25 
0.25 

i-f 

1 

4-25 
4-25 

30 

45 

2 
2 

24-18 

Premature 

24-18 

At  term 

10 

End  of  second  week  . .  . 

10 

End  of  third  week 

3.00 

6.00 

0.75 

O.ll 

0.25 

2 

60 

2 

9 

End  of  fourth  week 

3.50 

6.50 

1.00 

Q.lt 

0.50 

2i 

75 

2 

8 

End  of  sixth  week 

4.00 

7.00 

1.00 

0.9C 

)       0.60 

3 

90 

2h 

8 

End  of  eighth  week.  . . . 

4.00 

7.00 

1.25 

0.9C 

)       0.75 

3i 

105 

2* 

7 

End  of  twelfth  week.  .  . 

4.00 

7.00 

1.50 

0.9C 

)        1.00 

4 

120 

2i 

7 

End  of  four  months  .  .  . 

4.00 

7.00 

1.50 

0.7. 

)        1.25 

4i 

135 

l^ 

6 

End  of  five  months. .  .  . 

4.00 

7.00 

1.75 

5i 

165 

3 

6 

End  of  six  montlis. . .  .♦. 

4.00 

7.00 

2.00 

6 

180 

3 

6 

End  of  eight  months  . . 

4.00 

7.00 

2.50 

7 

210 

3 

6 

End  of  nine  months  . .  . 

4.00 

7.00 

3.00 

8 

240 

3 

6 

End  of  ten  months  .... 

4.00 

6.00 

3.00 

8 

240 

3 

6 

End  of  eleven  months  . 

4.00 

5.00 

3.00 

10 

300 

3 

5 

End  of  twelve  months  . 

4.00 

4.75 

3.50 

10 

300 

3 

5 

"The  data  given  above  are  simply  a  guide  to  the  rules  for  the  feed- 
ing of  the  average  healthy  baby;  they  are  only  approximate,  and  not 
intended  to  be  followed  in  cases  of  diflficult  feeding  without  due  con- 
sideration to  the  individual  requirements." 

Quite  low  dilutions  should  be  given  at  first,  and  they  should  be  grad- 
ually increased.  Attention  should  be  given  not  only  to  digestion  but 
to  nutrition,  the  proper  estimate  of  which  is  determined  by  regular 
weighing.  Sterilization  of  milk  destroys  certain  ferments,  as  the  rennet 
enzyme,  besides  protective  substances  (Ehrlich). 

Treatment  of  Acute  Dyspepsia. — (a)  The  stomach  should  be 
washed  out,  if  toxic  symptoms  are  at  all  marked  (Heubner);  plain 
water  or  a  1  to  3,000  resorcin  solution  should  be  used.  (6)  Calomel 
gr.  ss  and  magnesium  carbonate  gr.  j  every  three  hours  for  about 
three  doses,  or  one  dose  of  castor  oil  (5ss  to  j)  should  be  administered, 
(c)  The  howel  should  he  flushed  vf\i\iw2iTm.^aXeT;  one  pint  is  sufiicient 
in  children  of  one  year,  or  somewhat  larger  quantities  in  children  two 
years  old.  {d)  Food  should  he  withheld  (Czerny)  for  one  or  two  days, 
and  plenty  of  boiled  water  only  should  be  given.  Albumin  water, 
which  consists  of  the  whites  of  two  eggs  beaten  in  a  pint  of  water, 


INTESTINAL  DISORDERS  IN  INFANTS  663 

may  then  be  given,  and  thin  arrow-root  water,  beef  juice,  and  pepton- 
ized milk,  may  gradually  be  administered  until  the  green  color  of  the 
stools  changes  to  a  normal  yellow-brown,  (e)  Other  medication  is 
usually  superfluous.  Lesage  recommends  that  lactic  acid  be  given  for 
alkaline  green  stools,  5j  of  a  two  percent,  solution  (p.  c).  Resorcin 
^  grain  and  dilute  hydrochloric  acid  nji  v  may  be  given  after  meals. 

Treatment  of  (Dominating)  Enteritis. — If  the  case  is  seen  in  the 
early  stages,  a  calomel  purge  should  be  administered,  and  the  stomach 
washed  out;  and  in  all  cases  feeding  must  be  suspended  as  outlined 
above.  The  child  should  have  plenty  of  boiled  water,  and  cool  appli- 
cations to  the  skin  are  indicated  unless  the  extremities  are  blue  and 
cool.  Tannigen  or  tannalbin  may  be  given  in  relatively  large  doses, 
10  to  15  grains,  several  times  daily,  even  in  the  very  young,  and  may 
often  be  combined  with  minute  doses  of  calomel  (gr.  3*0  )•  As  in  enter- 
itis of  adults,  bismuth  subnitrate  is  given  in  large  doses,  5ss.  Bismuth 
salicylate,  in  doses  of  ^  to  1  grain,  is  also  given.  If  these  are  ineffective, 
opium  (s'o  grain)  may  be  administered  for  several  doses. 

Treatment  of  Cholera  Infantum. — Food  should  be  withheld.  Lav- 
age of  the  stomach  and  bowels  is  ineffective,  unless  it  is  done  in  the 
earliest  stages.  There  are  three  main  indications:  (a)  fluid  must  he 
restored  to  the  tissues;  this  is  possible  only  by  subcutaneous  saline 
transfusions  which  support  the  heart,  fill  the  vessels,  stimulate  the 
kidneys,  and  eliminate  the  toxins;  (6)  cardiac  stimulation,  by  hypo- 
dermics of  strychnine  300  to  s5o  grain,  and  by  camphor  and  local 
heat;  champagne  may  be  given  to  quiet  the  vomiting  and  support 
the  heart;  brandy  and  whiskey  are  given  in  doses  like  those  employed 
in  bronchopneumonia  {q.  v.),  though  Heubner  believes  that  alcohol 
further  injures  the  intestinal  epithelium;  and  (c)  secretion  must  he 
checked  by  administration  of  5  minims  of  paregoric  every  four  hours, 
of  small  enemas  of  starch  and  laudanum  (10  minims),  or,  which  is 
more  effectual,  of  morphine  (too  grain  for  a  child  one  year  old).  In 
the  fortunate  cases  which  rally,  nourishment  can  be  resumed  only 
with  the  greatest  caution.    The  serum  treatment  is  of  uncertain  value. 

The  Treatment  of  (Dominating)  Colitis. — This  is  much  like  that 
of  dysentery,  and  includes  the  measures  above  indicated.  Flushings 
with  normal  salt  solution,  1  per  cent,  tannin  or  1  to  1,000  salicylic 
acid  may  be  employed.    Tannigen  and  bismuth  should  be  given  freely. 

The  Treatment  of  Chronic  Dyspepsia. — Treatment  in  institutional 
cases  begins  with  nursing;  one  wet-nurse  can  nurse  several  children. 
Lavage  of  the  stomach  with  two  to  three  ounces  of  plain  warm  water, 
normal  salt  solution,  or  1  per  cent.  Carlsbad  salts  solution,  increases 
the  functional  activity  of  the  stomach.  The  extract  of  nux  vomica 
stimulates  secretion  (gr.  2^5  or  according  to  the  child's  weight).  The 
food  must  be  given  in  the  smallest  amounts  compatible  with  main- 
tenance of  weight  and  energy. 


664  DISEASES   OF  THE  DIGESTIVE  TRACT 


(G).  APPENDICITIS. 

Definition. — Appendicitis,  the  chief  abdominal  malady,  is  an  inflam- 
mation of  the  vermiform  appendix. 

History. — Fitz  in  1886  drew  attention  to  the  subject,  and  coined  the 
name.  Appendicitis  was  previously  confused  with  typhlitis,  or  inflam- 
mation of  the  caecum;  though  typhlitis  does  exist,  it  is  rare,  and  the 
term  "perityphlitis"  should  be  entirely  discarded.  Our  present 
knowledge  of  appendicitis  is  largely  due  to  the  work  of  American  sur- 
geons, Willard  Parker,  who  first  (1867)  advocated  operation.  Sands, 
Bull,  McBurney,  Keen,  Senn,  Murphy,  Weir,  Morton,  White,  Deaver, 
and  many  others. 

Etiology. — 1.  Predisposing  Factors. — (a)  The  appendix,  being  a 
functionless  vestige  of  the  caecum,  is  inherently  less  resistant.  (6)  Its 
lumen  is  smallest  at  its  coecal  end,  which  favors  retention  of  foreign 
bodies,  promotes  microbic  growth,  and  decreases  or  suspends  drainage 
into  the  bowel,  (c)  The  meso-appendix,  which  conveys  the  blood  to 
the  appendix,  is  shorter  than  the  appendix,  which  therefore  curls ;  the 
blood  supply  is  then  easily  altered  by  appendiceal  oedema  and  infiltra- 
tion, (d)  Foreign  bodies  and  fsecal  concretions  may  produce  erosions 
which  apparently  promote  microbic  access  and  therefore  inflam- 
mation. In  J.  B.  Murphy's  series  of  2,140  cases,  foreign  bodies  were 
found  in  about  20  per  cent,  and  fsecal  concretions  in  38  per  cent.  J.  F. 
Mitchell  found  foreign  bodies  in  7  per  cent,  of  1,400  cases  of  appendi- 
citis, and  Louis  J.  Mitchell  in  1,600  autopsies  found  them  in  about 
1  per  cent.  Foreign  bodies  include  seeds,  capsules,  gall-stones,  pins, 
nails,  shot,  fish-bones,  etc.  (e)  Age — Over  50  per  cent,  of  the  cases 
occur  in  persons  under  twenty  years  of  age,  and  30  per  cent,  in  those 
between  twenty  and  thirty.  It  is  rare  in  infancy,  and  with  advancing 
years  obliteration  and  atrophy  lessen  its  frequency.  (/)  Sex — Males 
constitute  about  80  per  cent,  of  cases;  in  women  it  is  thought  that 
an  extra  blood  supply  from  the  ovary  lessens  the  results  of  infection, 
though  this  supposition  is  disputed,  and  Murphy's  large  series  shows 
but  a  slight  preponderance  in  males,  (g)  Other  factors  are  trauma 
and  severe  exertion,  which  are  causal  in  a  small  number  of  cases; 
exposure,  which  is  a  frequently  alleged  factor;  and  enteritis,  which 
is  seldom  a  conspicuous  prodrome,  whence  errors  in  diet  are  of  no 
etiological  importance. 

2.  Bacteriology. — The  colon  bacillus  is  the  most  frequent  cause, 
and  is  found  in  80  per  cent,  of  cases,  though  probably  in  some  of  them 
it  has  overgrown  some  other  causal  organism.  Next  is  the  staphylo- 
coccus, the  virulent  streptococcus,  then  the  pneumococcus,  proteus, 
and  pyocyaneus.  Less  frequently  the  typhoid,  tubercle,  infiuenza,  or 
actinomycosis  organisms  are  found;  Fitz  found  5  typhoid  perforations 
of  the  appendix,  and  Fenwick  in  a  collection  of  2,000  cases  of  phthisis 
recorded  56  per  cent,  of  tuberculous  ulcerations  in  the  bowel,  of  which 
but  0.8  per  cent,  were  in  the  appendix. 


APPENDICITIS  665 

Sjrmptomatology  and  Pathology. — 1.  The  Early  Clinical  Course. — 
The  onset  is  precipitate,  is  without  prodromes  in  most  cases,  and  is 
characterized  by  the  four  main  symptoms  upon  the  sequence  of  which 
Murphy  has  placed  especial  stress,  (a)  Sudden  severe  abdominal  pain, 
the  intensity  of  which  ranges  between  colic  and  agony,  is  nearly  always 
due  to  acute  retention  within  the  appendix  caused  by  the  occlusion  of 
the  csecal  end,  and  resembles  the  pain  of  retention  in  acute  otitis  media. 
It  is  felt  over  the  right  lower  abdominal  quadrant  or  over  the  pit  of  the 
stomach,  and  may  even  radiate  along  the  genitocrural  nerve  to  the 
testis,  which  is  sometimes  retracted.  Reaching  its  greatest  severity  in 
a  few  hours,  the  pain  persists  until  the  pressure  of  the  pus  is  relieved, 
which  is  accomplished  by  drainage  into  the  bowel,  perforation,  or 
gangrene.  Sudden  relief  from  pain  is  most  ominous,  as  it  often  indi- 
cates gangrene.  (6)  Nausea  and  vomiting  result  reflexly  from  occlu- 
sion and  follow  within  a  few  hours  after  the  pain,  (c)  Abdominal 
tenderness  soon  develops,  is  rather  general  at  first,  and  is  often  associated 
with  a  cutaneous  hypersesthesia  (Sherrin),  which  covers  like  half  a 
girdle  the  right  lower  abdomen  from  the  spine  to  the  mid-line.  The 
right  rectus  muscle  resists  palpation.  A  little  later  the  general  tender- 
ness disappears,  leaving  well-localized  tenderness  over  the  appendix; 
this  point  is  almost  always  in  the  right  lower  quadrant  of  the  abdomen, 
at  McBurney's  point  (about  two  inches  from  the  anterior  superior  iliac 
spine  in  a  line  drawn  between  it  and  the  navel),  or  a  little  below  it  in 
adults  or  above  it  in  children;  less  frequently  the  tender  point  may 
be  found  in  the  loin,  in  the  pelvis  (5  per  cent.),  near  the  bladder, 
rectum,  or  uterus  on  rectal  or  vaginal  examination,  near  the  gall- 
bladder, or  very  exceptionally  on  the  left  side  of  the  abdomen,  or  in 
hernial  sacs,  all  of  which  correspond  to  possible  variations  in  appendic- 
ular location.  Pressure  with  the  hand  on  the  left  half  of  the  abdomen 
causes  pain  in  the  right  side  when  the  pressure  is  relieved.  Palpation 
must  be  made  gently,  lest  rupture  occur.  In  the  early  stage  of 
appendicitis  it  sometimes  seems  as  though  a  tumor  could  be  felt, 
though  it  is  usually  only  the  contraction  of  the  abdominal  muscle. 
{d)  Fever  is  almost  invariably  present  in  the  early  stage  of  acute  forms, 
and  develops  in  a  few  hours  to  a  day,  according  to  the  severity  of  the 
infection.  An  initial  chill  is  rare.  The  temperature  rises  to  101°-102° 
and  even  higher  in  some  virulent  types  or  in  children.  It  signifies 
septic  absorption,  and  may  cease  suddenly  in  gangrene  or  gradually 
in  rupture,  and  may  slowly  recur  from  extension.  It  does  not  signify 
cessation  or  absence  of  pus  formation,  as  abscess  or  peritonitis  may 
co-exist  with  low  temperature.  There  may  be  other  early  symptoms. 
The  pulse  usually  follows  the  temperature  curve,  though  the  author 
has  seen  it  remain  normal  in  cases  of  extensive  early  gangrene.  The 
leukocyte  count  runs  parallel  with  the  fever,  and  often — though  not 
always — measures  the  sepsis;  leukocytosis  may  amount  to  12,000, 
25,000,  or  even  50,000,  but  no  confident  reliance  can  be  placed  on  its 
absence  as  an  assuring  sign  nor  on  its  presence  as  an  indication  for 
operation.     Constipation  is  present  in  most  cases.    The  urine  is  often 


666 


DISEASES  OF  THE  DIGESTIVE   TRACT 


febrile,  scanty,  and  usually  contains  indican  and  sometimes  albumin; 
dysuria  may  result  from  appendicitis  in  the  pelvis.  Profuse  bowel 
hemorrhage  has  been  recorded.  In  Dieulafoy's  toxsemic  type  toxaemia 
may  obscure  the  local  symptoms. 

2.  The  Later  Clinical  Course. —  (a)  The  inflammation  subsides 
gradually  by  drainage  into  the  caecum.  Though  the  inflammation  may 
be  very  circumscribed,  the  appendix  rarely  returns  to  a  completely 


Fig.  37. 


Fig.  41. 


Fig.  43. 


Fig.  40. 


Figs.  37  and  38.  Obliterating  appendicitis.  Fig.  39.  Obliterating  appendicitis,  with  distal  enlarge- 
ment. Fig.  40.  Obliterating  appendicitis  (at  R)  with  calculi  (C).  Fig.  41.  Appendicitis  with 
bending,  obliteration  and  distal  distention.  Fig.  42.  Appendicitis  with  curling  around  its 
mesentery.    Fig.  43.  Strangulation  by  a  band.     Fig.  44.  Calculous  obstruction.      (Dieulafoy.) 


normal  condition;  it  suffers  necrosis  and  ulceration  from  microbes, 
from  feecal  concretions,  or  both,  which  leave  the  appendix  infiltrated, 
thickened,  rigid  and  more  or  less  constricted  at  one  or  more  points. 
The  mucous  membrane  may  be  wholly  substituted  by  granulation 


APPENDICITIS  667 

tissue.  Sometimes  the  lumen  is  entirely  obliterated  (appendicitis 
obliterans).  Occlusion  at  its  intestinal  end  causes  a  cyst-like  swelling 
as  large  as,  the  thuml)  or  even  as  a  sausage.  Adhesions  to  the  abdom- 
inal wall  and  gut  are  common.  (&)  After  a  few  days  a  localized  peri- 
tonitic  abscess  very  frequently  forms,  usually  over  the  psoas  muscle 
at  the  angle  between  the  ileum  and  caecum,  but  occasionally  over  the 
unusual  localization  of  the  appendix  {v.s.  under  Pain).  The  appendix 
perforates,  generally  near  its  middle  point  at  the  mesenteric  attach- 
ment, from  necrosis  or  gangrene,  and  a  localized  abscess  of  yellow, 
thick,  offensive  pus  forms;  when  the  abscess  is  well  demarked,  the 
pain,  fever,  and  pulse  rate  decrease.  A  well-defined  tumor  may  develop, 
over  which  no  peristalsis  occurs;  dulness  or  tympany  are  elicited 
according  to  the  depth  of  the  tumor  or  its  fluid  or  gaseous  contents; 
fluctuation  is  present  only  in  very  large  abscesses;  the  tumor  in 
infections  due  to  the  colon  bacillus  consists  more  largely  of  infiltration 
than  of  pus.  In  the  incised  abscess  the  green  or  black  and  totally 
gangrenous  appendix  may  be  seen,  or  it  may  be  difficult  to  find.  The 
abscess  may  form  without  any  symptoms  other  than  those  of  the  onset. 
The  result  of  the  abscess  may  vary  greatly :  (i)  it  may  rupture  into  the 
intestine  which  forms  its  wall  (2  per  cent.),  and  may  possibly  carry 
the  appendix  with  it;  (ii)  it  may  rupture  into  the  urinary  tract,  of 
which  cases  nearly  one-half  are  fatal;  (iii)  it  may  cause  thrombo- 
phlebitis purulenta,  and  any  or  all  of  the  manifestations  of  septico- 
pysemia  may  follow,  as  secondary  fever,  suppurative  pylephlebitis, 
liver  abscess,  subphrenic  abscess,  and  vomiting  of  blood;  (iv)  it  may 
rupture  into  the  retroperitoneal  tissue,  which  is  followed  by  high 
temperature;  and  all  possible  extensions  may  occur,  as  into  the  groin, 
the  scrotum  with  external  rupture,  the  pelvis,  the  pararenal  tissue,  the 
pleura  (84  per  cent,  are  right-sided),  the  lung,  gluteal  region,  back, 
hip  joint,  etc.;  and  (v)  it  may  rupture  into  the  free  peritoneal  cavity, 
(c)  The  third  cardinal  issue  is  diffuse  septic  peritonitis,  which  is  recog- 
nized by  all  its  unfortunate  and  unmistakable  symptoms;  these  are 
a  sudden  fall  of  temperature  followed  by  a  secondary  fever,  diffuse 
replacing  localized  tenderness  and  rigidity,  sudden  hyperleukocytosis, 
persistent  projectile  vomiting,  rapid  pulse,  Hippocratic  facies,  and 
collapse  from  profound  intoxication.  It  most  often  follows  the  local- 
ized abscess,  but  may  occur  directly  after  a  gangrene  which  is  so 
sudden  as  to  allow  of  no  protective  adhesions,  or  after  perforation 
from  a  foreign  body  in  the  appendix  without  infection;  the  latter 
occurs  in  about  1  per  cent,  of  cases,  according  to  Murphy.  This 
writer  distinguishes  variations  due  to  the  type  of  infecting  organism: 
(i)  The  staphylococcic  peritonitis  which  produces  generally  but  little 
pus,  or,  if  any,  a  seropurulent  fluid;  it  forms  a  plastic  lymph  which 
prevents  absorption  for  a  short  time,  but,  as  the  peritoneum  becomes 
abraded,  leads  to  intoxication;  this  is  evidenced  by  collapse,  an 
anxious  expression,  and  by  diarrhoea,  (ii)  The  streptococcic  form, 
which  produces  no  pus,  but  causes  a  granular,  blistered,  dry  peritonitis, 
which  is  quickly  followed  by  rapid  pulse,  talkative  delirium,  and  tym- 


668  DISEASES  OF  THE  DIGESTIVE  TRACT 

pany.  (iii)  Colon  infection,  which  produces  an  abundant,  creamy, 
thick,  offensive  pus,  and  slowly  causes  death  after  great  depression, 
low,  muttering  delirium,  somnolence,  and  low  arterial  pressure. 

3.  The  More  Remote  Sequences. — Intestinal  strangulation  hy  adhe- 
sions, deformity,  and  traction  from  chronic  changes  in  the  appendix, 
and  intractable  intestinal,  neurasthenic,  and  nutritional  disturbances, 
may  result  from  chronic  appendicitis. 

In  children  the  onset  is  usually  very  abrupt;  the  vomiting  is  repeated, 
the  pain  is  greater,  the  appendix  is  more  often  palpable,  diarrhoea  is. 
more  common,  and  the  percentage  is  greater  (than  in  adults)  of  diffuse 
peritonitis,  probably  because  the  omentum  is  less  able  to  envelop  the 
appendix.  In  aged  persons  gangrene  is  more  frequent  than  it  is  in 
youth  or  middle  life. 

Diagnosis. — The  diagnosis  depends  on  the  four  cardinal  symptoms 
of  onset,  in  the  sequence  named;  viz.,  pain,  nausea  or  vomiting, 
abdominal  tenderness,  and  temperature  (Murphy),  followed  by  leu- 
kocytosis and  the  other  secondary  manifestations,  and  by  the  develop- 
ments of  the  later  course,  as  circumscribed  abscess  or  diffuse  peritonitis. 
If  all  these  symptoms  are  considered  separately,  an  analysis  is  necessary 
of  every  abdominal  lesion  causing  pain  alone,  vomiting  alone,  tem- 
perature, sensitiveness,  abscess,  tumor,  disease  in  the  right  lower  abdom- 
inal quadrangle,  perforation,  or  peritonitis.  ^Vhile  the  existence  of  an 
acute  typhlitis  cannot  be  questioned,  it  is  very  rare  and  should  seldom 
receive  any  consideration. 

Pain  occurs  in  gall-stones,  renal  calculi,  tabetic  crises,  internal 
incarcerated  hernias,  epigastric  hernia,  intussusception,  gastric  or 
duodenal  ulcer,  tuberculous  peritonitis,  stone  or  torsion  of  the  ureter 
(Dietl's  crisis  in  floating  kidney),  uremia,  colica  mucosa,  acute  pan- 
creatitis, the  crises  of  angioneurotic  oedema,  pelvic  peritonitis,  rupture 
of  extra-uterine  pregnancy,  twisted  pedicles  (ovarian  tumors),  pyosal- 
pinx,  dysmenorrhoea,  and  the  reflected  pain  of  vertebral  disease, 
pleurisy,  and  pneumonia.  Fever  in  typhoid  precedes  the  local  symp- 
toms. These  affections,  as  well  as  gravitating  abscesses,  infected 
urachus,  lesions  of  the  abdominal  wall,  cancer,  hysteria,  and  hypo- 
chondriacal fear  of  appendicitis,  are  almost  invariably  excluded  by 
regarding  the  sequence  of  symptoms  and  by  a  careful  general  exami- 
nation. In  appendicitis  larvata  (Ewald),  pain  is  slight  or  absent, 
and  there  may  be  diarrhoea;  the  thickened  sensitive  appendix  is  often 
palpable. 

Exploratory  puncture  is  absolutely  contra-indicated. 

Prognosis. — The  prognosis  is  most  uncertain,  because  (a)  there  is  no 
safe  criterion  for  early  diagnosis  of  the  type;  (6)  the  symptoms  and 
signs  are  not  proportionate  to  the  actual  lesions — e.  g.,  light  cases  clini- 
cally may  prove  to  be  the  most  severe  anatomically;  (c)  apparent 
improvement  to  the  experienced  observer  is  often  only  the  onset  of 
alarming  complications,  which  are  in  reality  less  complications  than 
essential  parts  of  the  disease;  Dieulafoy  well  calls  them  "treacherous 
lulls"  (accalmies  traitresses);    (d)  though  appendicitis  often  subsides 


APPENDICITIS  669 

clinically,  recovery  is  seldom  complete  anatomically,  whence  recurrence 
(chronic,  relapsing,  or  residual  appendicitis)  often  occurs  in  a  more 
severe  form  in  24  per  cent.  (Hawkins)  to  44  per  cent,  of  cases  (Fitz). 
Treatment. — Cases  of  appendicitis  may  recover,  temporarily  (70  to 
80  per  cent,  or  perhaps  more),  but  it  is  impossible  to  predict  which  ones 
will  do  so.  Personal  prejudice  was  formerly  against  early,  frequent,  or 
universal  operative  treatment  as  advocated  by  many,  as  Deaver, 
Murphy,  Holmes,  and  others.  After  testing  and  seeing  tested  the  so- 
called  medical  treatment,  consisting  of  rest,  starvation,  laxatives,  and 
other  placebos,  and  seeing  gangrene,  peritonitis  with  low  temperature, 
and  even  death,  occur  in  "mild"  cases,  the  conviction  is  inevitable  that 
appendicitis  is  always  surgical,  regardless  of  type,  time,  or  tendencies, 
and  a  surgeon  should  at  once  be  associated  with  the  internist  or  prac- 
titioner in  every  case.  Medical  treatment  is  out  of  date  and  recovery 
under  it  is  due  to  good  fortune  alone.  The  so-called  indications  for 
operation  are  too  often  signs  of  irreparable  damage.  Of  course  the 
results  of  operation  depend  upon  the  experience  of  the  operator. 
Though  this  is  not  the  place  for  discussion  of  technique,  or  of  the 
indication  for  simple  drainage  or  appendicectomy,  the  following  points 
may  be  given :  (a)  Early  operation  within  one  to  two  days  of  onset  is 
attended  by  the  least  danger.  (6)  Many  operators  dislike  to  operate 
between  the  second  and  eighth  days  or  other  arbitrary  limits,  but  this 
position  implies  that  the  clinician  can  diagnosticate  the  anatomical 
changes  which  are  present;  gangrene,  thrombophlebitis,  imminent 
rupture,  etc.,  cannot  be  excluded;  in  this  period  simple  drainage  is 
indicated — possibly,  too,  appendicectomy,  if  the  appendix  obtrudes  in 
the  field  of  incision;  lavage,  exploration,  and  protracted  operation,  are 
dangerous,  (c)  In  later  cases,  when  there  is  apparent  regression,  treat- 
ment may  be  more  conservative;  complete  demarkation  may  be  waited 
for,  but  even  in  such  cases  thrombophlebitis  or  rupture  into  the  general 
peritoneum  may  intervene,  (d)  In  cases  of  diffuse  peritonitis  incision 
and  simple  drainage  are  indicated  unless  the  patient  is  moribund.  The 
patient  is  placed  in  the  semi-sitting  posture  (Fowler)  and  given  frequent 
or  constant  normal  salt  enemas  (Murphy).  Many  cases  recover  (see 
Peritonitis),  (e)  After  the  attack — Murphy's  reasons  for  operation 
are:  "First,  after  an  attack  of  appendicitis,  the  patient  is  prone  to 
recurrence;  second,  upward  of  60  per  cent,  of  the  cases  operated  on 
by  me  in  the  intermediate  stage  had  had  more  than  one  attack;  third, 
in  the  large  proportion  of  the  cases  in  which  there  was  only  incision 
and  drainage  of  the  abscess  (which  was  a  procedure  frequently  recorded 
by  me  in  my  first  three  hundred  cases)  the  attacks  recurred  (in  one 
patient  I  drained  a  peri-appendical  abscess  on  three  different  occasions, 
always  with  severe  sepsis,  before  I  succeeded  in  inducing  the  patient  to 
come  in  between  attacks  to  have  the  appendix  removed) ;  fourth,  the 
pathological  changes,  such  as  adhesions,  flexions,  and  stenosis,  follow- 
ing a  primary  attack,  very  much  favor  a  recurrence;  fifth,  even  if  there 
were  no  danger  of  recurrence  of  the  inflammatory  conditions,  the  adhe- 
sions, fixations,  stenoses,  flexions,   and  retentions  in   the  appendix, 


670  DISEASES  OF  THE  DIGESTIVE  TRACT 

produce  sufScfent  disturbance  of  the  digestive  tract  to  necessitate  an 
operation  for  their  prevention;  sixth,  recurrent  infections  are  practically 
as  dangerous  as  primary  attacks  (one  patient  died  in  the  seventh  attack) ; 
seventh,  the  appendix  can  be  removed  without  danger."  Dennis  states 
that  under  medical  treatment  the  mortality  is  16  per  cent.,  relapses 
occur  in  30  percent.,  and  diffuse  peritonitis  causes  100  percent.,  mortal- 
ity; under  surgical  treatment  4  per  cent,  die,  there  are  no  relapses,  and 
30  per  cent,  of  cases  of  peritonitis  recover. 


(H).  INTESTINAL  OBSTRUCTION. 

Etiology. — Obstruction  of  the  bowels  may  be  due:  (i)  to  intus- 
susception, the  most  frequent  cause,  which  is  due  to  invagination  of  one 
part  of  the  bowel  into  another;  (ii)  to  strangulation,  which  ranks  next; 
(iii)  to  twists  (volvulus)  and  knots;  (iv)  to  strictures;  (v)  to  tumors; 
(vi)  to  foreign  bodies;  (vii)  to  dynamic  (paralytic  and  spastic) 
obstruction.  The  figures  quoted  below  are  from  Fitz's  series  of  295 
cases,  Leicht  en  stern's  1,134  cases  and  Treves'  series. 


I.  Intussusception.     (Invagination.) 

This  is  the  most  frequent  form  (30  to  40  per  cent.)  of  acute  obstruc- 
tion. The  external  part  (the  intussuscipiens  or  vagina)  receives  into  it 
the  intestine  just  above  (the  intussusceptum  or  invaginatum).  The 
actual  cause  is  unknown;  it  develops  in  perfect  health,  in  various  acute 
and  chronic  affections,  in  tumors  and  strictures  of  the  gut,  in  diarrhoea 
and  other  functional  and  intestinal  disorders,  and  in  contusion.  Two 
theories  are  advanced:  (a)  that  the  gut  is  spastically  contracted 
(Nothnagel)  and  therefore  enters  the  gut  below,  and  (6)  that  the  gut 
below  is  paretic  (Leichtenstern).  The  author  saw  a  marked  case  in 
lead-colic,  which  recovered  under  operation  by  Van  Hook.  In  acute 
intussusception  50  per  cent,  occurs  under  ten  years  of  age  (Leichten- 
stern and  Fitz) ;  Wiggin  in  103  cases  found  50  per  cent,  in  the  fourth, 
fifth,  and  sixth  month  of  life.  In  chronic  intussusception  50  per  cent, 
occurs  in  persons  between  twenty  and  forty  years  of  age;  66  per  cent, 
occurs  in  males.  Pathologically  only  the  vital  or  inflammatory  form 
is  of  clinical  importance,  in  which  the  mesentery  and  its  vessels  are  also 
invaginated;  the  "agonal"  form  occurs  during  the  death  agony, 
chiefly  in  children,  in  the  small  gut,  is  often  multiple,  and  does  not 
involve  the  mesentery.  The  vital  form  is  usually  single,  descending 
(in  99  per  cent.),  and  complete;  incomplete  forms  may  result  from 
polyps  or  other  tumors,  usually  benign,  which  drag  down  the  gut. 
There  are  three  main  forms :  (a)  the  enteric,  the  small  gut  invaginating 
into  the  small  gut,  30  per  cent. ;  (6)  the  ileocaecal,  the  small  gut  enter- 
ing the  large  gut,  52  per  cent.  Leichtenstern  (75  per  cent.  Fitz  and  89 
per  cent.  Wiggin);  and  (c)  the  colonic,  the  large  gut  invaginating  into 


STRANGULATION  671 

the  large  gut  (18  per  cent.),  which  includes  the  colon  invaginating  into 
the  rectum;  in  rare  cases  a  Meckel's  diverticulum  may  invaginate  into 
the  small  ^ut. 

Sjnnptoms. — (a)  There  is  sudden,  severe,  re-jiex  'pain,  which  is 
usually  umbilical  in  children  but  sometimes  occurs  elsewhere  in  adults, 
is  continuous  or  intermittent,  or  paroxysmal  in  chronic  forms  of  intus- 
susception. (6)  Early  ref,ex  vomiting  may  occur  in  children,  though 
in  adults  it  is  less  frequent  than  in  other  forms  of  obstruction ;  the  later 
vomiting  is  seldom  fsecal  (13  per  cent.,  Fitz);  vomiting  is  more  marked 
in  high  than  in  low  invagination  and  depends  considerably  on  the 
degree  of  mesenteric  invagination  and  its  necessary  vascular  dis- 
turbance, (c)  The  stools  are  characteristic,  showing  blood  and  mucus 
in  80  per  cent,  of  acute  and  in  50  per  cent,  of  chronic  cases;  in  108 
cases  collected  by  Hare  and  Martin,  blood  was  present  in  the  stools  in 
104 ;  the  movements  may  not  stop  at  once  but  only  after  several  evacu- 
ations. Their  evacuation  is  attended  by  severe  tenesmus  (50  per  cent.), 
especially  in  the  young,  {d)  A  saiLsage-  or  egg-like  movable  firm  tumor 
(50  per  cent.  Leichtenstern,  61  per  cent.  Fitz)  may  be  palpated,  most 
often  over  the  ascending  or  transverse  colon,  sometimes  by  the  rectum 
or  vagina,  and  is  occasionally  visible  at  the  anus,  where  it  has  been 
mistaken  for  prolapse  or  polyp  and  has  been  extirpated.  It  is  most 
common  in  children,  and  in  the  ileocsecal  form.  According  to  Treves 
it  is  nearly  always  to  be  felt  during  paroxysms  of  pain,  (e)  Meteorism 
and  a  depression  in  the  right  flank  or  ileocaecal  region  are  infrequent. 

Issues, — Peritonitis  results  in  50  per  cent,  of  acute  and  nearly  100 
per  cent,  of  chronic  cases;  perforation  occurs  in  chronic  (15  per  cent.) 
more  often  than  in  acute  cases;  sloughing  off  of  the  gangrenous  bowel 
occurs  in  42  per  cent,  of  adult  cases,  and  seldom  in  children ;  in  Cruveil- 
hier's  case  three  yards  of  dead  gut  were  discharged.  Spontaneous 
reposition  and  fistula  are  very  uncommon. 


II.  Strangulation. 

This  causes  35  to  38  per  cent,  of  intestinal  obstructions.  Its  mech- 
anisms are  innumerable;  it  is  generally  due  to  bands,  or  isolated 
peritonitic  adhesions;  Meckel's  diverticulum,  the  remains  of  the 
omphalomesenteric  duct,  which  lies  within  a  yard  of  the  ileocsecal 
valve  and  is  sometimes  continuous  as  a  cord  to  the  navel,  has  caused 
strangulation  in  183  cases  (Hilgenreiner,  1902);  adhesions  from  pre- 
vious peritonitis,  appendicitis,  or  salpingitis;  omental  strands  forming 
bands  under  which  the  gut  is  caught ;  holding  of  the  gut  in  abnormal 
positions;  and  binding  of  coils  to  each  other.  Incarceration  may  occur 
when  there  are  congenital  or  acquired  orifices  and  clefts  in  the  omentum 
or  mesentery  or  under  the  suspensory  ligament  of  the  liver,  ligamentum 
teres,  or  ligamentum  latum  uteri.  Hernias  include  strangulations  in 
the  more  common  locations  (femoral,  inguinal,  umbilical),  or  in  the  less 
frequent  types  as  the  obturator,  sciatic,  lumbar,  intersigmoid,  retrocse- 


672  DISEASES  OF  THE  DIGESTIVE  TRACT 

cal  (Rieux),  foramen  of  Winslow,  duodenojejunal  (Treitz's  retro- 
peritoneal form),  or  diaphragmatic.  Seventy  per  cent,  of  cases  occurs 
in  males,  40  per  cent,  between  fifteen  and  thirty  years  of  age,  90  per 
cent,  in  the  small  intestine,  67  per  cent,  in  the  right  iliac  fossa,  and 
83  per  cent,  in  the  lower  abdomen  (Fitz). 

Symptoms. — The  symptoms  are  usually  acute  and  urgent,  (a) 
Early  reflex  vomiting,  from  shock,  voiding  in  succession  the  gastric 
contents,  bile,  and  fsecal  matter  which  usually  consists  of  yellow, 
brown,  or  black  fluid  or  very  rarely  solid  faeces,  is  strongly  indicative  of 
organic  strangulation;  vomiting  usually  lasts  from  the  beginning  to 
the  end  of  the  disease;  retching  results  from  nervous  reflex  irritation. 
(6)  There  is  early  severe  reflex  pain,  which  is  greatest  at  the  navel  and 
lasts  until  collapse,  peritonitis,  or  paralysis  of  the  gut  develops,  (c) 
Collapse,  with  Hippocratic  expression,  weak  pulse,  and  hurried 
breathing,  which  resembles  the  condition  in  cholera,  results  reflexly 
and  may  occur  early  from  the  disturbed  local  circulation  in  the  gut,  or 
later  from  peritonitis,  (d)  Complete  sudden  stoppage  of  the  bowels  may 
result  in  which  no  faeces  nor  flatus  can  pass;  some  faeces  from  the  lower 
gut  may  pass  after  enemata,  but  no  gas.  Meteorism  of  two  kinds 
occurs — (i)  the  static  variety  in  which  gas  accumulates  in  loops  above 
the  obstruction,  and  (ii)  the  local  variety,  in  which  the  strangulated 
loop  becomes  distended,  chiefly  because  its  circulation  is  impaired;  it 
may  be  seen  or  felt  as  an  immovable  tense  mass,  showing  no  peristalsis 
and  corresponding  to  the  thick,  oedematous,  hemorrhagically  infiltrated 
and  finally  gangrenous  gut.  (e)  The  urine  is  decreased,  because  of 
the  vomiting,  lack  of  food,  and  nervous  collapse;  it  contains  indican  if 
the  obstruction  lies  in  the  small  gut,  and  is  tested  by  treating  with 
Obermeyer's  solution  (2  pro  mille  solution  of  ferric  chloride  in  con- 
centrated hydrochloric  acid)  and  shaking  with  chloroform.  Sometimes 
casts,  albumin,  or  even  hemorrhagic  nephritis,  are  observed.  (/) 
Strangulation  in  some  cases  may  be  found  in  the  usual  or  accessible 
hernia  locations. 

Diaphragmatic  hernia  was  first  diagnosticated  by  Leichtenstern 
(1874);  it  is  left-sided  in  88  per  cent.,  is  congenital  or  acquired  (from 
trauma  especially),  and  is  recognized  in  but  3  per  cent,  of  the  reported 
cases;  its  signs  closely  resemble  those  of  pneumothorax  (see  Diagno- 
sis OF  Pneumothorax)  . 

In  strangulation  and  other  acute  obstructions  (v.i.)  the  mucosa  in 
the  occluded  area  may  become  eroded,  more  easily  penetrated  by 
bacteria,  ulcerated,  and  hemorrhagically  infarcted,  leading  to  necrosis, 
perforation,  and  peritonitis. 


III.  Twists  (Volvulus)  and  Knots.  ^ 

Volvulus  is  a  twisting  of  the  intestine,  which  in  nearly  all  cases 
occurs  around  the  mesenteric  axis ;  twisting  of  the  gut  on  itself  is  rare ; 
volvulus  occurs  in  14  per  cent,  of  obstructions  (Fitz) ;   68  per  cent,  of 


STRICTURE  (ENTEROSTENOSIS)  673 

the  cases  are  males,  usually  between  forty  and  sixty  years  old ;  it  occurs 
in  the  sigmoid  flexure  in  66  per  cent.  (Leichtenstern),  less  frequently 
in  the  csecum  (75  cases  collected  in  1905  by  Corner  and  Sargent),  colon 
ascendens,  and  small  gut,  and  then  especially  when  the  large  and  small 
intestines  have  a  small  mesentery;  only  three  cases  of  volvulus  of  the 
stomach  are  recorded.  The  predisposing  causes  of  volvulus  are  a 
vegetable  diet  (said  to  explain  its  frequency  in  Russian  peasants), 
persistent  constipation,  a  long  sigmoid  flexure  with  a  long  but  narrow 
mesentery,  and  mesenteritis.  The  twist  may  occur  through  180  to  360 
degrees  or  more. 

Sjmiptoms. — The  symptoms  closely  resemble  those  of  the  forms 
described,  especially  when  knots  form  between  two  coils  of  the  small 
intestine.  In  volvulus  of  the  sigmoid  there  is  pain  and  vomiting, 
which  is  less  marked  than  in  strangulation  or  invagination  and  is 
seldom  fsecal;  the  local  meteor  ism  is  more  pronounced  than  in  any  other 
type  of  obstruction,  for  the  huge  coil  of  the  obstructed  gut  passes  up- 
ward, possibly  to  the  right,  in  extreme  cases  pushes  up  the  diaphragm 
to  the  third  or  fourth  ribs,  and  seldom  shows  any  peristalsis,  which  its 
disturbed  circulation  prevents.  But  little  water  can  be  injected  into 
the  rectum.     Hemorrhagic  peritoneal  exudate  is  common. 


IV.  Strictures  (Enterostenosis). 

Strictures  more  often  cause  chronic  than  acute  obstruction,  (a) 
Congenital  stricture  is  even  rarer  than  the  rare  congenital  atresia 
(imperforate  anus,  ileocsecal,  duodenal,  or  sigmoid  atresia),  (b)  Cica- 
tricial stricture  results  from  healing  of  tuberculous,  syphilitic,  dysen- 
teric, duodenal,  and,  very  rarely,  typhoid  ulcers.  In  1904  Arbuson 
collated  129  cases  of  tuberculous  stricture,  (c)  Annular  cancer,  (d) 
compression  by  various  organs  or  tumors  (80  per  cent,  of  which  are 
pelvic),  and  (e)  traction,  are  other  causes.  (/)  Inflammatory  hyper- 
trophy of  the  mucosa  and  muscularis  is  exceedingly  uncommon. 

Symptoms. — The  symptoms  are  those  of  chronic  obstruction,  and 
vary  with  the  location  of  the  stenosis.  (I)  Stenosis  of  the  small  intes- 
tine may  occur  (a)  above  the  duodenal  papilla,  as  a  result  of  gall- 
stones or  duodenal  ulcer,  and  resembles  pyloric  stenosis,  from  which 
differentiation  is  practically  impossible;  it  may  occur  (6)  in  the  duo- 
denum below  the  papilla,  as  a  result  of  gall-bladder  adhesions,  duo- 
denal ulcer,  tumors,  or  pancreatic  disease  (acute  pancreatitis,  tumor, 
cyst);  icterus  is  frequent,  as  well  as  vomiting  of  bile  and  pancreatic 
juice  (which  digests  starch  and  fibrin  in  an  alkaline  medium);  other 
symptoms  are  dilatation  of  the  stomach,  pale  stools,  very  slight  ab- 
dominal meteorism  except  over  the  epigastrium,  and  the  absence  of 
indicanuria.  (c)  Jejuno-ileac  stricture  may  result  from  healed  ulcers, 
inflammation  in  replaced  hernias,  and  adhesions  to  the  internal  geni- 
talia; the  ulcer  stricture  may  be  multiple,  as  many  as  twelve  being 
recorded  in  one  case;  it  is  remarkable  that  extreme  stenosis  may  cause 

43 


674  DISEASES  OF  THE  DIGESTIVE  TRACT 

no  symptoms.  There  is  constipation,  which  sometimes  alternates  with 
diarrhoea,  coHc,  meteorism,  and  visible  palpable  peristalsis,  causing 
*' intestinal  stiffness"  (Nothnagel)  until  the  obstruction  is  finally  over- 
come by  the  hypertrophied  muscle  above  the  stricture,  when  a  gurgling 
sound  is  sometimes  heard.  The  colon  is  collapsed.  (II)  Stricture  of 
the  large  gut  is  marked  by  constipation,  which  is  significant  when  it 
develops  rapidly  in  a  person  not  previously  constipated  or  when 
cathartics  have  no  effect  in  constipated  individuals;  by  paroxysmal  or 
colicky  pain,  even  more  than  in  stricture  of  the  small  gut,  because  the 
stools  are  harder;  eventually  by  nausea  and  vomiting,  which  are  suc- 
cessively gastric,  bilious,  and  stercoraceous ;  by  meteorism  along  the 
colon  and  in  the  lumbar  region  behind,  which  it  is  usually  dull;  by 
increased,  even  tetanic,  peristalsis  in  the  intestinal  coils  above  the 
stricture,  which  possesses  a  distinct  localizing  value;  and  by  the 
evacuations  which  may  be  ribbon-like  or  sheep-stools,  and  which  are 
often  diagnostically  overestimated,  for  they  may  occur  in  tumors, 
starvation,  colica  mucosa,  and  spastic  constipation;  they  are  positive 
neither  by  their  absence  nor  presence. 


V.  Tumors  (see  page  677). 

VI.  Foreign  Bodies. 

Foreign  bodies  caused  obstruction  in  12  per  cent,  of  Fitz's  series. 
(a)  Gall-stones — of  which  250  obstruction  cases  are  on  record — lodge 
chiefly  in  the  upper  duodenum  or  lower  ileum,  ulcerate  through  the  gall- 
bladder into  the  duodenum  or  less  often  through  the  colon,  or  com- 
press the  duodenum  through  a  dilated  pouch  of  the  cystic  duct.  In  a 
surprisingly  small  per  cent,  is  there  a  history  of  colic  (19  per  cent.)  or 
of  icterus.  Collapse  is  usually  not  marked,  a  tumor  is  seldom  felt, 
and  the  constipation  is  often  but  relative;  indeed,  diarrhoea  may 
occur.  (6)  F cecal  masses  are  far  more  common  than  statistics  show, 
and  form  the  chief  obstruction  of  the  large  gut.  The  writer  saw  a 
case  of  acute  absolute  obstruction  develop  after  a  Thanksgiving  din- 
ner ;  there  was  fsecal  vomiting  and  severe  collapse  ;  a  mass  of  not 
particularly  hard  food,  measuring  two  inches  in  diameter,  was  found ; 
recovery  occurred,  though  the  bowel  was  partly  necrotic.  They  are 
found  especially  in  the  sigmoid  (see  Constipation),  (c)  Enteroliths 
are  not  common.  They  form  slowly  of  phosphates,  usually  with  an 
organic  nucleus;  sometimes  they  are  constituted  of  bismuth,  chalk, 
iron,  or  magnesia.  They  measure  an  inch  to  nine  inches  in  diameter, 
and  in  one  instance  an  enterolith  weighed  four  pounds.  Though  most 
common  in  the  large  intestine,  they  may  develop  in  diverticula  of  the 
small  intestine,  (d)  Hair  tumors,  twisted  masses  of  ascarides,  fruit 
seeds,  oatmeal  husks  (especially  in  Scotland),  stones,  and  foreign  bodies 
(in  children  or  insane  subjects),  are  possible  causes. 


DYNAMIC  ILEUS 


675 


VII.  Dynamic  Ileus. 

The  above  causes  are  mechanical.  Another  form  of  acute  obstruc- 
tion is  distinguished,  namely,  dynamic  ileus  (paralytic  or  spastic 
obstruction).  Under  this  topic  may  be  included  obstruction  follow- 
ing mesenteric  embolism,  trauma,  abdominal  operations,  or  inflam- 
mation in  an  undescended  testicle;  they  are  largely  but  not  absolutely 
associated  with  acute  peritonitis.  Spasmodic  obstruction  may  develop 
in  rare  cases  without  cause,  or  in  neurotics,  in  gall-stone  occlusion, 
ulceration,  and  intestinal  crisis  of  tabes.  It  rarely  produces  faecal 
vomiting;  Bregmann  (1901)  found  in  the  literature  20  cases  of 
hysterical  ileus. 

Diagnosis. — 1.  [Of  the  Fact  of  Obstruction. — ^The  symptoms  are 
generally  unmistakable,  and  consist  of  constipation,  cessation  of  flatus, 
distention  (particularly  the  local  form),  compensatory  peristalsis  (hyper- 
trophy), and  frequently  general  reaction  (collapse).  The  hernial  sites, 
the  rectum,  and  the  vagina,  must  always  be  carefully  examined. 

2.  Of  the  Location. — The  uncertainties  of  diagnosis  of  location  are 
manifold,  but  the  following  table  brings  out  some  of  the  leading  cri- 
teria : 


Obstruction  of  the  Small.- 


General  Condition — Earlier  and  more 
profoundly  impressed  (reflexly)  by 
toxaemia  and  peritonitis. 

Symptoms  more  marked,  more  stormy 
onset,  more  vomiting  (both  reflex 
and  *8ecal),  more  pain. 


Indicanuria — Develops    early,   and    to 
marked  degree. 

Urine — Much  decreased. 


. Of  the  Large  Intestine. 

Later  and  less  impressed. 


Signs  more  marked,  as  meteorism  along 
colon  (later  becoming  general),  less 
water  can  be  injected,  more  peristaltic 
effort  and  palpable  rigid  coils,  more 
results  by  rectal  or  vaginal  examina- 
tion, more  tenesmus. 

Develops  later  or  not  at  all  (also  pres- 
ent in  cancer  and  peritonitis). 

liittle  decreased. 


3 .  Of  I bs  Nature . — Only  the  broadest  probabilities  may  be  considered. 
(a)  It  is  practically  impossible  to  recognize  obstruction  by  bands, 
adhesions,  Meckel's  diverticulum,  clefts,  and  internal  hernias  (except 
diaphragmatic).  (6)  Invagination  is  not  only  the  most  frequent  but 
also  the  most  characteristic  form,  because  of  its  sudden  onset  (in 
children),  severe  (intermittent)  pain,  tumor,  bloody  stool  (very  rare  in 
hernias  replaced  by  operation  or  taxis,  in  strangulation,  volvulus  or 
gall-stones),  tenesmus,  results  of  rectal  palpation,  and  the  exfoliation 
of  dead  intestine,  (c)  Strangulation  is  next  in  frequency,  and  is  differ- 
entiated from  coprostasis,  stone  occlusion,  compression,  stenosis,  and 
tumors,  by  its  more  marked  and  earlier  collapse,  its  more  severe  initial 
pain  and  vomiting,  its  greater  local  meteorism,  and  more  frequent 
hemorrhagic  peritoneal  effusion,      (d)   Volvulus  is  suggested  by  the 


676  DISEASES  OF  THE  DIGESTIVE  TRACT 

advanced  age  of  the  patient,  constipation,  relatively  slower  onset  and 
course,  infrequent  faecal  vomiting,  and  the  meteorism,  which  is  greater 
than  in  any  other  form  and  is  accompanied  by  little  peristalsis.  The 
small  amount  of  fluid  which  can  be  injected,  the  frequent  hemorrhagic 
peritoneal  fluid,  the  tenesmus,  and  the  slightness,  lateness  or  absence  of 
indicanuria,  are  also  suggestive,  (e)  Gall-stones  often  give  no  positive 
symptoms;  in  some  instances  the  lack  of  shock,  of  increased  pulse,  and 
of  meteorism,  and  the  paradoxical  intermittent  release  of  flatus  and 
faeces,  may  be  suggestive.  In  no  other  type  is  faecal  vomiting,  combined 
with  the  passage  of  flatus  and  faeces,  so  common. 

4.  Differentiation. — Confusion  with  flatulent  colic,  gall-  or  kidney- 
stones,  and  incarceration  of  the  kidney,  uterus,  or  testis,  is  avoided 
because  in  intestinal  obstruction  there  is  rapid  stoppage  of  the  bowels; 
the  author  saw  one  case  of  lead-colic  with  intussusception.  The  possi- 
bility of  acute  pancreatitis  must  be  considered.  Peritonitis  is  charac- 
terized by  early  fever,  early  diffuse  tenderness,  meteorism,  cessation  of 
peristalsis,  board-like  abdominal  rigidity,  often  by  fluid  in  the  perito- 
neum, late  collapse,  late  faecal  vomiting,  later  and  less  complete  ob- 
struction, and  by  frequent  singultus. 

Treatment. — In  stenosis,  which  is  typified  by  ulcer  cicatrices,  a  con- 
centrated fluid  or  semi-fluid  diet  should  be  given,  and  thorough  masti- 
cation of  solid  food  and  avoidance  of  coarse  food,  or  food  with  chaff, 
skins,  stone,  or  gristle,  should  be  insisted  on.  Cathartics  are  to  be 
avoided,  and  the  bowels  should  be  moved  with  enemata  of  oil  or  water. 

Thiosinamin  has  been  recommended  to  dissolve  cicatricial  stenosis: 

Thiosinamin 3]. 

Glycerini 3iij. 

Acoholis  diluti 3vj. 

M.  et  S. — Inject  8  to  15  drops  subcutaneously  once  daily. 

Operative  measures  may  be  instituted  for  foreign  bodies  or  for  malig- 
nancy, in  which  case  the  outlook  is  best  in  lesions  of  the  colon  and 
ileum. 

1.  Medical  Treatment  of  Obstruction. — In  every  case  the  physician 
should  at  once  divide  the  responsibility  with  a  surgeon.  In  acute  cases, 
especially  in  the  small  intestines,  food  causes  aggravation.  Early  gastric 
lavage  affords  some,  though  transitory,  relief.  The  possibility  of 
chronic  f cecal  obstruction  should  be  flrst  eliminated  by  colonic  flushings, 
given  with  the  patient's  head  down  or  body  inverted ;  hard  desiccated 
faeces  must  be  dug  out  with  the  finger,  with  frequent  enemata  to  bring 
away  fragments;  in  colonic  injections  a  soft  tube  cannot  be  passed 
easily  above  the  sigmoid,  and  hard  tubes  may  cause  perforation.  High 
enemata  and  colonic  inflation  with  air  occasionally  reduce  volvulus  and 
intussusception.  Laxatives,  massage,  and  puncture  of  the  gut  with  an 
exploring  needle,  are  always  contra-indicated.  Opium  is  useful  in  the 
early  stage  to  relieve  shock;  in  moderate  dosage  it  does  not  produce 
intestinal  paresis.  Stimulants  hypodermatically  are  frequently  indi- 
cated.   The  use  of  atropine  (Theden,  1788)  has  been  recently  revived. 


INTESTINAL  TUMORS  677 

especially  by  Batsch  (1900);  some  eases  are  relieved  by  it,  but  danger- 
ously large  doses  are  necessary. 

2.  Operative  Treatment. — Medical  treatment  of  strangulation, 
intussusception,  or  volvulus,  is  of  little  value.  A  most  convincing 
statistical  argument  for  early  operation  is  Naunyn's  series  of  288  cases, 
in  which  75  per  cent,  of  recoveries  was  obtained  by  operation  in  the 
first  two  days,  while  each  successive  day  lowered  the  patient 's  chances 
to  40  per  cent.,  30  per  cent.,  etc.  Obalinski  (110  cases)  reports  35  per 
cent,  recoveries,  Treves  (155  cases)  54  per  cent.,  and  Kocher  in  his 
earlier  experience  38  per  cent,  and  later  70  per  cent.  (96  cases  of  his 
own).  Much  depends  on  the  physiological  resistance  of  the  patient. 
In  intussusception  Gibson's  figures  (239  cases)  give  53  per  cent,  as  the 
average  mortality  from  operation,  being  39  per  cent,  for  operations  in 
the  first  two  days,  and  increasing  with  each  day  of  postponement;  it 
was  82  per  cent,  in  children  under  three  months  of  age;  Rydygier's 
mortality  in  chronic  forms  was  but  24  per  cent.  Forty  per  cent,  of  adults 
and  80  per  cent,  of  children  die  under  medical  treatment  (Leichten- 
stern).  In  100  cases  of  intussusception  in  children  63  per  cent,  of 
operated  recoveries  are  reported  by  Clubbe  (1905).  Fifty-two  per  cent, 
of  obstruction  by  gall-stones  recover  under  expectant  and  33  per 
cent,  under  surgical  treatment.  For  the  indications  and  technique  of 
resection,  anastomosis,  enterostomy,  colostomy,  etc.,  reference  should 
be  made  to  surgical  treatises. 


(I).   INTESTINAL  TUMORS. 

Carcinoma  is  the  only  neoplasm  of  clinical  importance.  It  is  esti- 
mated that  it  constitutes  22  per  cent,  of  all  cancers.  Its  etiology  is  as 
obscure  as  that  of  all  cancers.  Trauma  is  seemingly  an  occasional 
factor  and  previous  ulceration  is  a  predisposing  cause.  It  is  most  fre- 
quent in  males  over  forty  years  of  age;  according  to  Maydl,  17  per 
cent,  occurs  in  persons  between  thirty  and  forty  and  14  per  cent,  in 
those  under  thirty  years  of  age. 

Pathology.— According  to  Leube,  80  per  cent,  occurs  in  the  rectum, 
15  per  cent,  in  the  caecum  and  colon,  and  5  per  cent,  in  the  small  intes- 
tine. Haussmann,  in  268  cancers  of  the  bowel  (excluding  those  of 
the  rectum) ,  found  91  per  cent,  in  the  large  and  9  per  cent,  in  the  small 
bowel;  if  figured  more  in  detail,  37  per  cent,  occurs  in  the  sigmoid, 
18  per  cent,  in  the  caecum,  11  in  the  descending  colon,  9  in  the  trans- 
verse and  8  per  cent,  in  the  ascending  colon,  8  per  cent,  in  the  ileum, 
4  in  the  splenic  and  3  in  the  hepatic  flexure,  and  2  per  cent,  in  the 
jejuni^m.  Kanzler  (1906)  found  in  the  literature,  only  twenty-five 
cases  of  cancer  in  the  jejunum  and  ileum  (i.  e.,  in  the  small  intestine  ex- 
clusive of  the  duodenal  and  ileocaecal  regions).  The  sigmoid,  splenic 
and  hepatic  flexures  are  especially  predisposed,  probably  because 
these  sites  are  more  fixed  and  exposed  to  irritation.  It  is  usually  pri- 
mary, sometimes  secondary  by  contiguity,  but  very  rarely  metastatic. 


678  DISEASES  OF  THE  DIGESTIVE  TRACT 

Originating  in  tlie  intestinal  glands,  it  is  usually  annular  in  form,  and 
causes  stenosis  and  ultimate  occlusion  of  the  bowel ;  it  is  less  often 
nodular  and  is  very  rarely  diffuse  and  flat.  Histologically  it  may  be 
an  adenocarcinoma  (especially  when  it  occurs  in  the  duodenum), 
scirrhus  (in  the  sigmoid),  medullary,  cylindrical-celled,  (in  the  caecum 
and  sigmoid),  colloid  or  flat-celled  (in  the  rectum).  Beginning  in  the 
mucosa,  early  involvement  of  the  other  coats  and  lymph  vessels  usually 
occurs,  followed  by  later  involvement  of  the  peritoneum  and  metastasis, 
especially  in  the  liver,  (A.  O.  J.  Kelly  finds  in  the  literature  49  ap- 
pendiceal cancers.) 

Symptoms. — 1.  Disturbance  of  the  Intestinal  Function. —  (a)  There 
is  usually  constipation,  resuhmg  from  narrowing  of  the  intestinal  lumen; 
it  is  most  marked  in  tumors  of  the  large  intestine.  Ulceration  frequently 
causes  diarrhoea,  (b)  The  stools  are  irregular  and  sometimes  assume 
peculiar  forms,  as  band-like  or  sheep-like  stools,  to  which,  however, 
undue  importance  has  been  attached,  as  they  occur  in  inanition, 
starvation,  constipation,  etc.  (c)  Blood,  mucus,  and  pus,  are  common 
in  the  faeces,  though  equally  frequent  in  other  ulcerations  and  in  enteri-  . 
tis.  The  evacuations  may  be  stinking,  (d)  Fragments  of  tissue  are 
uncommon;  they  also  occur  in  dysentery  and  are  diagnostic  only  when 
shomng  carcinomatous  arrangement  of  the  cells,  (e)  Pain,  due  to 
enterostenosis,  is  usual;  it  may  be  sacral  when  due  to  sigmoid  cancer. 
(/)  Sudden  complete  occlusion  of  the  bowel  may  follow  pre%dous 
gradual  narrowing  of  the  lumen,  (g)  The  lower  the  tumor  in  the 
intestinal  tract  the  greater  is  the  tympany  and  foecal  retention  and  the 
purer  the  pus  and  blood  {i.e.,  the  less  mixed  with  the  faeces).  Above 
the  stricture  the  bowel  is  dilated  (tympany)  and  its  muscle  is  hyper- 
trophied  (visible  peristalsis),  (h)  Indicanuria  has  much  the  same 
significance  as  it  has  in  intestinal  obstruction. 

2.  Cachexia  and  Marasmus. — These,  with  the  above  symptoms,  are 
most  suggestive. 

3.  Tumor. — Until  a  tumor  is  detected,  the  symptoms  described  are 
not  diagnostic.  It  is  best  felt  if  the  bowel  is  empty;  it  may  be  confused 
with  a  normal  contracted  colon,  the  edge  of  the  ileopsoas,  or  with  faecal 
masses;  it  is  irregularly  oval  in  clear  cases,  though  in  annular  forms  it 
escapes  detection,  for  it  merely  constricts  the  bowel.  It  is  usually 
tender,  and  is  movable  or  immovable  accordingly  as  the  bowel  involved 
is  naturally  free  or  fixed  (incomplete  peritoneal  investment),  or  is 
adherent  to  other  structures  by  adhesions  or  extension  by  contiguity. 
Whether  free  or  fixed,  the  tumor  is  generally  below  the  navel.  Gas 
and  fluid  are  sometimes  felt  or  heard  to  escape  through  the  stenotic 
point,  and  distention  of  the  large  bowel  by  introduction  per  rectum  of 
air  or  fluid  may  aid  in  localization  of  the  tumor.  If  the  tumor  grows 
from  a  part  of  the  gut  which  is  movable  it  may  disappear  and  reap- 
pear from  time  to  time.  When  no  tumor  is  detected  by  abdominal 
palpation  and  inspection,  a  rectal  and  vaginal  examination  should 
always  be  made. 


INTESTINAL  TUMORS  679 

4.  Complications. — Complications  may  first  declare  the  malignancy 
of  primarily  ambiguous  symptoms,  as  (a)  icterus,  especially  in  duo- 
denal cancer;  (b)  hemorrhage  from  the  bowels;  (c)  rupture  into  the 
bladder  or  vagina,  or  into  the  stomach  (with  fsecal  vomiting  and 
diarrhoea  from  food  entering  the  colon). 

Diagnosis. — The  diagnosis  is  often  difficult,  except  in  cases  of  rectal 
localization,  for  latency  is  common  and  many  symptoms  merely 
indicate  stenosis  without  declaring  its  nature.  According  to  Leube, 
differentiation  is  required  from  other  movable  and  immovable  tumors : 

1.  Movable  Tumors. —  (a)  These  may  be  pyloric,  requiring  differen- 
tiation from  duodenal  cancers;  the  symptoms  may  be  identical,  but 
icterus,  the  presence  of  free  HCl,  bile,  and  pancreatic  juice,  in  the 
stomach  are  aids  in  diagnosis.  (6)  The  corset  liver,  movable  spleen 
and  kidney  will  be  considered  under  those  topics,  (c)  Omental  and 
mesenteric  tumors  may  be  confusing,  but  they  do  not  produce  the  same 
enterostenosis.  (d)  Scybala  may  co-exist  with  malignancy;  the 
repeated  use  of  enemata  and  cathartics  determines  the  diagnosis  (see 
Constipation). 

2.  Immovable  Tumors. —  (a)  Renal  and  retroperitoneal  tumors  lie 
beyond  the  colon  (on  its  inflation)  and  rarely  cause  the  same  degree  of 
intestinal  obstruction.  (6)  Encapsulated  peritoneal  exudate  may  be 
difficult  of  diagnosis;  the  author  has  seen  two  chronic  appendicitic 
abscesses  in  individuals  over  sixty  years  of  age  which  were  diagnos- 
ticated as  tumor,  were  hard  on  palpation,  and  which  recovered  by 
discharging  pus  into  the  bowel,  (c)  Ovarian  or  uterine  tumors  are 
less  obstructive  and  are  located  more  in  the  pelvis,  (d)  Localized 
inflammatory  infiltration  of  the  intestinal  wall  is  distinguished  by  its 
regressive  evolution.  Bittorf,  particularly,  has  called  attention  to  cir- 
cumscribed inflammation  of  the  sigmoid  flexure  and  colon. 

Rectal  cancer  should  receive  special  consideration  in  diagnosis.  It 
is  usually  annular,  and  when  developed  is  rigid,  frequently  resembles  an 
inverted  funnel,  becoming  narrow  upward  and  may  even  resemble 
a  hard  cervix  uteri.  The  colloid  form  extends  upward  and  down- 
ward, is  often  tubular,  and  causes  much  regional  invasion.  A 
systematic  rectal  examination — which  is  unaccountably  more  often 
neglected  than  any  other  simple  method  of  physical  examination — 
saves  many  lamentable  errors.  The  early  stricture  may  yield  when 
ulceration  develops,  and  this  usually  occurs  with  discharge  of  blood, 
often  ichorous  pus,  and  sometimes  malignant  tissue.  Pain  is  usually 
but  not  always  present,  tenesmus  is  the  rule,  and  hemorrhoids  are  very 
suggestive.  Cachexia  develops  with  great  rapidity,  though  it  is  no 
necessary  symptom;  the  author  has  seen  death  result  from  obstruc- 
tion with  perfect  preservation  of  color,  nutrition,  and  energy.  In- 
toxication symptoms  are  frequent,  as  stupor  and  other  evidences  of 
brain  depression. 

Syphilitic  strictures  are  slower  and  subject  to  greater  variations  than 
those  due  to  cancer;  tuberculous  ulcers  are  flatter,  softer,  and  more 
undermined. 


680  DISEASES  OF  THE  DIGESTIVE  TRACT 

Cancer  in  any  part  of  the  bowel  cannot  be  clinically  differentiated 
from  sarcoma,  of  which  Lecene  (1904)  collected  75  cases  involving  the 
small  bowel;  their  course  is  more  rapid  and  they  seldom  stenose  the 
lumen.     (Ward  [1904]  found  34  lipomata  recorded.) 

Prognosis. — ^The  prognosis  of  all  forms  and  locations  is  bad.  Mar- 
asmus, coma  carcinomatosum,  anasarca,  thrombosis,  embolism,  sec- 
ondary infections,  stenosis,  or  perforation,  may  be  the  cause  of  death. 

Treatment. — Treatment  is  that  of  enterostenosis,  in  regard  to  diet. 
Opium  must  inevitably  be  used  toward  the  end.  Operation,  either 
palliative  (enterostomy,  colostomy)  or  curative  (enterectomy),  may 
be  indicated.  In  1896,  Wolfler's  series  of  cases  of  resection  resulted  in 
a  mortality  of  54  per  cent.,  as  against  a  death  rate  of  39  per  cent,  in 
resection  for  causes  other  than  malignancy.  Hochenegg  (1902)  in  194 
radical  operations,  reports  a  mortality  of  but  12  per  cent.,  and  estimates 
his  recoveries  at  16  per  cent.  Czerny  (228  operated  cases,  1902)  reports 
14  per  cent,  of  permanent  recoveries. 


(J).  ENTERO PTOSIS. 

Enteroptosis  is  not  a  disease  per  se,  but  only  a  condition  in  which  the 
abdominal  viscera  "fall"  or  prolapse  in  the  abdomen.  The  stomach 
(gastroptosis),  intestine  (enteroptosis),  colon  (coloptosis),  or  solid 
viscera  (splanchnoptosis),  as  the  liver,  kidney,  or  spleen,  may  be  impli- 
cated. The  condition  is  known  as  Glenard's  disease,  and  Glenard 
referred  it  to  laxness  of  the  hepatocolic  ligament.  Ewald  and  others 
combat  this  view,  and  explain  the  transverse  rigidity  felt  in  the  ab- 
domen not  as  the  colon,  but  the  pancreas,  exposed  by  sinking  of 
the  intestines.  Its  exact  explanation  is  still  disputed,  though  whatever 
causes  relaxation  of  the  abdominal  wall  or  of  the  intra-abdominal 
suspensory  structures  may  induce  prolapse,  as  trauma,  coughing,  loss 
of  weight,  pregnancy,  tumors  of  the  liver,  spleen  or  kidney,  spinal 
deformity,  and  corsets.  Seventy-five  per  cent,  of  the  cases  occur  in 
women.  Stiller  maintains  that  splanchnoptosis  is  a  congenital  asthenic 
condition  whose  most  frequent  stigma  is  a  floating  tenth  rib  (casta 
fluctuans  decima) ;  this  is  found  in  80  per  cent,  of  cases.  He  also  speaks 
of  a  habitus  enteroptoticus ,  which  somewhat  resembles  the  habitus 
phthisicus;  in  the  normal  chest  the  vertical  line  drawn  from  the  ensiform 
to  the  navel  is  short,  compared  with  the  distance  from  the  median  line, 
horizontally,  to  the  floating  ribs;  in  the  habitus  enter optoticus  the 
vertical  line  is  much  longer  and  the  horizontal  line  is  shorter  than 
normal  and  shorter  compared  with  the  vertical  line;  this  habitus  is 
considered  a  congenital  predisposing  cause,  and  enteroptosis  is  the 
resulting  acquired  disease.  The  tendency  develops  the  disease,  when 
the  patient's  nutrition  suffers. 

Symptoms. — 1.  Stomach  Findings. — Gastroptosis  is  characterized 
by  falling  of  the  organ  to  a  lower  point  in  the  abdomen,  whereby  both 
its  upper  and  lower  limits  are  abnormally  low,  the  epigastrium  is 


ENTEROPTOSIS  681 

flattened,  and  the  hypogastrium  is  distended.  Eichhorst  and  Einhorn 
find  it  in  35  per  cent,  of  women  and  in  5  per  cent,  of  men.  Dilatation 
of  the  stomach  is  excluded  by  finding  the  lesser  curvature  at  a  lower 
point  than  normal,  which  is  determined  by  inflation  with  carbon  diox- 
ide. In  marked  gastroptosis  the  lesser  curvature  lies  near  the  umbil- 
icus; dilatation  and  gastroptosis  may  co-exist.  The  sharp  angle 
formed  at  the  pylorus  or  duodenum,  too,  may  cause  difiiculty  in  gastric 
evacuation.  Gastric  symptoms  may  be  noted,  as  anorexia,  a  sense  of 
pressure,  eructations,  nausea,  and  gastric  or  intestinal  hypersesthesia, 
or  as  complications,  vomiting,  hyperacidity,  or  motor  insufficiency. 
In  many  cases  gastric  and  other  symptoms  are  entirely  lacking. 

2.  Intestinal  Findings. — Enteroptosis  or  coloptosis  is  frequently 
found  with  gastroptosis.  The  transverse  colon  sinks  in  its  central 
segment  so  as  to  assume  the  form  of  the  letter  U  or  V.  Constipation, 
sometimes  alternating  with  diarrhoea,  and  rumblings  in  the  bowel,  are 
frequent. 

3.  Visceral  Findings. — Floating  kidney,  liver,  and  spleen,  will  be 
described  separately;  in  this  connection  the  only  necessary  comment  is 
that  floating  kidney  is  neither  cause  nor  effect  of  gastroptosis  or  enter- 
optosis, but  merely  coordinate  to  a  third  general  causal  factor. 

4.  Nervous  Symptoms. — These  occur  in  50  per  cent,  of  cases.  Many 
subjects  are  nervous,  delicate,  slight,  and  irritable  women.  The  most 
common  nervous  symptoms  are  lassitude,  depression,  a  sense  of  cephalic 
pressure,  backache,  and  other  neurasthenic  manifestations.  The  abdom- 
inal aorta  frequently  throbs  with  violence.  The  patient  complains 
of  a  "falling  out"  sensation.  Emaciation,  constipation,  and  ansemia, 
are  quite  common. 

Treatment. —  (a)  For  the  neurasthenic  symptoms  the  treatment 
outlined  under  neurasthenia  (q.v.)  is  indicated.  The  diagnosis  should 
not  be  disclosed  to  the  patient,  for  this  initiates,  by  suggestion,  a 
long  train  of  additional  symptoms,  (b)  Increase  in  weight  should  be 
sought,  by  ample  feeding  and  rest  in  bed,  which  indication  is  met  by 
the  rest  cure,  (c)  Supports  to  restore  and  maintain  the  viscera  in  their 
normal  location  often  give  considerable  and  immediate  relief.  The 
direction  of  the  pressure  should  be  upward  and  inward.  Strips  of 
adhesive  plaster  are  useful  but  are  uncomfortable,  (d)  No  drugs  can 
restore  tone  to  the  lax  ligaments.  Strychnine  may  be  beneficial  as  a 
general  and  digestive  tonic,  (e)  Operation,  indicated  only  in  cases 
with  neurasthenic  symptoms;  sometimes,  however,  surgical  inter- 
ference is  contra-indicated  by  these  very  symptoms.  Shortening  the 
mesentery,  resecting  parts  of  the  recti  muscles,  suture  of  the  liver, 
stomach  and  other  organs  to  fixed  tissues,  have  been  performed  seem- 
ingly with  success,  but  this  procedure  can  as  yet  receive  no  general 
commendation. 


682  DISEASES  OF  THE  DIGESTIVE  TRACT 

(K).   DILATATION  OF  THE  COLON. 

Colectasia  may  be  classified  as  follows:  (a)  Gaseous  distention, 
which  may  occur  in  acute  toxaemias.  Fenwick  recorded  a  case  so 
marked  that  death  resulted  from  heart  paralysis.  The  treatment  is 
that  of  tympanites  (v.  Typhoid  and  Enteritis).  (&)  Cases  which  are 
due  to  obstruction  by  fseces,  foreign  bodies,  volvulus,  (c)  The  so-called 
idiopathic  colectasia,  which  occurs  in  children  (in  80  per  cent,  of  cases) 
as  a  congenital  lesion,  or  in  male  adults  over  fifty  years.  Up  to  1904, 
80  cases  were  published  (Kredel).  It  is  also  known  as  Hirschsprung's 
disease,  being  first  described  by  Hirschsprung,  of  Copenhagen.  Treves 
holds  that  it  is  always  due  to  obstruction,  though  cases  without  ob- 
struction are  noted,  as  Formad's  case,  in  which  there  was  great  hyper- 
trophy of  the  muscularis  without  organic  stricture;  the  maximum 
circumference  of  the  colon  was  30  inches  and  its  weight  with  the  con- 
tained faeces  was  47  pounds.  The  leading  symptoms  are  obstinate 
constipation  and  meteorism.  Of  the  reported  cases  only  about  25 
per  cent,  recovered  either  under  medical  treatment  or  after  resection  of 
the  sigmoid,  or  colostomy.  Death  results  from  marasmus,  auto-intoxi- 
cation, intestinal  obstruction,  perforation,  or  peritonitis. 

(L).  INTESTINAL  HEMORRHAGE. 

Etiology. — There  are  five  groups  of  causes,  (a)  Abnormal  intes- 
tinal contents,  as  hard  faeces,  foreign  bodies,  gall-stones,  caustic  poisons, 
or  parasites  (anchylostomum  or  distomum).  (6)  Intestinal  lesions,  as 
ulcerations  (dysenteric,  tuberculous,  duodenal,  typhoid,  carcinoma- 
tous, polypoid,  hemorrhoidal),  inflammation,  as  enteritis  senihs, 
toxica,  or  cathartica;  invagination,  volvulus,  and  trauma,  (c)  General 
affections;  cardiac  or  portal  stasis,  amyloid  disease,  infarction  of  the 
superior  mesenteric  vessels,  inanition,  aneurysmal  rupture,  scurvy, 
uraemia,  and  cholaemia.  (d)  Infections,  including  typhoid,  dysentery, 
malaria,  yellow  fever,  syphilis,  tuberculosis,  septicopyaemia,  and 
hemorrhagic  exanthemata.  In  the  young  (melaena  neonatorum) 
sepsis  is  a  prominent  factor  (see  Hemorrhagic  Diseases  of  the  New- 
born), (e)  Blood  from  the  stomach.  The  blood  may  be  of  capillary, 
arterial,  or  venous  origin. 

Symptoms. — The  symptoms  are:  (a)  Blood  in  the  fceces.  It  may  be 
obvious  or  "occult" — i.e.,  found  only  microscopically,  chemically,  or 
spectroscopically.  Blood  is  generally  present  microscopically  a  number 
of  hours  before  it  is  seen  by  the  naked  eye.  It  is  usually  mixed  with 
faeces,  and  dark,  tarry  and  offensive  when  it  comes  from  the  small  gut; 
it  may  coat  the  movements  and  be  bright  in  color  when  it  comes 
from  the  lower  intestine.  (6)  Acute  anaemia  may  follow  profuse  hemor- 
rhage; this  is  evidenced  by  pallor,  syncope,  rapid  heart,  and  slight 
febrile  movement,  (c)  There  are,  finally,  the  symptoms  of  the  caudal 
disease,  as  typhoid  or  cancer 


PILES  683 

Diagnosis. — The  diagnosis  of  enterorrhagia  concerns  (a)  the  de- 
tection of  hlood,  which  may  be  simulated  by  bismuth  or  blueberries, 
but  its  presence  is  easily  established  by  the  red  disks,  the 
hsematin  crystals,  the  guaiac  reaction,  and  the  spectroscopic  lines;  (6) 
the  question  whether  the  blood  comes  from  the  bowel  or  from  the 
mouth  or  stomach;  (c)  whether  it  comes  from  the  large  or  small  gut 
{v.s.);  and  {d)  its  causes,  which  are  most  often  hemorrhoids,  typhoid, 
dysentery  and  cancer  of  the  lower  bowel.  It  goes  without  saying 
that  no  examination  of  the  abdomen  is  permissible  at  the  time  of  the 
hemorrhage. 

Prognosis  and  Treatment. — The  prognosis  and  treatment  is  involved 
in  the  basic  lesion  {v.  Typhoid).  Symptomatic  treatment  includes 
absolute  rest  of  body  and  mind;  5  grains  of  ergotin  and  one  grain  of 
opium  should  be  given  every  two  hours  until  bleeding  ceases. 


(M).  PILES. 

Etiology. — Hemorrhoids  result  from  (a)  stasis;  portal  stasis  operates 
through  the  superior  hemorrhoidal  and  inferior  mesenteric  veins,  and 
is  more  potent  than  cardiac  stasis,  which  congests  the  middle  hemor- 
rhoidal and  internal  iliac  veins;  (6)  from  constipation,  pregnancy,  and 
other  obstructive  lesions,  as  cancer  of  the  rectum.  According  to  Duret, 
vigorous  contraction  of  the  abdominal  muscles  is  more  potent  as  a 
cause  than  is  constipation.  Piles  are  most  common  in  the  fifth  decade 
of  life  and  in  men.  Hemorrhoids  are  usually  spoken  of  as  varices  but, 
as  Reinbach  has  shown,  they  are  often  cavernous  angiomata. 

Symptoms. — External  'piles  appear  as  tender,  painful,  dusky-red  or 
purple  swellings  outside  the  sphincter  ani ;  they  occur  singly  or  may 
grow  in  a  circle  around  the  anus;  they  may  be  soft  or  hard.  The  pain 
produced  is  throbbing  and  may  be  very  severe.  Itching  is  very  com- 
mon. They  may  bleed,  waste,  ulcerate,  or  suppurate.  Piles  which 
bleed  are  called  "open,"  and  those  which  do  not  are  called  "blind." 
Internal  piles  occur  above  the  sphincter,  below  which  they  may  prolapse 
and  strangulate.  Tenesmus,  mucus  secretion,  and  dull  pain  some- 
times referred  to  the  back  and  the  sacro-ileac  articulation,  may  be  noted. 

Diagnosis. — Mere  inspection  is  sufficient  to  exclude  prolapse, 
condylomata,  papillomata,  etc.  The  possibility  of  carcinoma  in  their 
etiology  should  be  borne  in  mind. 

Treatment. — (a)  General  treatment  should  deal  with  the  basic 
factors.  Exercise  is  indicated  for  those  of  sedentary  habits,  and  con- 
stipation (q.v.)  should  be  relieved.  (6)  Local  treatment:  a  small 
injection  of  cold  water  before  each  movement  softens  the  irritating 
hard  passage  and  constricts  the  piles,  thereby  favoring  their  reduction. 
Cleanliness  is  of  prime  importance  in  the  relief  of  itching,  for  which 
also  a  1  per  cent,  carbolic  salve  is  of  great  value.  In  acutely  painful 
cases  a  cocaine  salve  is  beneficial.  The  following  formulae  are  astrin- 
gent  and   anodyne: 


684  DISEASES  OF  THE  DIGESTIVE  TRACT 

^  .      .. 

Extract!  opii .    .    .   gr.  ij. 

Extract!  belladonnse gr-  ij- 

Acidi  tannici oss. 

Olei  theobromatis qS. 

M.  et  ft.  in  suppositoria  No.  X. 
S. — One  at  bedtime. 
Or- 

Cocainse  (alkaloid) gr.iij. 

lodoformi     . sr.  x. 

Orthoformi gr.  v. 

Olei  theobromatis q.s. 

M.  et  ft.  in  suppositoria  No.  XII. 
S. — One  at  bedtime. 

They  must  be  given  with  reserve,  lest  the  opium  or  cocaine  habit  be 
acquired.     Surgical  treatment  is  indicated  when  local  measures  fail. 


(N).  DIARRHCEA. 

Definition. — ^^Increased  frequency  of  the  stools  with  decreased  con- 
sistence. Diarrhoea  is  not  synonymous  with  intestinal  catarrh,  though 
a  sharp  differentiation  is  often  difficult.  In  some  individuals  two  or 
three  movements  a  day  are  physiological. 

Etiology. — (a)  Irritation  from  the  intestinal  contents  may  cause  it. 
Diarrhoea  cathartica;  some  cathartics,  as  the  aromatics,  increase 
peristalsis,  and  others,  as  salts,  cause  increased  transudation;  diar- 
rhoea dyspeptica  is  caused  by  intestinal  or  gastric  dyspepsia,  and  by 
fruits  and  vegetables;  diarrhoea  stercoralis  is  caused  by  irritation  from 
the  fsecal  masses;  diarrhoea  entozoica  is  caused  by  intestinal  parasites. 
In  general  there  are  two  mechanisms :  (i)  the  stools  are  hurried  through 
the  bowel  by  increased  peristalsis  (irritation  of  the  ganglia  in  the  gut), 
in  which  case  bile  is  found  in  them;  and  (ii)  there  is  increased  serum 
transudation  into  the  intestine,  when  little  or  no  bile  is  found.  (6) 
Nervous  diarrhoea  causes  from  two  to  fifteen  thin  movements,  contain- 
ing no  increased  mucus;  they  are  attended  by  rumbling  in  the  bowels, 
peristaltic  unrest,  and  are  chiefly  observed  after  mental  excitement, 
as  in  taking  examinations,  or  in  neurotic  individuals  (hysteria,  neuras- 
thenia, or  exophthalmic  goitre) ;  some  cases  are  reflex,  as  from  uterine 
or  dental  irritation,  (c)  Toxic  substances  in  the  blood  may  cause 
irritation  of  the  ganglia  or  act  upon  the  brain;  for  instance,  uraemia, 
typhoid,  sepsis,  cholera,  and  possibly  cold,  produce  diarrhoea  by  one  or 
both  of  these  mechanisms. 

Treatment. — Opium  is  the  most  valuable  remedy  in  diarrhoea, 
except  in  the  stercoral  and  dyspeptic  types;  it  acts  less  by  checking 
secretion  than  by  suspending  peristalsis  and  mitigating  pain  and 
spasm;  the  crude  drug  is  superior  to  its  alkaloids,  as  its  absorption 
from  the  bowel  is  slower,  and  its  effect  is  therefore  more  marked;  |  of 
a  grain  of  the  extract,  or  a  dram  of  the  camphorated  tincture,  should 
be  given  with  bismuth  in  massive  doses  as  in  acute  or  chronic  enteritis 


CONSTIPATION  685 

(q.v.).  Important  adjuncts  are  local  heat  (quieting  irritation  and  peri- 
stalsis), rest,  and  a  spare  diet  (boiled  milk,  eggs,  toast,  and  later  lean 
meat,  as -in  enteritis.).  In  nervous  diarrhoea  two  drops  of  Fowler's 
solution  before  meals  is  often  advantao;eous. 


(0).   CONSTIPATION. 

Constipation  is  a  relative  term,  for  some  persons  normally  have 
movements  every  second  or  third  day,  and  constipation  (insufficient 
amount  of  fseces)  may  exist  even  with  daily  movements. 

Etiology. — (1)  "Physiological"  constipation  results  from  irregu- 
larity in  going  to  stool,  as  in  travel,  from  obesity,  from  insufficient 
exercise  or  water,  from  loss  of  fluid  by  sweating,  from  a  dietary  rich  in 
proteids,  as  milk,  and  from  various  kinds  of  over-medication.  (2) 
Constipation  may  be  symptomatic  of  other  affections,  as  (a)  gastric 
ulcer,  cancer,  dilatation,  or  hyperacidity;  (b)  intestinal  obstruction, 
cancer,  adhesions,  catarrh,  passive  congestion,  or  Glenard's  enter- 
optosis;  (c)  pelvic  conditions,  as  pregnancy,  ovarian  or  uterine 
disease,  or  enlarged  prostate;  (d)  infections  (which  stimulate  the  in- 
hibitory nerves);  (e)  nervous  disease,  meningitis,  tumors,  myelitis, 
the  neuroses;  (/)  diabetes  and  old  age.  (3)  Habitual  constipation, 
constipation  per  se,  may  occur  in  families.  It  may  result  from  insuf- 
ficient nervous  energy  (acquired  or  congenital)  in  the  large  intestine. 
Atony  of  the  intestinal  muscle  may  result  from  general  debility  or 
marasmus;  it  is  very  frequently  a  sign  of  neurasthenia,  hysteria,  or 
hypochondriasis,  and  results  but  seldom  from  actual  disease  of  the 
musculature  itself — that  is,  from  atrophy  or  degeneration.  Nervous 
constipation  may  be  due  to  a  spastic  condition  of  the  bowels. 

Sjnnptoms. — Symptoms  other  than  constipation  are  often  entirely 
absent,  even  after  weeks,  and  when  present  are  more  often  local  (anor- 
exia, coated  tongue,  bad  taste  in  the  mouth,  or  abdominal  uneasiness) 
than  general. 

It  should  be  remembered  that  two  or  three  movements  in  one  day 
or  a  movement  every  two  or  three  days  come  within  physiological 
limits.  The  stools  normally  accumulate  in  the  sigmoid  and  pass  every 
twenty-four  hours  into  the  lower  rectum,  causing  a  desire  to  defecate, 
usually  at  the  same  hour  each  day.  The  constipated  stool  is  dry  and 
accumulates  in  thehaustra  of  the  colon  or  ampullae  of  the  rectum.  Con- 
stipation may  occur  even  with  daily  movements,  a  small  amount  being 
retained  each  time.  It  is  difficult  to  state  the  quantity  of  the  normal 
passage,  which  certainly  does  not  depend  wholly  on  the  amount  of 
food  ingested ;  fseces  consist  largely  of  mucus  and  bacteria,  and  form 
even  during  starvation;  experimentally,  fseces  form  in  a  loop  of  intes- 
tine isolated  by  ligature.  The  stools  may  resemble  sheep's  dung,  and 
this  is  probably  due  to  intestinal  muscular  spasm.  Retained  fseces  are 
usually  voided  spontaneously  in  a  few  days  as  scybala  covered  with 
mucus  which  results  from  irritation  or  with  a  serous  diarrhcea.     Con- 


686  DISEASES  OF  THE  DIGESTIVE  TRACT 

siderable  obstruction  may  cause  f cecal  colic,  which  is  due  to  contraction 
of  the  gut  above  the  obstruction;  there  may  be  stercoral  fever  and 
meteorism.  The  retained  fceces  may  be  palpable.  Still  more  marked 
obstruction  may  very  rarely  simulate  organic  enterostenosis,  being 
marked  by  collapse,  vomiting,  and  great  vesical  or  rectal  tenesmus, 
which  should  always  excite  suspicion.  Extreme  neglected  cases  may 
occasionally  result  fatally,  especially  in  the  old,  debilitated,  or  insane,  or 
in  cases  in  which  defecation  causes  great  pain,  as  from  fistula  or  piles. 

Faecal  concrements  (coproliths)  almost  always  occur  in  the  large 
intestine.  When  large  they  may  simulate  tumors  of  the  intestine, 
omentum,  kidney,  or  spleen,  from  which  differentiation  may  be  possible 
only  after  thorough  purging  and  flushing.  They  may  be  soft  and  easily 
indented  with  the  finger,  hard,  nodular,  and  tender  from  the  bowel 
ulceration  they  incite,  or,  far  less  often,  tender  from  localized  peritonitis. 
The  history  is  not  always  conclusive,  because  fsecal  tumors  may  develop 
with  daily  though  inadequate  movements.  Gersuny  found  that  on 
pressure  the  bowel  may  at  first  seem  to  adhere  to  the  fsecal  masses  and 
then  become  free,  though  the  author  and  many  others  have  failed  to 
note  Gersuny 's  sign. 

General  symptoms  are  uncommon.  Nervous  symptoms  are  usually 
causal  rather  than  sequential,  as  in  the  neurasthenic  subject,  who 
believes  he  would  be  well  if  his  bowels  would  move,  and  who  has  most 
unpleasant  sensations  when  they  do.  Vertigo,  pressure  in  the  head, 
and  mild  dyspnoea  are,  in  the  author's  opinion,  always  neurotic  and 
never  coprostatic.  Copropsychiatry  is,  according  to  Nothnagel,  grossly 
exaggerated.  Intoxication  (ptomainsemia)  is  rare,  but  has  been  con- 
sidered causal  of  neuralgia,  chlorosis,  and  numerous  other  merely  con- 
comitant conditions.  The  aromatic  sulphates  of  the  urine  may  be 
increased,  which  is  due  to  formation  in  the  gut  of  indol,  skatol,  and 
pyrocatechin. 

Treatment. — Treatment  of  the  causal  factors  {q.v.)  is  most  im- 
portant, as  of  irregularity  of  habit,  insufficient  exercise,  or  neurasthenia. 

1.  Diet. — (a)  Coarse  foods,  as  whole  wheat,  graham,  rye,  corn 
meal,  and  bran  breads,  probably  act  less  mechanically  than  chemically 
by  the  production  of  lactic  or  oleic  acid.  (&)  Fruits  relax  the  bowels, 
because  of  the  malic,  tartaric  and  citric  acids  they  contain,  as  plums, 
apples,  peaches,  pears,  prunes,  strawberries,  and  grapes;  grapes 
sometimes  and  bananas  and  persimmons  usually  cause  constipation. 
(c)  Vegetables  act  by  the  acids  and  gases  they  form;  melons,  sprouts, 
cabbage,  cauliflower,  cucumbers,  turnips,  carrots,  spinach,  tomatoes, 
asparagus,  onions,  cress,  celery,  and  squash,  should  be  given  freely,  but 
it  should  be  borne  in  mind  that  excessive  amounts  may  cause  fatigue  of 
the  bowel  and  constipation,  (d)  Sweets,  in  so  far  as  they  do  not  cause 
indigestion,  are  laxative;  if  used  with  discretion,  sugars,  syrup,  candy, 
sauces,  molasses,  jellies,  jams,  marmalades,  and  honey,  are  valuable 
laxatives,  (e)  Fats — Moderate  amounts  of  butter  and  olive  oil  are 
helpful;  vegetable  are  superior  to  animal  fats,  which  tend  to  derange 
digestion.     (/)   Cold  water,  taken  on  rising  and  through  the  day,  is 


CONSTIPATION  687 

valuable  in  exciting  peristalsis.  Charged  waters  operate  similarly. 
Hard  water  (containing  an  excess  of  lime)  constipates,  which  point 
should  be  remembered  both  in  regard  to  drinking  and  cooking,  (g) 
The  following  are  to  be  avoided:  red  wines  (containing  tannic  acid), 
excess  of  meat,  eggs  or  carbohydrates  (rice,  buckwheat,  macaroni, 
and  others  containing  little  water),  tea,  milk  (sometimes  laxative  when 
not  taken  in  sips  but  swallowed  in  larger  quantities)  and  beef  tea. 
The  diet  recommended  affords  material  for  bacterial  action,  which 
follows  the  idea  advanced  by  Strassburger  and  Lohrisch,  that  constipa- 
tion is  due  to  impaired  motility,  resulting  in  turn  from  too  complete 
utilization  of  the  average  diet  by  the  intestinal  bacteria. 

2.  Punctuality  at  Stool. — The  necessity  of  being  punctual  at  stool 
was  insisted  upon  by  Trousseau.  The  best  time  for  evacuation  is 
immediately  after  breakfast,  except  in  cases  of  piles  or  prolapse  which 
may  come  down  during  the  day  after  the  morning  stool;  in  these 
cases  the  bowels  should  be  moved  at  bedtime. 

3.  Posture  at  Stool. — Squatting  is  the  natural  posture;  this  may  be 
approximated  by  leaning  well  forward  or  by  placing  the  feet  on  a  foot- 
stool; the  thighs  thus  support  and  compress  the  abdomen,  a  matter  of 
particular  importance  when  it  is  relaxed.  Working  the  thumb  of  the 
left  hand  downward  over  the  abdomen  from  the  navel  to  the  left  iliac 
fossa  is  also  recommended. 

4.  Massage. — Massage  may  give  relief  if  continued  for  months. 
Its  direction  is  not  especially  important,  though  the  course  of  the  colon 
should  be  followed.  It  should  be  given  for  a  quarter  of  an  hour,  pref- 
erably before  breakfast.  Sahli  's  method  was  to  roll  over  the  abdomen 
a  7-pound  cannon-ball  covered  with  chamois.  Massage  should  be 
gentle,  especially  in  the  aged.  It  is  seldom  beneficial  in  the  obese.  It 
is  indicated  in  atonic  but  contra-indicated  in  spastic  constipation. 

5.  Mild  Faradization. — This  arouses  short  contractions  in  the  colon 
and  is  given  with  a  moist  sponge.  Strong  applications  are  avoided. 
Faradization  and  galvanization  are  inferior  to  massage. 

6.  Hydrotherapy. — ^The  cold  compress  to  the  abdomen  is  a  good 
adjunct. 

7.  Exercise. — Exercise  is  indicated  to  develop  and  contract  the 
abdominal  muscles,  as  in  tennis,  or  rowing,  or  by  lifting  the  legs  while 
lying  on  the  back,  or  lifting  the  rigid  body  from  the  lying  to  the  erect 
posture  solely  by  the  abdominal  muscles.  Walking,  bicycle-riding,  and 
horse-back  riding,  do  not  exercise  these  muscles  equally  well.  In  women 
with  ovarian  and  uterine  diseases,  exercise  only  increases  the  constipa- 
tion, which  is  generally  due  to  reflex  spastic  inhibition  of  peristalsis, 
as  shown  by  the  laxative  effect  of  narcotics  (Littlejohn  and  Brunton). 
It  is  claimed  that  constipation  is  spastic  (not  atonic)  in  25  per  cent,  of 
female  cases,  as  evidenced  by  colic,  palpable  or  visible  knots  in  the 
intestine,  and  sometimes  by  ribbon-like  passages;  in  these  cases 
irritating  and  coarse  diet,  massage,  cold,  and  electricity,  are  to  be 
avoided.  Hot  Sitz  baths  or  full  hot  baths,  hot  compresses  to  the 
abdomen  for  spasm  or  colic,  are  indicated;  an  enema  of  eight  ounces  of 


688 


DISEASES  OF  THE  DIGESTIVE  TRACT 


warm  olive  oil  is  given  each  evening,  and  an  attempt  is  made  to  have  it 
retained  until  morning;  one-third  of  a  grain  of  extract  of  belladonna  is 
given  as  a  suppository  one  to  three  times  a  day,  to  relieve  spasm  and 
the  frequent  rectal  tenesmus;  the  diet  should  not  consist  of  coarse  food 
but  of  fine  carbohydrates,  butter,  and  cooked  fruit. 

8.  Enemata. — Enemata  excite  peristalsis,  lessen  intestinal  hyper- 
semia,  and  apparently  are  beneficial  to  the  hepatic  secretion  and  circu- 
lation. They  do  not  derange  digestion  as  do  cathartics,  but  after  a 
time  they  may  lose  their  effect  by  dilating  the  colon,  whence  the 
indication  for  their  intermittent  use.  Water  and  olive  or  linseed  oil 
maybe  used;  oil  enemata  (five  to  eight  ounces)  are  especially  indicated 
in  spastic  constipation  and  colica  mucosa,  in  which  the  oil  may  be 
left  in  the  bowel  over  night.  Glycerine  suppositories  are  valuable,  if 
used  alternately  with  other  methods.  In  fsecal  impaction  with  marked 
obstruction  enemata  are  invaluable,  and  should  be  combined  with 
cathartics  and  digital  evacuation  of  the  hardened  masses. 

9.  Cathartics. — The  use  of  cathartics  is  governed  by  the  following 
general  rules :  (a)  they  should  be  administered  in  chronic  cases  only 
after  failure  of  the  measures  enumerated  above;  (6)  their  most  suc- 
cessful employment  is  intermittent  and  alternating;  (c)  drastics, 
hydrogogues,  and  cathartics  producing  secondary  constipation,  should 
be  avoided,  save,  of  course,  in  extreme  cases. 

Varieties. — Aloes,  found  in  nearly  all  proprietary  and  ofiicinal  pills, 
should  be  avoided  in  piles  and  uterine  hemorrhage,  because  it  congests 
the  pelvic  vessels.  Like  other  cathartics,  it  is  usually  given  in  combina- 
tion, e.g. — 

Extr.  aloes  aquosi    .    .    .    .  gr.  ss.  Acting  in  fifteen  to  twenty  hours,  on 

the  large  bowel  chiefly. 

Extr.  rhei gr.  ij.  to  v.        Actively    purgative    in    four    to    eight 

hours;    stomachic  and  tonic. 

Extr.  nucis  vomicae      .    .    .  gr.  J.  Acting  on  peristalsis    and    combating 

atony. 

Resinse  podophylli   .    .    .    .  gr.  j^q  Acting  in  ten  hours,  producing  "  bilious 

stools." 

Extr.  belladonna? gr- i-  Reheving  spasm  (griping)  and  operating 

(or  extr.  hyoscyami)  on  the  intestinal  nerves. 

Extr.  teraxici gr.  j . 

M.  et  ft.  pil.  I. 

Rhubarb  has  the  disadvantage  of  griping  and  of  producing  secondary 
constipation,  which  is  caused  by  its  tannic  acid  ("a  patient  sells  his  soul 
to  rhubarb"),  whence  it  should  never  be  given  alone: 

Pulveris  rhei  compositi .....  5iv. 

Sodii  sulphatis 3iv. 

Sodii  bicarbonatis 3j  ■ 

M.  et  S. — One  teaspoonful  at  bedtime. 


FUNCTIONAL  (NERVOUS)  AFFECTIONS  OF  THE  BOWEL     689 

Cascara  sagrada  is  an  excellent  laxative,  and  produces  very  little 
constipation  afterward;  the  fluidextract,  fluidextractum  rhamni 
purshianse,  tt^x  to  xx,  is  very  bitter;  the  solid  extract,  extractum 
rhamni  purshianse,  is  given  in  doses  of  from  two  to  eight  grains. 
Licorice  is  given  as  pulvis  glycyrrhizse  compositus,  3ss  to  5j-  Castor 
oil  is  a  soothing  laxative,  relieving  irritation  and  spasm  (in  nervous  or 
lead  constipation,  in  which  latter  it  may  be  combined  with  opium  gr. 
I);  its  offensive  taste  may  be  partly  overcome  by  combining  with 
glycerine  and  gaultheria: 

^      .   .  .  . 

Olei  ricini ■.....§  ij . 

Olei  gaultherise gtt.  xl. 

Glycerini §ij. 

M.  et  S. — One  teaspoonful  to  one  tablespoonful. 

In  anaemic  patients  the  following  formula  is  recommended: 


Ferri  sulphatis      

Extract!  aloes  aquosi  .  .  . 
Extract!  rhamn!  pursh!anse 
Extract!  belladonnse  .  .  . 
Extract!  nuc!s  voni!cse  .  . 
M.  et  ft.  piluliB  No.  X. 
S. — One  after  meals. 


gr.  V. 
gr.  XX. 
gr.  i!j . 
gr.  iij. 


CaZomeZ  should  be  given  in  the  evening  in  fractional  doses,  and  may  be 
advantageously  combined  with  podophyllin,  which  acts  in  the  same 
time  (eight  hours) ;  they  should  be  followed  the  next  morning  by  half 
an  ounce  of  magnesium  sulphate.  Senna  easily  deranges  digestion ;  a 
small  amount  may  be  added  to  prunes  and  both  cooked  together; 
confectio  sennce  is  given  in  dram  doses.  Tobacco  smoking,  and 
coffee  in  the  morning,  are  beneficial,  but  tea  promotes  flatulency 
and  constipation.  Consideration  of  the  salines  and  drastics  is  inten- 
tionally omitted,  as  their  use  except  for  emergencies  is  contra-indicated. 


(P).   FUNCTIONAL   (NERVOUS)  AFFECTIONS  OF  THE  BOWEL. 

1.  Neuroses  of  Motility. — (a)  Nervous  diarrhoea  has  been  partly 
considered.  It  may  occur  in  the  neuroses,  in  reflex  irritation  during 
dentition,  or  in  the  crises  of  tabes;  it  is  usually  transient  and  is  marked 
by  absence  of  inflammatory  symptoms,  as  mucus,  pus,  or  blood.  There 
is  constant  danger  that  nervous  diarrhoea  may  be  confused  with  organic 
disease.  In  some  cases  ingestion  of  food  may  be  immediately  followed 
by  diarrhoea,  and  is  treated  by  giving  rr^ij  of  Fowler's  solution  before 
meals,  (&)  Enterospasm  is  caused  by  simultaneous  contraction  of  the 
circular  and  longitudinal  muscles,  which  normally  contract  alternately; 
the  abdomen  is  temporarily  retracted,  and  in  very  exceptional  cases 
obstruction  (ileus  spasticus)  and  faecal  vomiting  occur.  (See  Dynamic 
Ileus,  Spastic  Constipation  and  Colica  Mucosa.)  (c)  Sphincter 
spasm,  aside  from  local    rectal    or  anal   lesions,  results  from  sensory 

44 


690  DISEASES  OF  THE  DIGESTIVE  TRACT 

hyperirritability,  or  decreased  cerebral  inhibition ;  it  is  most  common 
in  hysteria  and  tabes,  (d)  Perutaltic  unrest  may  be  associated  with 
diarrhoea  if  the  colon  is  involved,  but  more  commonly  aflfects  the  small 
bowel  only,  when  constipation  or  normally  frequent  movements  are 
usual,  (e)  Nervous  constipation  (atony)  may  result  from  the 
neuroses,  intoxication  from  carbon  dioxide,  and  organic  cerebrospinal 
diseases,  in  which  condition  (/)  sphincter  paralysis  may  also  result. 

2.  Neuroses  of  Sensation. — Among  the  neuroses  of  sensation,  neu- 
ralgia mesenterica  (enteralgia,  enterodynia)  is  most  important;  it  is 
inflammatory,  nervous,  or  colicky  in  origin;  strictly  speaking,  it  is 
always  nervous,  i.  e.,  not  due  to  organic  causes;  practically,  other  forms 
of  abdominal  pain  are  frequently  included  under  enteralgia.  The  chief 
symptom  is  the  abdominal  pain,  which  is  usually  umbilical,  and  some- 
times relieved  by  pressure  and  sometimes  is  not;  the  abdominal  wall 
itself  may  be  hypersesthetic.  Reflex  disturbances  in  other  organs  may 
accompany  enterodynia  and  aid  in  establishing  its  functional  character; 
they  are  hiccough,  vomiting,  dyspnoea,  palpitation,  rectal  or  vesical 
tenesmus,  testicular  retraction,  muscular  twitchings,  etc.  The  diag- 
nosis necessitates  exclusion  of  innumerable  affections,  chiefly  abdom- 
inal but  also  general:  (a)  rheumatism  of  the  abdominal  muscles 
which  is  superficial;  (6)  lumbo-abdominal  neuralgia,  in  which 
Valleix's  three  tender  points  are  found  (see  Neuralgia);  (c)  hys- 
teria, which  may  simulate  many  affections;  its  stigmata  should  be 
looked  for;  (d)  tabetic  crises;  (e)  intestinal  affections,  as  appendicitis, 
peritonitis,  coprostasis,  parasites,  flatulent  colic  (from  beer,  milk,  or 
spoiled  food),  excessive  catharsis,  lead  colic,  or  colica  mucosa;  (/) 
gout,  arthritis,  or  cold;  (g)  malaria  and  typhoid;  (h)  renal  and  biliary 
calcuh. 

Its  treatment  and  that  of  the  motor  disturbances  is  of  the  fundamental 
nervous  state.  Symptomatically,  hypodermics  of  narcotics  produce  the 
quickest  but  most  dangerous  cure. 

A  hypodermic  injection  of  atropine  is  often  helpful. 

^     .  . 

Spiritus  ammonii  aromatici 3iii. 

Tincturae  cardamomi  compositse oiij. 

Spiritus  chloroformi oij- 

Tinctures  opii  camphoratse 5  iv. 

Tincturae  asafoetidae oiv. 

M.  et  S. — One  tablespoonful  in  hot  water  every  fifteen  minutes  for  three  or  four 

doses. 

3.  Neuroses  of  Secretion. — ^The  secretion  neuroses  are  important. 
The  chief  types  are  serous  nervous  diarrhoea  and  colica  mucosa,  which 
have  already  been  considered. 


(Q).  AFFECTIONS  OF  THE  MESENTERY. 

I.  Inflammation. — Mesenteritis  is  chiefly  important  in  its  relation 
to  ascites,  tuberculous  peritonitis,  and  other  peritonitides  (q.v.). 


AFFECTIONS  OF  THE  MESENTERY  691 

II.  Hemorrhage. — Hemorrhage  is  most  rare  as  a  primary  manifes- 
tation. It  is  generally  secondary  to  acute  hemorrhagic  pancreatitis, 
retroperitoneal  hgematoma,  aneurysmal  extravasation,  or  the  hemor- 
rhagic specific  fevers. 

III.  Diseases  of  the  Mesenteric  Vessels. — (a)  Infarction  by 
embolism  or  thrombosis  was  first  described  by  Virchow,  and  involves 
chiefly  the  arteria  mesenterica  superior,  which  is  essentially  a  terminal 
vessel.  Most  cases  develop  in  men  past  middle  life.  Jackson,  Porter, 
and  Quimby,  have  collected  225  cases.  (See  Symptoms  of  Valvular 
Heart  Disease.)  Its  onset  is  sudden,  with  intense  abdominal  pain, 
collapse,  nausea  and  vomiting  (usually  bloody  and  perhaps  faecal,  due  to 
intestinal  obstruction),  diarrhoea  (40  percent.),  and  bloody  stools  (40 
per  cent.).  Unless  there  is  an  apparent  cause  for  embolism,  as  (mitral) 
valvular  disease,  the  diagnosis  of  infarction  is  rarely  made,  for  periton- 
itis or  obstruction  is  usually  suspected.  The  usual  outcome  is  early 
death  from  collapse,  but  sometimes,  if  the  patient  lives  long  enough, 
acute  peritonitis  sets  in,  with  distended  abdomen  and  diffuse  tender- 
ness. In  very  rare  cases  collateral  circulation  allows  of  recovery.  In 
the  Porter,  Jackson,  and  Quimby  series,  94  per  cent,  were  fatal.  The 
treatment  is  purely  symptomatic  and  supportive,  but  successful  opera- 
tion is  recorded  by  J.  W.  Elliott,  I^eclerc,  and  Buetter.  (b)  Peri-arteritis 
nodosa  (v.  Diseases  of  the  Vessels),  (c)  Dilatation  of  the  mesenteric 
veins  and  phlebosclerosis  occur,  especially  in  cases  of  liver  cirrhosis. 
(d)  Suppuration  (thrombophlebitis  suppurativa)  may  mark  umbilical 
pyaemia  of  the  new-born  or  may  carry  infection  from  the  appendix 
or  rectum.  (See  H^matemesis.)  (e)  Simple  thrombosis  of  mesenteric 
veins.  Kraft  in  1897  collected  16  cases ;  in  over  half  of  the  cases  syphilis 
or  liver  cirrhosis  was  the  cause. 

IV.  Affections  of  the  Chyle  Vessels. — These  offer  more  patho- 
logical than  clinical  interest.  These  vessels  may  become  varicose  or 
even  hyperplastic  (chylangioma).  Cysts  containing  chyle  may  eause 
tumors,  and,  by  rupture,  may  result  in  chylous  extravasation  in  the 
mesentery,  or  chylous  ascites  (q.v.).  Twenty-four  chylous  cysts  are 
described  by  Broca. 

V.  Mesenteric  Tumors. — These  may  be  dermoid,  hydatid,  serous, 
sanguineous,  chylous,  or  mahgnant.  In  some  cases  they  may  attract 
only  accidental  pathological  attention,  or  they  may  in  other  instances 
fill  the  entire  abdomen.  Their  symptoms  are  those  of  an  abdominal 
tumor,  which  is  centrally  located,  is  movable,  and  covered  with  a  zone 
of  resonant  intestine.  Confusion  is  possible  with  hydronephrosis  or 
ovarian  cvsts. 


692  DISEASES  OF  THE  LIVER 

DISEASES  OF  THE  LIVER. 

(A).  ACUTE  YELLOW  ATROPHY. 

Definition. — An  acute  and  usually  fatal  degeneration  of  the  liver 
cells,  accompanied  by  shrinking  of  the  liver,  icterus,  and  nervous 
toxaemia.  Ballonius  (1600)  reported  the  first  case.  It  is  a  rare  affection; 
Best  collected  450  cases. 

Etiology. — (a)  Sixty-six  per  cent,  occurs  in  women  and  50  per  cent, 
between  the  ages  of  twenty  and  thirty  years.  It  is  rarely  observed  in 
infanc}  or  old  age.  (6)  Thirty-three  to  50  per  cent  of  women  with  the 
disease  (or  27  per  cent,  of  all  reported  cases)  are  in  the  last  half  of  preg- 
nancy; the  first  three  months  of  gestation  almost  render  the  individual 
immune  (Eichhorst).  It  occurs  less  frequently  in  the  puerperium. 
(c)  It  rarely  occurs  as  an  epidemic;  10  soldiers  were  affected  in  Ar- 
nould's  series,  (d)  Injections,  as  osteomyelitis,  diphtheria,  sepsis, 
erysipelas,  typhoid,  recurrent  fever,  and  secondary  syphilis  (10  per  cent. 
Lebert);  or  (e)  poisoning,  as  from  phosphorus,  alcohol,  ptomaine 
poisoning,  chloroform  narcosis,  and  possibly  bacterial  poisons,  may 
antedate  the  disease. 

It  may  occur  primarily  in  a  sound  or  secondarily  in  a  diseased  liver 
(fatty  or  cirrhotic  liver,  or  in  bile  stasis).  Worry  is  thought  to  be  a 
predisposing  factor,  caused,  e.  g.,  by  pregnancy  or  syphilis. 

Pathology. — The  liver  is  small,  the  minimum  weight  recorded  being 
400  grams,  or  about  thirteen  ounces;  in  marked  cases  it  is  so  lax  that  it 
can  be  rolled  up;  the  capsule  is  wrinkled,  the  color  is  usually  yellow 
(atrophia  hepatis  fusca),  and  the  lobular  markings  are  obscure.  The 
liver  cells  are  granular,  fatty,  indistinct  in  contour,  and  some  are  tinged 
with  bile;  some  are  necrotic  and  others  show  evidences  of  regeneration. 
Foci  of  red  tissue  are  observed;  this  is  usually  considered  as  an  ad- 
vanced stage  in  which  the  fatty  necrotic  cells  have  been  absorbed; 
this  tissue  shows  few  or  no  cells,  is  homogeneous,  and  is  composed  of 
detritus;  the  left  lobe  is  often  red,  showing  the  most  advanced  process, 
and  the  right  lobe  is  yellow,  showing  the  earliest  changes.  The  cells  of 
the  bile  channels  are  degenerated  and  sometimes  appear  to  multiply. 
Crystals  of  tyrosin  are  found.  The  apparent  increase  of  the  connective 
tissue  is  relative  only.  Sometimes  infiltration  with  red  or  white  cells 
occurs.  In  other  organs  icterus  staining,  small  hemorrhages,  and  fatty 
degeneration,  are  found,  as  in  the  heart,  kidneys,  muscles,  epithelial 
cells,  and  glands  of  the  bronchi,  lungs,  and  digestive  tract. 

In  nature  the  disease  is  sometimes  considered  inflammatory  (acute 
parenchymatous  hepatitis),  but  is  usually  classified  as  a  degenerative 
or  necrotic  process.  It  is  not  yet  determined  whether  the  disease  is  an 
injection,  to  which  it  has  a  certain  resemblance,  or  an  intoxication.  The 
changes  in  other  organs  are  held  to  result  from  the  liver  change  or  from 
a  common  unknown  cause.    Bacteria  are  found  in  some  cases,  but  their 


ACUTE  YELLOW  ATROPHY  693 

role  has  not  yet  been  determined.  Various  microorganisms  have  been 
found  at  autopsy,  as  the  pneumococcus,  pyogenic  organisms,  colon 
baciUus,  and  other  organisms,  but  not  in  all  cases ;  Prochaska  cultivated 
the  streptococcus,  from  a  case  of  Eichhorst,  before  death. 

General  Clinical  Picture. — Acute  yellow  atrophy  begins  with  a 
'prodromal  stage  in  which  stomach  disturbance  predominates;  icterus 
develops  in  a  few  days  or  a  week,  and  the  second  stage  then  begins 
suddenly  with  cerebral  symptoms  of  unrest,  delirium,  oppression,  vom- 
iting and  convulsions;  with  shrinking  of  the  liver,  hepatic  tenderness, 
enlarged  spleen,  cutaneous  and  mucous  membrane  hemorrhages, 
abortion  and  hemorrhage  if  pregnancy  exist;  with  urinary  symptoms, 
as  bile,  albumin,  leucin,  tyrosin,  and  other  unusual  products  of  metab- 
olism in  the  urine;  and  with  subnormal  or  normal  temperature.  The 
issue  is  almost  invariably  fatal. 

Individual  Symptoms. — The  proc^rowa/^to^e  may  last  from  a  few  days 
to  three  and  a  half  weeks  or  more,  and  is  not  characteristic.  In  the  latter 
half  of  gestation,  icterus  and  hepatic  tenderness  are  suspicious  symp- 
toms. The  stomach  symptoms  and  icterus  become  marked.  Icterus, 
which  is  rarely  absent  except  in  extremely  rapid  cases,  is  obstructive 
from  intrahepatic  changes;  the  stools  are  light  (acholic)  and  the 
jaundice  increases  with  the  second  stage.  Occasionally  there  is  some 
prodromal  swelling  of  the  liver. 

In  the  second  stage,  (a)  the  hepatic  dulness  lessens  to  one-half  or 
one-quarter  of  its  former  dimensions,  which  first  involves  the  left  lobe. 
The  liver  is  small,  flabby,  and  falls  back  toward  the  spine  so  that  in 
some  cases  there  is  no  liver  dulness.  The  liver  dulness  may  remain 
normal,  first,  if  death  is  rapid,  as  from  hsematemesis  (Leube) ;  second, 
if  the  liver  is  cirrhotic;  or,  third,  if  it  is  adherent  to  the  abdominal  wall. 
The  liver  is  tender  and  painful,  and  pain  is  occasionally  referred  to 
other  parts  of  the  abdomen.  The  region  of  the  liver  may  appear 
sunken  and  the  liver  may  feel  flabby  or  may  pit  to  the  finger  (Leube). 
(&)  The  spleen  is  enlarged  in  66  per  cent.;  it  is  not  enlarged  when 
perisplenitis,  profuse  hemorrhage,  or  diarrhoea,  are  present,  (c)  Vomit' 
ing  is  almost  invariable,  the  vomitus  consisting  of  mucus,  bile,  and 
finally  blood;  it  is  accompanied  by  hiccough,  a  dry  brown  or  white 
tongue,  sordes,  and  constipated,  usually  uncolored,  stools,  {d)  The 
nervous  symptoms  may  come  on  gradually  with  headache  and  dulness, 
or  very  abruptly  with  delirium,  anxiety,  meningeal  symptoms,  grinding 
of  the  teeth,  trismus,  wide  pupils,  amaurosis,  cerebral  vomiting,  and 
convulsions  (in  33  per  cent,  of  adults  and  almost  constantly  in  chil- 
dren). The  nervous  symptoms  are  due  to  hepatic  insufficiency  (hepa- 
targia),  the  degenerated  liver  being  unable  to  protect  the  nervous 
system,  as  it  does  in  health,  against  various  ptomaines  and  leuko- 
maines,  (e)  The  urine  is  decreased  or  even  suppressed.  Bile  pigment, 
albumin,  casts,  and  epithelial  cells,  are  found.  Unusual  products  are 
found  in  the  urine,  due  to  the  breaking  down  (autolysis)  of  the  liver 
cells;  leucin  and  tyrosin  occur  most  frequently,  though  they  are  neither 
constant  nor  pathognomonic;    sarcolactic  acid,  oxyamygdalic  acid, 


694  DISEASES  OF  THE  LIVER 

peptone,  and  albumose,  are  also  found.  The  urea  is  decreased  and 
may  be  entirely  absent.  The  ammonium  compounds,  which  normally 
constitute  2  to  5  per  cent,  of  the  nitrogen  excretion,  are  increased, 
even  to  17  or  20  per  cent.,  because  they  are  needed  to  neutralize  the 
increased  amount  of  acid  products  in  the  blood  and  because  the  liver 
cells  cannot  convert  the  ammonium  compounds  into  urea.  The  uric 
acid  and  xanthin  are  increased.  Indicanuria  may  be  noted.  Strangely, 
glycosuria  is  rare,  though  the  glvcogenic  function  of  the  liver  can 
hardly  be  normal.  Bouchard,  Hervouet,  Brouardel,  and  Chauffard, 
speak  of  urinary  crises  with  increase  in  the  amount  of  urine  voided 
and  in  its  nitrogenous  constituents.  (/)  Fever  may  occur  earlj.  in  the 
disease,  but  the  temperature  is  usually  normal  or  subnormal  at  the 
height  of  the  process.  The  pulse  may  be  at  first  slow,  but  later  becomes 
very  rapid.  Dyspnoea  is  almost  invariably  present,  (g)  Hemorrhages 
occur  in  the  majority  of  cases,  largely  from  the  stomach  and  into  the 
skin.  Bowel  hemorrhage  is  less  frequent,  as  are  those  from  the  nose, 
mouth,  g,nd  genital  mucosae.  Uterine  hemorrhages  occur  if  pregnancy 
exist.  Hemorrhages  in  the  retina  are  frequent,  together  with  white 
flecks  due  to  tyrosin  deposit  and  fatty  change.  Punctate  hemorrhages 
into  the  serous  membranes  are  common  autopsy  findings.  Erythem- 
atous eruptions,  muscular  pain,  and  articular  swellings,  may  occur. 
In  a  case  seen  by  the  writer  herpes  was  the  first  symptom.  Leuko- 
cytosis is  infrequent. 

Course. — The  cHnical  course  is  rapid;  50  per  cent,  of  cases  die 
between  the  fifth  and  fourteenth  days,  and  30  per  cent,  between  the 
third  and  fifth  week.  The  second  stage  usually  lasts  one  and  a  half 
to  three  days,  rarely  more  than  a  week,  but  may  be  longer  in  the  rare 
eases  which  recover.  The  more  abrupt  and  severe  the  cerebral 
symptoms,  the  more  rapid  is  the  course.  Pregnancy  hastens  the  issue. 
Remi'ssions  may  be  observed;  temperature  may  develop  during  the 
death  agony.  The  pulse  becomes  very  rapid,  the  breathing  difficult 
and  irregular,  and  the  symptoms  of  nervous  excitation  are  followed 
by  paralysis  of  the  brain  centres. 

Diagnosis. — The  diagnosis  is  based  upon  (a)  the  icterus,  (b)  nervous 
symptoms,  and  (c)  shrinking  of  the  liver.  Diminution  of  the  liver  may 
be  simulated  by  tympanites  or  by  the  colon  lying  over  the  liver;  it 
may  not  shrink  when  previously  cirrhotic  or  when  bound  to  the  abdom- 
inal wall  by  adhesions,  even  though  the  liver  cells  atrophy.  The  urine 
shows  distinct  disturbances  of  metabolism,  which  are  valuable  diag- 
nostically  with  the  above  mentioned  symptoms.  Confusion  may  occur 
in  icterus  gravis,  or  in  the  so-called  bilious  typhoid,  pneumonia,  recur- 
rent fever,  puerperal  fever,  yellow  fever,  phosphorous  poisoning  or 
Weil's  disease;  most  of  these  affections  are  febrile,  while  acute  yellow 
atrophy  is  almost  always  without  fever;  in  addition  to  this,  the  intensity 
of  the  icterus  and  shrinking  of  the  liver,  severe  cerebral  symptoms  in 
which  periods  of  depression  and  exaltation  alternate,  and  the  urinary 
findings,  are  diagnostic.  The  greatest  difficulty  of  diagnosis  is  in 
acute  phosphorous  poisoning,  for  which  Quincke  gives  the  following 


PORTAL  CIRRHOSIS 


695 


diJfferentiation,  though  Leube  maintains  that  differentiation  is  impos- 
sible, except  etiologically. 


Acute  Yellow  Atrophy  — 

One  to  two  weeks  of  moderate  symp- 
toms from  icterus. 

Icterus  intense. 

Liver  sensitive,  smaller.  If  colon  is  dis- 
tended, entirely  obliterating  the  liver 
dulness,  the  urinary  symptoms  are 
suggestive. 

Liver  cells  greatly  degenerated,  and  but 
little  increase  in  the  fat  (5  per  cent.). 

Sudden  cerebral  symptoms  with  alter- 
nating irritation  and  depression  one 
to  two  days  before  death. 

Urine;  oxyamygdalic  acid,  leucin, 
tyrosin. 

Hemorrhages:    smaller  and  fewer. 
Duration  of  one  to  two  weeks. 


—  Acute  Phosphorous  Poisoning. 

Acute  gastro-intestinal  symptoms;  then 
icterus  on  the  third  day. 

Icterus  less. 

Liver  sensitive  and  swollen. 


Very  extensive  fatty  degeneration  (30 
per  cent.). 

Cerebral  symptoms  more  of  depressive 
order. 

Sarcolactic  acid  (though  peptone,  sarco- 
lactic  and  tyrosin  are  found  in  both 
diseases). 

Hemorrhages:     more  numeroiis. 

Duration  .shorter. 


Though  admitting  that  subjects  of  acute  yellow  atrophy  may  recover, 
such  recoveries  usually  indicate  errors  in  diagnosis.  From  simple 
atrophy  of  the  liver  differentiation  is  easily  made  by  the  general  mar- 
asmus and  the  absence  of  icterus  and  of  nervous  and  urinary  symp- 
toms. Cirrhosis  is  differentiated  by  absence  of  ascites  and  the  presence 
of  a  larger  spleen,  firmer  liver,  and  collateral  circulation    {v.  page  724). 

Treatment. — Treatment  is  wholly  expectant  and  entirely  negative 
in  its  results.  The  heart  depression,  vomiting,  and  nervous  excitement, 
are  treated  as  in  typhoid  (q.v.). 


(B).  PORTAL  CIRRHOSIS. 

Synonyms. — Laennec's  cirrhosis,  alcoholic  or  atrophic  cirrhosis. 

Classification. — The  classification  of  the  varieties  of  cirrhosis  is 
difficult;  it  may  be  made  upon  an  etiological,  pathological,  or  clinical 
basis.  From  a  practical  standpoint  the  chief  points  are  included  in 
the  following  classification: 

r  Portal  vein  syphilis. 
\  Chronic  perihepatitis. 

Portal  vein  cirrhosis,  first  in  clinical  importance;  its 
leading  type  is  the  alcoholic,  atrophic  type  of  Laennec. 
(A  sub-type  is  a  hypertrophic  cirrhosis,  like  the 
atrophic  in  every  respect  save  that  the  liver  remains 
large.) 

Hepatic  vein  cirrhosis,  occurring  in  stasis  (cyanotic 
induration),  and,  according  to  French  authors,  with 
portal  vein  cirrhosis. 


(1).  Capsular  or 
.    Glissonian. 


(2).  Vascular. 


(3).  Biliary  Cirrhosis.     Hanot's  disease. 

(4).  Mixed  Cirrhosis.        (Portal  vein  and  biliary  cirrhoses  combined.) 


696  DISEASES  OF  THE  LIVER 

Of  these  forms,  given  in  the  hope  of  elucidating  the  numerous 
classifications,  two  main  forms  are  conspicuous — the  portal  and  biliary. 

Definition. — Portal  cirrhosis  is  a  fibrosis  of  the  liver,  characterized 
(a)  etiologically  by  alcoholism;  (b)  anatomically,  by  induration  around 
the  portal  vein  radicles  and  enclosing  numbers  of  liver  lobules,  whose 
cells  degenerate;  and  (c)  clinically,  by  portal  obstruction  (dyspepsia, 
ha^matemesis,  enlarged  spleen,  and  ascites),  and  often  by  signs  of  hepatic 
insufficiency. 

Etiology. — (a)  Sixty  to  75  per  cent,  of  cases  are  found  in  men 
between  forty  and  fifty  years  of  age.  Musser  (1889)  collected  685 
cases  in  children.  (6)  Alcoholism  is  the  chief  though  not  the  sole 
cause;  cirrhosis  may  be  due  to  whisky,  wine,  beer,  or  absinthe,  especially 
in  sedentary  individuals ;  alcohol  is  absorbed  by  the  gastric  and  intestinal 
veins,  and  is  conveyed  to  the  portal  vein  radicles,  where  its  toxic 
effects  are  expended  on  the  liver  cells  or  interstitial  tissue,  but  in  what 
sequence  it  is  not  known.  Of  late  the  role  of  alcohol  has  been  dis- 
puted, but  it  remains  a  striking  though  perhaps  an  indirect  factor, 
(c)  Syphilis  is  a  cause,  especially  in  the  young,  in  whom  the  toxins 
are  directly  conveyed,  by  the  umbilical  vein,  to  the  liver,  {d)  Other 
infections,  as  malaria  (especially  where  it  is  endemic),  cholera,  typhoid, 
tuberculosis,  scarlet  fever,  measles,  and  diphtheria,  are  possible  causes ; 
experimentally  cirrhosis  has  been  caused  by  the  Bacillus  pyocyaneus, 
Bacillus  coli,  and  staphylococcus;  focal  mycotic  necrosis  is  thought 
to  be  followed  by  fibrosis;  in  this  group  the  toxins  probably  enter  by 
the  hepatic  artery,  (e)  Spices,  curry,  drastics,  lead,  phosphorus, 
arsenic,  haemochromatosis,  anthracosis  (^Velch),  silicosis  (Adami),  cer- 
tain shell-fish,  and  possibly  auto-intoxication  from  dyspepsia,  are  excep- 
tional etiological  factors.  It  may  be  associated  with  gout,  diabetes, 
rickets,  or  other  constitutional  affections.  Experimental  cirrhosis  has 
been  produced  by  lactic,  acetic,  and  butyric  acid.  There  may  be 
multiple  causes,  e.g.,  syphilis  plus  malaria  or  alcoholism.  In  some 
cases  no  cause  is  discoverable. 

Pathology. — The  essential  change  is  fibrosis  around  the  branches 
of  the  portal  vein.  Some  consider  that  the  connective  tissue  growth  is 
primary,  causing,  as  it  contracts,  atrophic  or  fatty  alteration  of  the 
liver  cells,  sometimes  with  pigmentation;  others  maintain  that  the 
cells  are  first  injured  and  are  replaced  by  fibrous  tissue.  Whatever 
the  pathogenesis,  the  connective  tissue  forms  and  surrounds  several 
lobules  at  a  time  {multilohular  cirrhosis).  Histologically  the  cirrhosis 
is  atrophic,  and  this  point  is  emphasized  first,  because  the  size  and 
weight  of  the  liver  may  vary.  Some  clinicians  maintain  that  the  liver 
is  first  large  (the  so-called  hypertrophic  stage)  and  later  is  shrunken. 
Undue  importance  is  attributed  to  size  alone,  for  a  normal-sized  or 
even  enlarged  cirrhotic  liver  is  histologically  atrophic.  An  actually 
atrophic  hver  may  be  large  from  (a)  fat  deposit,  {h)  passive  congestion, 
(c)  compensatory  hyperplasia,  or  {d)  active  congestion.  The  weight 
is  usually  decreased  from  1,500  or  2,000  gm.  (50  or  65  ounces)  to  1,000 
gm.  or  less.      Its  edge  is  rough;  i.e.,  granulations  can  be  felt  which 


PORTAL  CIRRHOSIS  697 

represent  the  remaining  relatively  normal  liver  tissue.  The  surface 
is  sometimes  smooth,  and  microscopic  examination  may  be  necessary 
for  confirmation.  Granulations  also  occur  in  fatty  Hver,  pylephlebitis, 
and  passive  congestion.  Its  consistence  is  increased.  The  liver  is 
gritty  to  the  knife;  its  color  is  yellow  (cirrhosis),  perhaps  green  or 
brown.  The  connective  tissue  is  increased  and  prominent,  encroaching 
on  the  parenchyma.  Injections  of  the  organ  through  the  portal  vein 
are  not  successful;  i.e.,  there  is  portal  obstruction,  which  causes  many 
of  the  clinical  symptoms.  No  connection  between  the  portal  vein  and 
the  hepatic  artery  can  be  demonstrated,  though  injections  are  success- 
ful through  the  hepatic  artery  and  the  biliary  system. 

General  Clinical  Picture. — The  disease  often  exists  for  several  years 
without  symptoms;  this  latency  is  usually  marked  by  enlargement  of 
the  liver,  which  is  due  to  compensatory  hyperplasia.  In  the  minority 
of  cases,  swelling,  pain,  or  active  hypersemia  of  the  liver;  dyspepsia, 
fever,  or  icterus,  are  observed ;  they  last  a  short  time  only  and  are  by 
no  means  characteristic.  With  marked  shrinking  there  are  symptoms 
(a)  of  general  disturbance  of  nutrition,  as  constipation,  emaciation 
(which  is  often  not  noticed  because  the  abdomen  remains  obese),  and 
an  earthy,  sallow  look  to  the  skin,  in  which  dilatation  of  the  small 
arterioles  (toxaemia  or  alcohohsm),  dryness,  and  hemorrhages,  are  also 
observed;  (b)  of  portal  congestion,  as  early  hsematemesis,  epigastric 
pressure,  ascites,  small  liver,  large  spleen,  and  disturbed  breathing, 
circulation,  and  digestion ;  (c)  of  intoxication,  resulting  from  functional 
failure  of  the  heart,  liver,  and  kidneys,  id)  There  may  be  complica- 
tions, as  hemorrhage,  diarrhoea  or  the  so-called  cholfemia. 

Sjnnptoms.— 1.  The  Liver. — The  liver  may  be  enlarged  at  first;  it 
is  enlarged  about  as  often  as  it  is  decreased  in  size;  the  left  lobe  suffers 
most  and  earliest  contraction.  The  liver  may  be  found  to  be  high,  as 
a  result  of  paresis  of  the  diaphragm,  due  to  perihepatitis.  Its  edge  is 
hard,  but  often  cannot  be  felt,  even  after  tapping,  on  account  of  its 
shrinkage  or  because  the  bowels  cover  it.  The  edge  is  uneven,  but  its 
granulations  may  be  confused  with  the  small  islets  of  the  fatty  tissue 
in  the  abdominal  wall,  which  are  due  to  unequal  disappearance  of 
the  adipose  tissue  as  a  result  of  emaciation.  Palpation  of  the  liver 
is  the  only  certain  way  of  determining  its  lower  limit,  the  results  of 
percussion  being  decidedly  unreliable.  In  infantile  forms  of  portal 
cirrhosis  the  liver  and  spleen  are  larger  than  in  adult  types. 

2.  Portal  Stasis. — This  results  from  obstruction  to  the  return  portal 
circulation,  (a)  The  peritoneum  is  thickened,  oedematous,  and  the 
seat  of  transudation,  i.e.,  ascites,  which  occurs  in  85  per  cent,  when 
the  patient  dies  of  the  cirrhosis  itself  and  in  50  per  cent,  when  he  dies 
from  other  causes.  It  is  more  common  in  small  than  in  large  livers. 
Some  writers  hold  that  toxaemia  and  peritonitis  are  more  potent  factors 
than  portal  obstruction.  Ascites  usually  appears  first  without  general 
osdema,  though  later  the  legs  may  become  swollen  as  the  ascites  com- 
presses the  inferior  vena  cava.  Pre-ascitic  oedema  of  the  legs  or  abdom- 
inal wall  may  develop  from  cardiac  or  renal  complications,  involvement 


698  DISEASES  OF  THE  LIVER 

of  the  cava  by  perihepatitis,  or  from  thrombosis  of  the  ihae  veins. 
Under  ascites,  its  physical  signs  will  be  more  closely  considered. 
The  amount  of  fluid  may  be  enormous;  Liebermeister  reports  a  case 
in  which  he  withdrew  nine  gallons. 

The  fluid  is  usually  amber-colored,  seldom  red  from  admixture  of 
blood,  or  very  rarely  turbid  from  fat  (adipose  ascites)  or  lecithin 
(chyliform  ascites);  the  two  latter  forms  also  contain  nucleo-albumin. 
The  specific  gravity  is  1,008  to  1,015,  with  0.6  to  1  per  cent,  albumin. 
Though  ascites  is  rather  rarely  absent  in  advanced  cases  of  atrophic 
cirrhosis,  the  patient  may  die  before  ascites  develops — for  instance, 
from  hemorrhage,  which  is  dangerous  when  there  is  no  ascites  (Ley- 
den).  An  extensive  though  slowly  developing  collateral  circulation 
may  permanently  relieve  an  earlier  ascites.  It  is  not  an  infallible 
sequence  of  atrophic  cirrhosis  (Lecorch^,  Hanot),  and  may  disappear 
after  hemorrhage  (Fauvel),  diarrhoea  (Linas),  or  carcinoma  of  oesoph- 
agus (Lecorch^,  Telamon).  (b)  The  spleen  is  from  two  to  six  times 
its  normal  size,  which  is  due  to  the  early  toxaemia  and  the  later  stasis. 
The  splenic  tumor  is  present  in  75  per  cent,  of  cases  and  is  a  measure 
of  the  degree  of  cirrhosis.  Its  capsule  is  hard  and  thickened  (some- 
times preventing  splenic  enlargement),  the  trabeculse  are  thicker,  and 
a  systolic  murmur  is  sometimes  heard  (Bouchard  and  Leudet).  (c) 
Gastro-intestinal  catarrh  is  due  to  stasis  and  to  alcoholism.  Pain  after 
eating,  especially  in  obese  persons,  a  coated  tongue,  vomiting,  singultus, 
constipation,  piles,  diarrhoea  (which  is  rare  unless  toward  the  end 
of  the  course),  and  meteorism,  also  occur,  (d)  A  collateral  circulation 
may  be  evidenced  by  enlargement  of  the  veins  about  the  navel  (ciV- 
somphalos  or  caput  Medusce).  Prominence  of  the  epigastric  veins 
occurs  regularly,  but  results  from  compression  of  the  inferior  cava. 
Anastomoses  occur  (i)  between  the  median  and  inferior  hemorrhoidal 
veins  (passing  by  the  hypogastric  to  the  cava)  on  the  one  hand,  and  the 
superior  hemorrhoidal  (passing  by  the  superior  mesenteric  to  the  portal 
vein)  on  the  other  hand;  (ii)  between  the  coronary  veins  of  the  stomach 
on  the  one  hand,  and  the  oesophageal  and  phrenic  veins  on  the  other, 
which  empty  into  the  vena  azygos;  (iii)  between  the  veins  in  the  liga- 
ments of  the  liver  and  new  adhesions  and  the  phrenic  veins;  between 
the  veins  of  the  ligamentum  teres  and  the  veins  of  the  abdominal  wall 
and  epigastric  veins,  which  may  sometimes  be  felt  and  may  produce 
murmurs  (Bamberger  and  von  Jaksch);  (iv)  the  mesenteric,  peri- 
toneal and  parumbilical  veins  also  communicate  with  those  of  the 
abdominal  walls.  A  well-developed  collateral  circulation  is  both  a 
favorable  and  an  unfavorable  symptom;  on  the  one  hand  it  relieves 
the  portal  stagnation  and  probably  gives  the  over-taxed  liver  a  better 
opportunity  to  perform  its  functions;  on  the  other  hand,  the  dilated 
collateral  vessels  are  likely  to  rupture  and  they  convey  directly  into  the 
general  circulation  toxic  substances  which  the  liver  normally  destroys 
or  alters;  this  produces,  according  to  Stockton,  the  frequent  arterio- 
sclerosis, granular  kidneys,  and  more  acute  toxaemia,  which  resembles 
uraemia,     {e)   The  kidneys  are  congested,  degenerated,  and  often  show 


PORTAL  CIRRHOSIS  699 

hypertrophy.  The  urine  is  decreased  in  amount,  darker,  and  of  higher 
specific  gravity,  because  the  arterial  tension  is  low  in  cirrhosis.  More 
urine  is  often  secreted  during  fasting  than  during  digestion  (opsiuria), 
which  is  the  converse  of  normal  conditions.  The  urobilin  may  be 
increased  two-fold,  giving  a  fluorescent  filtrate  when  equal  parts  of 
urine  and  a  10  per  cent,  solution  of  zinc  acetate  in  absolute  alcohol  are 
mixed  and  filtered.  The  chlorides  are  decreased,  as  they  accumulate 
in  considerable  amounts  in  the  ascitic  transudate.  The  urea  is  often 
decreased,  but  the  aTnmonium  compounds  (as  in  acute  yellow  atrophy) 
are  often  increased,  less  from  interference  with  the  liver  functions 
than  from  increase  of  acid  products  in  the  blood  (acidosis),  which  the 
ammonium  salts  seek  to  neutralize.  Albuminuria  may  result  from 
stasis  or  nephritis  (v.  i.).  Blood  may  be  found  in  the  urine,  as  a  result 
of  stasis  in  the  bladder.  Glycosuria  is  uncommon  save  in  the  pig- 
mentary cirrhosis  (see  Diagnosis).  Alimentary  glycosuria  may  be 
produced  by  administration  of  100  gm.  (3  ounces)  of  grape  sugar  with 
a  meal. 

3.  General  Symptoms. — There  is  considerable  loss  in  weight,  some 
ancemia,  and  a  sallow,  earth-like  color.  Great  malnutrition  is  readily 
explained  (a)  by  the  inability  of  the  liver  to  properly  handle  the  carbo- 
hydrates, proteids,  etc.,  and  (6)  by  the  diversion  through  the  collateral 
circulation  of  toxins  into  the  general  circulation,  because  the  liver  is 
the  normal  barrier  against  toxins  which  are  injurious  to  the  nervous 
system.  In  a  recent  case  with  well-developed  collateral  circulation, 
scurvy  developed  which  the  writer  interpreted  as  toxsemic.  It  was 
once  thought  that  bile  salts  or  pigment  entered  the  blood  and  produced 
"cholcemia,"  or  that  substances  were  retained  which  the  bile  normally 
excreted,  producing  "acholia";  now  the  term  liver  insufficiency  (hepa- 
targia)  is  more  often  employed.  Toxsemic  nervous  symptoms  include 
adynamia,  headache,  itching,  delirium,  stupor,  convulsions,  paralysis, 
contractures,  or  coma.  Much  depends  upon  the  activity  and  integrity 
of  the  kidneys,  which  may  for  a  time  maintain  adequate  excretion. 

Complications  of  Cirrhosis. — 1.  Hemorrhage. — (a)  Cachectic  capil- 
lary hemorrhage  from  the  nose,  mouth,  lungs,  or  stomach,  is  less  fre- 
quent than  it  is  in  biliary  cirrhosis.  Epistaxis  occurs  from  dilatation 
of  the  vessels  on  the  anterior  part  of  the  septum.  (&)  Of  mechanical 
congestive  hemorrhages  from  the  oesophagus,  stomach,  bowels,  kid- 
neys, bladder,  or  uterus,  those  from  the  oesophagus  are  most  important. 
Zenker  found  oesophageal  varices  in  20  per  cent,  of  cirrhosis  autopsies. 
Their  rupture  causes  haematemesis  (which  occurs  in  23  per  cent,  of 
cirrhosis  cases),  chiefly  in  adults  and  rarely  in  children;  if  they  are 
very  profuse,  blood  may  come  up  without  vomiting.  It  is  usually  an 
early  symptom,  antedating  ascites;  the  amount  is  generally  profuse, 
and  in  one  of  Osier's  cases  amounted  to  10  pounds;  it  often  causes 
blood  in  the  stools.  It  may  pour  out  slowly  and  form  dark  clots;  it 
is  usually  attended  by  less  collapse  than  is  hemorrhage  from  ulcer, 
but  acute  ansemia  or  slight  fever  may  follow  it.  Preble  in  a  careful 
study  of  the  subject  concludes  that:   (i)  Hemorrhage  is  not  a  rare  com- 


700  DISEASES  OF   THE  LIVER 

plication  of  cirrhosis,  (ii)  It  occurs  chiefly  in  atrophic  forms,  (iii) 
In  33  per  cent,  the  first  hemorrhage  is  fatal;  in  66  per  cent,  hemor- 
rhages occur  over  a  period  of  several  months  to  years,  eleven  years 
being  the  maximum,  (iv)  In  33  per  cent,  a  diagnosis  of  cirrhosis  was 
possible  at  the  time  of  the  first  hemorrhage,  (v)  Oesophageal  varices 
were  present  in  80  per  cent.,  and  in  over  half  of  these  macroscopic 
rupture  was  detected;  yet  (vi)  fatal  hemorrhage  may  occur  without 
macroscopic  rupture,  and  is  due  to  a  simultaneous  rupture  of  many 
capillaries,  (vii)  Hemorrhage  may  be  the  first  sign  of  cirrhosis,  but 
other  symptoms  are  usually  found  first,  (viii)  The  symptoms  of 
cirrhosis  were  typical  in  but  6  per  cent,  of  cases  of  oesophageal  varix. 

2.  Peritonitis. — (a)  Chronic  retracting  peritonitis  (in  10  to  19  per 
cent..  Gratia),  may  occur  with  shortening  of  the  mesentery  and  intes- 
tines; according  to  Botazzi  it  prevents  absorption  of  the  ascites.  (6) 
Tuberculous  peritonitis  (10  to  25  per  cent.)  may  occur  with  fever,  pain, 
and  often  a  hemorrhagic  exudate  which  produces  tuberculosis  on 
inoculation.  It  usually  follows  the  ascites  of  cirrhosis  (the  converse 
being  very  rare)  and  hastens  the  fatal  outcome.  One  would  think 
that  stasis  would  tend  to  prevent  the  development  of  tuberculosis. 

3.  Nephritis. — Nephritis  occurs  in  33  per  cent,  of  cases. 

4.  Heart. — The  heart  is  arteriosclerotic  in  60  per  cent.;  chronic 
myocarditis,  endocarditis,  fatty  degeneration,  and  dilatation  of  the 
right  ventricle,  often  occur.    The  arterial  tension  is  low  in  cirrhosis. 

5.  Lungs. — In  the  lungs,  oedema,  catarrh,  emphysema,  various  in- 
flammations, and  very  frequently  pulmonary  tuberculosis  occur;  the 
latter  is  rare  in  infantile  cirrhosis.  Right  hydrothorax  occurs  from 
stasis  in  the  vena  azygos  and  in  the  right  intercostal  veins;  right- 
sided  pleurisy,  due  to  extension  of  perihepatitis  through  the  diaphragm, 
occurs  in  10  per  cent,  of  cases  (Caro). 

6.  Brain. — Pachymeningitis,  meningitis,  or  brain  hemorrhage,  may 
occasionally  occur. 

7.  Fever. — "Intermittent  hepatic  fever"  may  result  from  hepatargia 
(hepatic  intoxication),  perihepatitis,  or  from  complications.  The  tem- 
perature is  usually  subnormal  in  advanced  cases,  though  the  author 
has  often  observed  slight  terminal  temperature  and  leukocytosis,  which 
is  referable  to  terminal  infections, 

8.  Icterus. — In  atrophic  cirrhosis  jaundice  is  a  genuine  complica- 
tion; it  is  due  to  duodenal  catarrh,  enlarged  portal  glands,  or  a  diffuse 
cirrhotic  process  (Andral),  though  few  patients  pass  through  the  dis- 
ease without  having  a  muddy  yellow  areola  under  the  eyes.  If  present 
it  is  incomplete,  and  is  caused  by  compression  of  bile  ducts  by  con- 
tracting connective  tissue.    Its  frequency  is  15  to  20  per  cent. 

9.  Anasarca. — Anasarca  results  from  pressure  on  the  cava  by  an 
extensive  ascites,  from  perihepatitis  -^dth  cicatricial  involvement  of  the 
cava,  and  from  complicating  cardiac  or  renal  disease  and  marasmus. 

10.  Other  Complications. — These  are  rarer;  for  instance,  pyle- 
thrombosis,  clubbed  fingers,  alcoholic  multiple  neuritis,  or  delirium 
tremens;   acute  yellow  atrophy  and  venous  thrombosis  seldom  occur. 


PORTAL  CIRRHOSIS  701 

Course  and  Prognosis. — The  clinical  course  is  essentially  chronic; 
it  usually  lasts  not  more  than  two  or  three  years,  but  its  duration, 
after  the  "diagnosis  is  once  made,  is  more  often  months  than  years, 
though  a  ten  to  fifteen  year  course  has  been  observed.  Following 
Strieker,  Hanot,  and  Lenhartz,  the  author  excludes  all  acute  cases 
from  the  category  of  cirrhosis.  Compensatory  factors  include  (a)  the 
collateral  circulation,  which  may  throw  toxins  directly  on  the  nervous 
centres  and  produce  symptoms  like  those  of  ursemia;  (6)  hyperplasia 
of  the  liver  cells,  which  may  produce  veritable  adenomata.  As  Hanot 
puts  it,  the  diagnosis  is  based  on  the  condition  of  the  connective  tissue, 
but  the  prognosis  depends  on  that  of  the  liver  cells,  (c)  The  kidneys 
may  compensate  to  a  small  degree.  Hale  White  holds  that  ascites 
is  ominous  and  that  the  patient  rarely  survives  the  second  tapping; 
this  does  not  conform  to  the  author's  experience,  though  ascites  is  a 
late  symptom;  the  author  has  seen  numerous  cases  which  survived 
frequent  tappings,  and  he  has  felt  justified  in  excluding  peri- 
hepatitis, which  White  considers  explanatory  of  these  cases.  The 
prognosis  is  relatively  favorable  in  subjects  under  forty  years  with 
large  livers  and  small  spleens.  Recovery  after  a  positive  diagnosis 
has  been  made,  is  possible,  especially  if  the  diagnosis  is  made  early. 
In  advanced  stages  death  is  the  usual  outcome,  although  the  author 
has  seen  relative  recoveries  lasting  for  five  or  six  years  follow  adhe- 
sions from  multiple  paracentesis. 

Death  results  from  hepatargia  (cholsemia,  acholia),  marasmus, 
hemorrhage,  ascites,  intercurrent  pneumonia,  or  other  terminal  infec- 
tions; exhausting  diarrhoea  or  vomiting;  cardiac,  renal,  or  other  com- 
plications (v.  s.). 

Differential  Diagnosis.— Two  classes  of  conditions  require  differen- 
tiation :  on  the  one  hand,  those  in  which  the  liver  is  large;  on  the  other, 
those  in  which  the  liver  is  small. 

1.  When  the  Liver  is  Large. — (a)  The  fatty  liver  is  soft  and  presents 
no  evidences  of  portal  stasis.  (To  avoid  repetition  the  diseases  are 
differentiated  later,  in  tabular  form  [see  page  724].)  (5)  The  amyloid 
liver  is  hard;  the  spleen,  kidnevs,  and  alimentary  mucosa,  are  almost 
always  involved,  icterus  is  very  rare,  and  occurs  only  when 
amyloid  glands  at  the  porta  hepatis  produce  mechanical  icterus; 
anaemia  is  common,  (c)  Leuk(jemic  deposits  in  the  liver  cause  hepatic 
intumescence,  but  the  blood  examination  is  decisive,  (d)  Some  swell- 
ing of  the  liver  may  result  from  simple  icterus,  but  the  history,  absence 
of  portal  stasis,  and  shorter  course,  are  distinctive,  (e)  Passive  hyper- 
emia from  heart  or  lung  disease  produces  an  evenly  enlarged  tender 
liver,  subicterus,  and  cyanosis.  (/)  Cancer  of  the  liver  is  usually 
clearly  marked  by  hard  and  nodose  enlargement,  by  detection  of  the 
primary  growth  (e.g.,  in  the  stomach),  by  icterus,  and  cachexia;  in 
some  cases  early  cirrhosis  may  simulate  cancer,  as  in  a  patient  whom 
Kahler  saw  and  diagnosticated  cancer,  though  the  later  course  proved 
that  cirrhosis  was  present,  (g)  In  syphilis  of  the  liver  the  history,  knobs, 
and  depressions,  the  more  rapid  course,  greater  perihepatitic  pain,  the 


702  DISEASES  OF  THE  LIVER 

icterus  (in  33  per  cent.),  the  findings  in  other  parts,  and  the  results  of 
treatment,  usually  make  the  diagnosis  clear  (see  Syphilis),  (h)  Peri- 
carditic  pseudocirrhosis,  described  by  Pick  (1896),  occurs  in  young, 
rheumatic,  and  cardiac  subjects,  and  is  characterized  by  symptoms 
which  on  the  one  hand  resemble  extreme  passive  congestion  of  the 
liver,  and  on  the  other  a  capsular  cirrhosis;  the  liver  is  large  and  firm, 
there  is  recurrent  ascites  without  oedema  of  the  extremities,  and  little 
or  no  icterus.  Its  mechanism  is  disputed;  contracting  pericarditic 
adhesions  may  perhaps  cause  dilatation  of  the  right  auricle  and  vena 
cava  inferior,  thereby  distending  the  hepatic  vein  system;  or  possibly 
the  inflammation  extends  down  the  cava  inferior  to  the  liver;  the  liver, 
however,  is  permanently  and  disproportionately  congested,  (i)  The 
enlarged  liver  in  Banti's  disease  is  cirrhotic,  but  the  spleen  is  enlarged 
first  and  there  is  early  splenic  anaemia  while  the  cirrhosis  and  hsema- 
temesis  occur  later. 

2.  When  the  Liver  is  Small. — The  following  possibihties  should  be 
considered:  (a)  Syphilis,  characterized  by  stellate  scars,  nodes,  and 
pain,  (b)  Passive  congestion;  the  nutmeg  liver  may  atrophy,  but 
anasarca  is  observed  first  and  usually  there  are  primary  and  suffi- 
ciently characteristic  heart  findings,  (c)  Simple  marantic  atrophy  is  of 
little  clinical  interest;  the  liver  is  small,  there  is  no  portal  stasis,  and 
arteriosclerosis  is  found  in  other  organs,  (d)  Pylethrombosis  is  charac- 
terized by  a  rapid  onset  with  swelling  of  the  spleen,  severe  or  repeated 
haematemesis,  dilated  veins,  and  rapid  recurrence  of  the  ascites  after 
tapping;  it  is  due  to  some  special  cause,  as  pressure  of  a  tumor,  nearby 
ulcers,  suppuration,  or  gall-stones,  (e)  Perihepatitis  has  a  very  much 
slower  course  than  has  cirrhosis;  it  lasts  for  years  with  intermissions, 
and  very  often  results  from  pericarditis.  (/)  In  chronic  peritonitis  the 
fluid  is  turbid,  often  hemorrhagic,  with  high  specific  gravity  and  many 
leukocytes;  it  is  characterized  by  absence  of  symptoms  of  portal  vein 
stasis;  there  may  be  pain,  fever,  and,  in  the  tuberculous  form,  positive 
results  from  inoculations;  the  differentiation  of  chronic  peritonitis  is 
considered  in  detail  under  Ascites,  (g)  The  peculiar  pigmentary 
cirrhosis  of  hsemochromatosis  (diabete  bronz^)  was  first  described  by 
Troisier  (1871),  was  named  by  Recklinghausen,  and  was  particularly 
elaborated  by  the  French  school  (Hanot,  Chauffard).  Its  symptoms 
are  three-fold :  (i)  cirrhosis  (which  causes  the  hemorrhages,  indurated 
hver,  and  enlarged  spleen),  (ii)  diabetes,  and  (iii)  pigmentation  of  the 
skin,  which  somewhat  resembles  Addison's  disease.  It  is  thought  that 
some  toxic  substance  destroys  the  red  blood  cells  (haemolysis),  and  so 
operates  on  the  cells  of  the  liver,  pancreas,  and  other  organs,  that  they 
transform  the  soluble  blood  pigment  into  insoluble  haemosiderin.  This 
pigment  and  an  iron-free  haemofuscin  are  found  in  the  muscles  of  the 
intestine,  heart,  liver,  and  pancreas,  whose  cells  become  pigmented, 
degenerated,  and  necrotic;  the  pigment  passes  into  the  connective 
tissue  of  the  part.  The  essential  lesion  is  pigmentation  of  the  liver, 
skin,  and  pancreas,  with  the  fibrosis  of  the  liver  and  of  the  islands  of 
Langerhans  in  the  pancreas,  which  latter  causes  the  diabetes.  Diabetes 


PORTAL  CIRRHOSIS  703 

has  occurred  in  all  but  five  of  the  French  cases,  but  seems  less  common 
in  those  reported  in  this  country.  In  Letulle's  series  of  30,  29  were 
males  between  forty  and  fifty  years  of  age. 

Treatment. — 1.  Causal  Therapy  and  Prophylaxis. — These  have  but 
limited  applications,  save  in  preventing  further  injury  to  the  affected 
liver  by  syphilis  and  by  use  of  alcohol.  All  forms  of  liquors  or  med- 
icinal tinctures  are  absolutely  interdicted,  but  too  frequently  with  no 
effect.  Syphilitic  forms  are  greatly  benefited  by  appropriate  treat- 
ment, which  some  clinicians  think  may  help  all  forms  of  cirrhosis. 

2.  Medicinal  Treatment. — This  is  of  little  value,  for  cirrhosis  cases 
come  under  observation  only  after  contracting  connective  tissue  has 
already  formed.  Naunyn  has  used  ten  grains  of  ammonium  chloride 
three  times  daily,  but  it  does  not  arrest  cicatrization.  Rolleston  believes 
that  potassium  iodide  and  ammonium  chloride  are  beneficial  in  acid 
intoxication  (acidosis);  he  never  gives  arsenic  and  salicylates. 

3.  Diet. — ^The  diet  should  exclude  rich  proteids,  for  meat  is  less 
well  tolerated  than  milk.  Skimmed  milk  is  best  for  it  contains  but 
1  per  cent,  of  fat.     Rich  or  highly  seasoned  foods  are  to  be  avoided. 

4.  Symptomatic  Treatment. — The  same  treatment  which  is  insti- 
tuted in  chronic  gastritis  or  alcoholism  (q.v.)  may  be  indicated. 
Flatulence  should  be  met  by  calomel  in  fractional  doses,  then  by  salol 
10  grains  after  each  meal,  or  possibly  by  beta-naphthol  10  grains, 
though  it  may  cause  renal  irritation.  Diarrhoea  should  not  be  checked, 
at  least  not  until  the  bowels  have  been  thoroughly  cleansed,  for  it  is 
eliminative.  Unusual  splenic  intumescence  may  be  treated  by  purg- 
ing, for  it  is  often  a  forerunner  of  hsematemesis.  Haematemesis  should 
be  treated  by  absolute  rest  and  by  rectal  feeding,  as  in  gastric  ulcer 
(q.v.);  calcium  chloride  5ss  to  j  may  be  given  by  rectum  for  two  or 
three  doses.  Pain  is  controlled  by  application  of  Reat  locally,  by 
calomel,  ammonium  chloride,  and  by  salines.  Nervous  symptoms 
necessitate  the  same  treatment  as  uraemia;  namely,  laxatives,  sweats, 
and  transfusions  to  which  sodium  bicarbonate  may  be  added  as  it  is 
in  diabetes,  for  the  acidosis. 

5.  Ascites. — Ascites  is  seldom  benefited  by  the  use  of  cardiants, 
sweats,  diuretics,  or  purges.  Early  repeated  punctures  (see  Ascites) 
are  beneficial,  and  may  induce  adhesions  and  consequent  collateral 
circulation. 

6.  Operation. — Talma  and  Van  der  Meulen  (1889)  recommended 
operative  measures,  which  were  later  amplified  in  various  ways 
and  induce  a  collateral  circulation;  these  consist  of  sewing  the 
omentum  to  the  abdominal  wall,  rubbing  the  surface  of  the  liver 
until  it  is  abraded  to  promote  adhesions,  and  other  similar  meas- 
ures. In  the  series  collected  by  Harris,  Greenough,  and  Allyn, 
amounting  (in  1903)  to  125  cases,  about  40  per  cent,  were  improved, 
and  about  90  per  cent,  were  alive  and  in  improved  health  two 
years  after  the  operation.  Montprofit  found  in  224  operations, 
30  per  cent,  cures.  Bunge  collected  (1905)  274  operations  of  the 
Talma-Drummond  type;    the  immediate  mortality  of  the  operation 


704  DISEASES  OF  THE  LIVER 

was  3.6  percent.;  of  the  surviving  cases,  14  per  cent,  were  some- 
what improved,  30  per  cent,  recovered,  and  56  per  cent,  were  not 
improved.  Perhaps  better  results  will  be  recorded  if  operation  is 
resorted  to  early  in  the  disease,  but  it  must  be  recalled  that  the  ascites 
and  collateral  circulation  involve  vital  as  well  as  mechanical  considera- 
tions. How  the  operation  is  beneficial  is  still  a  matter  of  doubt;  its 
mechanical  collateral  side  is  known;  perhaps  lessening  of  venous 
tension  in  the  portal  circuit  helps  the  liver  cells  to  a  better  functional 
activity. 

(0).  BILIARY  CIRRHOSIS. 

Definition.— A  cirrhosis  occurring  chiefly  in  adolescence,  not  due 
to  alcoholism,  and  characterized  by  fibrosis  of  a  mono-  and  intralobular 
type,  by  enlargement  of  the  liver  without  contraction,  by  splenic 
enlargement,  by  chronic  icterus  without  gross  obstruction  of  the  bile 
vessels,  by  paroxysmal  fever,  and  by  absence  of  portal  stasis.  It  is 
also  known  as  Hanoi's  disease,  for  it  was  first  clearly  described  by  him, 
in  1876.  The  term  hypertrophic  cirrhosis  is  unfortunate  and  am- 
biguous. 

Etiology. — Its  etiology  is  obscure.  Alcoholism  is  not  a  factor. 
Sometimes  it  apparently  results  from  (a)  infection,  either  an  ascending 
cholangitis  due  to  the  Bacillus  coli  or  pneumococcus,  or  an  infection 
through  the  blood  stream.  (6)  Age.  Most  cases  develop  between  the 
twentieth  and  thirtieth  years  of  age;  it  is  rare  in  persons  over  forty; 
a  considerable  percentage  occurs  in  the  young,  especially  in  residents 
of  India  (Gibbons,  Ghoses).  (c)  -Sex.  Over  80  per  cent,  of  adult 
cases  are  males;    in  the  young  the  sexes  are  equally  involved. 

Symptoms.— The  onset  is  usually  characterized  by  the  early  develop- 
ment of  icterus  and  less  often  by  malaise,  muscular  asthenia,  fever, 
splenic  pain,  dyspepsia,  diarrhoea,  or  abdominal  pain. 

Cardinal  Symptoms. — -1.  The  liver  is  uniformly  enlarged,  and  may 
weigh  five  to  ten  pounds  (2,000  to  4,000  gm.).  Its  surface  is  Smooth 
and  its  edge  is  fairly  even,  though  somewhat  blunt.  Its  pathological 
characters  will  be  considered  under  diagnosis.  Its  dulness  extends 
from  the  fourth  rib  in  the  nipple  line  to  the  umbilicus  or  even  to  the 
iliac  crest;  it  visibly  bows  outward  the  right  costal  arch;  and  possibly 
by  its  weight  drags  down  the  right  shoulder.  The  gall-bladder  is 
not  enlarged  for  there  is  no  obstruction  of  the  large  bile-ducts.  The 
liver  progressively  increases  in  size,  often  paroxysmally  with  fever, 
pain  over  the  liver,  and  increase  of  the  icterus.  It  never  shrinks,  except 
when  combined  with  portal  cirrhosis. 

2.  Icterus  develops  early,  and  is  constant,  'permanent,  and  character- 
istic. It  varies  in  degree  though  it  is  usually  quite  intense.  It  is  due 
to  obstruction  of  the  smaller  bile  vessels;  it  is  not  certain  that  it  is 
due  to  over-secretion  of  bile  (polychoha)  or  of  bile  pigments  (poly- 
chromia).  In  extreme  cases  the  skin  becomes  green  or  brown.  It  is 
frequently  accompanied  by  itching,  xanthelasma,  eczema,  and  lichen. 


BILIARY  CIRRHOSIS  705 

3.  The  spleen  is  hypertrophied,  is  usually  increased  relatively  more 
than  the  liver,  averaging  one  to  two  pounds  (400  to  1 ,000  gm.)  in  weight 
but  sometimes  actually  outweighs  it  (2,600  gm.),  especially  in  infantile 
forms.  It  is  hard,  smooth,  and  evenly  increased  in  all  its  elements  and 
dimensions.    It  is  often  clearly  visible  and  is  distinctly  palpable. 

Other  Symptoms. — Digestive. — The  condition  of  the  tongue  and  of 
the  appetite  is  variable.  Nausea,  vomiting,  dyspepsia,  and  tympan- 
ites, are  uncommon.  Diarrhoea  is  frequent.  The  normal  or  diarrhoeal 
movements  contain  bile  (in  over  90  per  cent,  of  cases). 

Nutritive. — Nutrition  is  often  maintained  for  years,  despite  the 
icterus,  but  wasting  subsequently  appears.  Development  is  retarded 
in  young  subjects,  and  infantilism  may  be  as  marked  as  in  cretinism 
or  congenital  syphilis.  Clubbed  fingers,  from  hyperplasia  of  the  soft 
tissues,  is  not  an  uncommon  development;  Gilbert  and  Lereboullet 
collected  40  cases  in  1901. 

Urinary. — The  urine  is  highly  colored,  bile-stained,  and  is  usually 
increased  in  amount;  its  freezing  point  is  high  and  it  may  contain 
urobilin,  indican,  or  albumin. 

Circulatory. — The  pulse  is  not  slow;  the  heart  is  often  dilated 
and  may  reveal  a  systolic  murmur;  dyspnoea  is  frequent,  and  results 
from  pressure  on  the  diaphragm  by  the  swollen  liver  and  spleen;  the 
blood  shows  secondary  anaemia,  decreased  coagulability,  and  some- 
times moderate  leukocytosis.  Arthritis  and  multiple  neuritis  are  rare 
complications. 

Diagnosis. — The  following  table  shows  the  essential  pathological  and 
clinical  points  of  contrast  with  the  portal  type: 

Portal    (atrophic)    cirrhosis. vs. Biliary  (hypertrophic)  cirrhosis. 

1.  Etiology:     alcoholism;    over    forty         Infection;    under  forty  years. 

years  of  age. 

2.  Liver,  large  or  small  (possibly  both         Always   large   and   to   greater   degree. 

in  succession);    shrinks  often.  Never  shrinks  in  pure  forms. 

Granulations:    larger.  Small;  very  fine. 

Yellow.  Dark,  icteric,  green. 

3.  Connective  tissue  and  inflammation         Begins  in  lobule  (monolobular  or  insular) 

ensnaring  several  lobules    (mul-  around    smaller   bile    radicles    (chol- 

tilobular  or  annular),  and  around  angitis)  in  early  stages  at  least,  later 

portal  vein  radicles.  less  clear. 

Distinction  between  connective  tis-         Not  sharp, 
sue  and  lobules  sharp. 

Connective     tissue,      firmer,    more         More  delicate,  reticular,  richer  in  cells, 
fibrous;   more  elastic  tissue.  embryonal. 

Scar-like  and  contracts.  Does  not  contract  (elephantiasis  hepa- 

tis). 

4.  Liver-cells,  early  fatty,  degenerate,         Seldom  fatty,  remain  normal  for  long 

disappear.  time,     may    regenerate,     more    jaig- 

mented. 
(Concluded  on  page  706.) 
45 


706  DISEASES  OF  THE  LIVER 

Portal  (atrophic)  cirrhosis. vs. Biliary  (  hypertrophic  )  cirrhosis. 

5.  Portal  system  cannot  be  injected  by         Easily  injected. 

portal  vein. 

6.  Bile  vessels.    (Proliferating  bile  vessels  in  biliary  form  are  not  characteristic, 

and  are  probably  merely  compressed  rows  of  liver  cells.) 

7.  Icterus  infrequent,  a  complication;         Constant  throughout  course,  and  still 

when  present,  usually  catarrhal.  the  stools  contain  bile. 

8.  Ascites  rarely  absent  in  advanced         Absent  in  all  (except  mixed  forms). 

cases. 

9.  Collateral  circulation — usual.  Never. 

10.  Hcematemesis,  frequent,   early,  Very  rare,  late,  cachectic,  or  toxsemic. 

mechanical. 

11.  Constipation  usual.  Diarrhoea  quite  frequent. 

12.  Duration  of  two  to  three  years.  Five  to  ten  years. 

Death  results  from  hsematemesis,nephri-        Rare;   death  from  hepatargia  (so-called 
tis,  tuberculosis,  peritonitis.  cholsemia)  with  fever,  nervous  symp- 

toms, delirium,  typhoid  state,  coma. 

It  is  a  rare  affection,  and  a  diagnosis  of  biliary  cirrhosis  is  too 
often  made.  If  the  cardinal  features  under  its  definition  are  borne  in 
mind,  it  can  usually  be  separated  with  ease  from  the  following  affec- 
tions: (a)  In  hepatic  cancer,  the  subject  is  older  and  more  cachectic, 
the  course  is  shorter,  there  is  no  splenic  tumor,  the  primary  growth 
e.g.,  in  the  stomach,  may  be  recognized,  the  liver  often  presents  ir- 
regularities, the  neoplastic  obstruction  of  the  bile  duct  produces 
acholic  stools,  and  obstruction  of  the  portal  vein  causes  ascites.  (6) 
Multilocular  echinococcus  (q.v.)  also  produces  icterus,  and  enlarged 
liver  and  spleen,  but  is  exceedingly  uncommon,  (c)  Fatty  and  amyloid 
liver  are  unattended  by  jaundice,  and  in  amyloidosis  the  enlargement  of 
liver  and  spleen  is  usually  associated  with  albuminuria,  diarrhoea, 
oedema,  and  cachexia,  (d)  Obstruction  of  the  bile  ducts  may  produce  an 
enlarged  gall-bladder  {v.  Icterus)  ;  the  stools  are  usually  but  not  neces- 
sarily acholic  (e.  g.,  in  stone  of  the  common  duct).  The  spleen  is  not 
large.  In  this  connection  it  may  be  stated  that  some  recognize  a  (so- 
called)  biliary  cirrhosis  due  to  chronic  obstruction  of  the  duct,  as 
described  by  Charcot  and  Gombault  in  1876;  Osier  and  Hale  White 
properly  hold  that  simple  mechanical  obstruction  never  causes  fibrosis, 
though  it  may  follow  ascending  cholangitis.  The  liver  is  far  less  large 
in  this  obstructive  type  and  is  seldom  hard,  (e)  In  hsemochromatosis 
and  pigmentary  cirrhosis,  icterus  is  absent  and  glycosuria  is  present  in 
about  85  per  cent,  of  cases.  (/)  For  Banti's  disease,  see  diagnosis  of 
portal  cirrhosis.      (See  page  724.) 

Treatment.— The  treatment  is  that  of  portal  cirrhosis;  no  means 
are  knowai  which  stop  the  formation  of  connective  tissue.  A  generous 
diet  may  be  given.  Cold  and  dampness  are  especially  to  be  avoided. 
Calomel  in  small  doses  (grain  e-a  to  4^0  t.i.d.)  may  be  given  for  weeks 


ABSCESS  OF  THE  LIVER  707 

at  a  time,  and  salol,  the  salicylates,  and  simple  salines,  are  some- 
times beneficial.  Operative  relief  is  suggested  by  drainage  of  the  gall- 
bladder, but  in  the  reported  cases  the  true  biliary  cirrhosis  is  often 
confused  with  obstructive  icterus:  operation  might  be  helpful  in 
biliary  cirrhosis  due  to  ascending  infections. 


(D).  ABSCESS  OF  THE  LIVER. 

Suppurative  hepatitis  may  be  considered  as  a  local  affection,  though 
it  is  sometimes  a  part  of  septicopysemia  (q.  v.).  Virchow  found  it  in  1.5 
per  cent,  of  autopsies.    Ninety-seven  per  cent,  occurs  in  males. 

Varieties. — 1.  In  the  septic  type,  53  to  55  per  cent,  of  cases  (Baren- 
sprung  and  Luda)  the  hepatic  artery  is  the  usual  carrier  of  infection; 
the  primary  focus  is  usually  in  the  external  parts,  especially  the  skull 
(Hippocrates).  It  may  result  from  osteopayelitis,  external  inflam- 
mations, pulmonary  abscess  or  gangrene,  putrid  bronchitis,  and,  less 
often,  from  ulcerative  endocarditis.  Liver  abscess  occurs  in  15  per  cent. 
of  cases  of  surgical  septicopysemia  (Barensprung).  Infected  thrombi 
in  the  peripheral  veins  may  become  detached,  infarct  the  lungs,  and 
thence  reach  the  arterial  circulation.  In  rare  cases  infective  material 
may  fall  back  from  the  cava  into  the  hepatic  vein;  this  is  known  as 
retrograde  embolism.  The  bacteria  are  those  enumerated  under 
sepsis — the  pyogenic  organisms,  pneumococcus,  colon,  and  typhoid 
bacillus. 

The  symptoms  of  septic  abscess  are  not  distinctive  because,  first,  they 
are  obscured  by  the  general  toxaemia,  and,  second,  the  multiple  abscesses 
when  scattered  through  the  liver  usually  produce  few  decisive  local 
symptoms.  The  liver  enlargement  is  uniform  and  is  generally  indis- 
tinguishable from  the  cloudy  swelling  of  sepsis;  fluctuation  is  rare;  the 
portal  circulation  is  rarely  obstructed;  pain  and  tenderness  are  usually 
present;  jaundice  is  inconstant;  the  spleen  is  swollen  from  sepsis;  the 
course  is  rapid.  The  septic  type  may  occasionally,  and  the  traumatic 
often,  consist  of  a  single  large  abscess. 

2.  The  second  variety  results  from  infection  through  the  tributaries 
oi  the  portal  vein  (31  percent.)  (Kelsch  contends  that  85  per  cent,  of  500 
liver  abscesses  were  due  to  dysentery) ;  it  has  been  known  since  Mor- 
gagni's  time  and  is  clinically  the  most  important  type.  Any  ulcerative 
or  suppurative  affection  in  parts  containing  these  branches  may  be 
causal,  for  instance,  amoebic  dysentery  (the  most  frequent  cause), 
appendicitis  (in  6  per  cent,  of  its  fatal  cases),  neglected  hemorrhoids, 
gastric  ulcer  or  cancer,  and  disease  of  the  bile  vessels,  the  vessels  of 
which  are  portal  tributaries.  Pyogenic  organisms,  the  Amoeba  dysen- 
terise,  foreign  bodies  (as  fish-bones,  pins,  liver  flukes,  and  parasites),  may 
enter  by  the  portal  circulation.  Pus  organisms  may  enter  and  infect 
tuberculous,  echinococcic,  or  actinomycotic  foci,  of  which  latter  40  cases 
are  recorded.  The  form  of  lesion  varies ;  (a)  there  may  be  the  solitary  or 
tropical  liver  abscess,  which  will  be  considered  separately,  or  (h)  there 


708  DISEASES  OF   THE  LIVER 

may  be  suppurative  pylephlebitis,  which  is  less  a  suppuration  of  the 
liver  substance  than  an  extension  of  inflammation  in  the  portal 
vein  itself,  and  follows  in  a  dendritic  fashion  through  all  of  its  intra- 
hepatic ramifications;  its  branches  are  distended  and  present  small 
accumulations  of  pus,  which  may  appear  as  yellowish  foci  through  the 
capsule,  but  show  more  clearly  on  section  as  portal  vein  suppuration; 
the  whole  liver  may  be  involved,  or  certain  areas  may  be  exempted  by 
total  thrombotic  occlusion  of  the  larger  branches.  In  some  cases  the 
purulent  thrombophlebitis  may  be  traced  back  to  the  original  lesion  in 
the  stomach  or  intestine;  the  hver  is  enlarged  but  the  diagnosis  is  rarely 
more  than  a  probable  one. 

3.  The  third  variety  is  infection  by  the  bile  vessels  (10  per  cent.),  in 
which  an  ascending  cholangitis  (q.v.),  often  calculous  in  origin,  pro- 
duces multiple  small  abscesses  through  the  liver  substance;  this  is 
rather  similar  in  appearance  to  the  pylephlebitic  form.  These  three 
varieties  account  for  94  to.  96  per  cent,  of  cases  of  liver  abscess. 

4.  The  fourth  variety  is  infection  in  infants  through  the  navel,  and 
is  an  infrequent  occurrence. 

5.  The  fifth  variety  is  direct  involvement  of  the  liver  by  contiguity, 
which  may  occur  in  various  diseases,  as  in  suppuration  of  the  gall- 
bladder or  ulcer  of  the  stomach. 


Solitary  or  Tropical  Abscess. 

The  abscess  is  solitary  in  75  per  cent,  of  cases;  in  11  per  cent,  there 
are  two,  and  in  14  per  cent,  more  than  two,  foci.  Twenty  to  30  per  cent, 
of  cases  of  amoebic  dysentery,  by  far  the  most  common  cause,  is  com- 
phcated  by  liver  abscess.  Amoebic  abscess  may  even  occur  without 
intestinal  ulceration,  though  amoebae  are  found  in  the  stools;  in  5  out  of 
27  of  Futcher's  cases  there  were  no  intestinal  symptoms.  Over  50  per 
cent,  of  tropical  abscesses  operated  on  in  England  by  Manson  con- 
tained amoebge.  Shiga's  bacillary  dysentery  is  rarely  a  cause.  Single 
abscess  may  occasionally  occur  from  trauma,  pyaemia,  typhoid  (pro- 
bably pyaemic),  or  in  hydatid  cysts.  It  occurs  chiefly  in  the  tropics, 
though  it  is  seen  in  the  Southern  states  and  sometimes  in  the  North.  In 
the  tropics  it  is  thirty-five  times  as  frequent  in  Europeans  as  in  the  natives ; 
alcoholism  and  a  rich  diet  are  particularly  predisposing  factors;  97  per 
cent,  occurs  in  males  and  50  per  cent,  in  those  between  twenty  and 
thirty  years  of  age. 

Pathology. — Amoebae  reach  the  liver  by  the  portal  vein,  and  cause 
necrosis  by  their  toxins;  tliis  is  followed  by  suppuration,  which  may 
cause  single  or  multiple  foci.  The  smaller  and  sometimes  the  miliary 
foci  contain  glairy,  gelatinous,  translucent  fluid;  the  larger  foci  contain 
white,  yellow,  green,  reddish  (Hke  anchovy  sauce,  Budd),  or  chocolate- 
colored  fluid,  which  may  be  serous,  bloody,  or  viscid.  Lafleur  and 
Councilman  consider  that  the  absence  of  leukocytes  in  the  wall  and 
contents    is    pathognomonic    of    amoebic    abscess.      Red    disks    and 


SOLITARY  OR  TROPICAL  ABSCESS  709 

necrotic  liver  cells  are  frequent.  As  Kartulis  pointed  out,  the  pus  is 
usually  sterile.  The  amoebse  are  more  abundant  in  the  abscess  wall 
than  in  its  contents,  and  may  be  found  in  the  vessels  outside  of  the 
abscess.  In  contrast  to  other  abscesses,  the  walls  of  the  amoebic  type 
are  soft,  ragged,  and  produce  but  little  granulation  tissue  or  j&brous 
encapsulation. 

Symptoms. — Absence  of  all  symptoms  (latency)  occurs  in  13  per 
cent,  of  cases.  Symptoms  may  be  classified  as  (1)  septic,  (2)  hepatic, 
and  (3)  other  symptoms  and  complications. 

1.  Septic  Symptoms. — (a)  Fever  is  the  most  important;  it  is  re- 
mittent or  intermittent,  is  less  often  continuous,  and  in  chronic  cases 
there  may  be  a  normal  or  subnormal  register.  (6)  Rigors  and  sweats 
are  frequent,  (c)  Leukocytosis  occurs  in  about  50  per  cent.  only.  In 
43  uncomplicated  dysentery  cases,  the  leukocyte  count  was  above  the 
average  count  of  the  abscess  cases  in  23.4  per  cent.  (Futcher).  (d)  The 
pulse  is  small  and  frequent,  (e)  Progressive  emaciation  is  usual,  and 
the  facies  is  a  combination  of  hectic,  depression,  subicterus,  and 
cachexia,  which  is  difficult  to  describe.  (/)  The  urine  is  febrile  and 
may  contain  albumin  or  albumose. 

2.  Hepatic  Symptoms. — The  liver  is  enlarged  from  the  abscess  and 
from  sepsis.  The  abscess  in  70  per  cent,  is  located  in  the  right  lobe; 
Serege  by  injections  has  shown  that  venous  blood  from  the  pancreas 
and  intestine  is  conveyed  to  the  right  lobe  (whence  the  right  lobe  is 
chiefly  involved  in  intestinal  ulceration  or  cancer),  while  the  blood  from 
the  stomach  and  spleen  finds  its  way  to  the  left  lobe.  The  enlargement 
is  more  often  upward  than  downward,  wherein  abscess  differs  from 
cancer  and  resembles  echinococcus.  The  swelling  is  often  localized, 
occasioning  a  dome-like  dulness  on  the  upper  border  of  the  liver  (Fre- 
richs) ;  in  other  cases  there  is  bulging  of  the  lower  interspaces  or  of  the 
hypochondrium.  In  very  large  abscess  the  entire  organ  is  greatly 
swollen,  as  in  one  reported  case  of  an  abscess  which  contained  2^  gallons 
of  fluid.  When  it  occurs  below  the  ribs,  fluctuation  in  the  liver,  and,  less 
often,  oedema  of  the  abdominal  wall,  may  be  noted.  The  liver  con- 
sistence may  be  increased  at  first.  (6)  Pain  is  usually  present,  and  is 
due  to  increased  weight  or  to  capsular  tension  and  inflammation; 
perihepatitis  or  sometimes  pleurisy  may  cause  a  friction  rub  which 
results  from  fresh  inflammation;  or  may  cause  adhesions  in  more 
chronic  cases.  The  patient  usually  lies  on  the  back  or  right  side  to 
avoid  the  pain  caused  by  sagging  of  the  liver  which  occurs  when  he  is 
in  the  left  lateral  decubitus.  Pain  is  present  in  the  right  shoulder  in  17 
per  cent.,  being  reflected  from  the  phrenic  filaments  on  the  liver  con- 
vexity along  the  phrenic  nerve  to  the  acromial  branch  of  the  fourth 
cervical  nerve,  with  which  the  phrenic  nerve  is  connected;  in  rare  cases 
the  deltoid  may  waste;  the  left  shoulder  is  seldom  the  seat  of  referred 
pain,  (c)  Tenderness  over  the  liver  is  usually  circumscribed,  but 
sometimes  general.    The  right  rectus  muscle  is  frequently  tense. 

3.  Other  Symptoms;  Complications. — (a)  Icterus  occurs  in  16  per 
cent,  of  cases;  it  may  be  slight  from  sepsis  or  from  compression  of  some 


710  DISEASES  OE   THE  LIVER 

bile  ducts  within  the  hver,  or  it  may  be  complete  from  catarrh  of  the 
common  duct,  ibj  The  spleen  is  seldom  enlarged,  except  from  a  causal 
septicopysemia.  (c)  A  dry  spasmodic  reflex  cough  may  be  noted 
(tussis  hepatica).  (d)  Rupture  may  be  the  first  sign  of  abscess  of  the 
liver.  In  AYaring's  300  cases^  56  per  cent,  remained  intact^  16  per  cent. 
Tvere  operated  on,  and  28  per  cent,  ruptured,  (i)  It  occurs  i?ito  the 
lungs  in  about  10  per  cent,  (average  of  the  figures  of  Waring  and  Cyr); 
abscess  of  the  lung  results  more  often  from  direct  rupture  than  froin 
indirect  metastasis  by  the  hepatic  vein.  The  patient  presents  signs  of 
lung  abscess  (q.  v.)  and  expectorates  chocolate-,  anchovy-  or  cream- 
colored  pus  containing  amoebse,  often  liver  and  lung  tissue,  heematoidin 
crystals,  and  perhaps  bile.  Death  may  be  caused  by  profuse  haemop- 
tysis, (ii)  Rupture  into  the  right  pleura  '6  per  cent.;  causes  empyema. 
Pleurisy,  both  fibrmous  and  serous,  may  also  occur  without  rupture, 
resulting  from  attenuated  infection  passing  through  the  lymphatics  of 
the  diaphragm;  a  right-sided  friction  rub,  serothorax  or  empyema, 
should  always  suggest  the  possibihty  of  an  hepatic  etiology,  (iii) 
E.upture  into  the  peritoneum-  (6  per  cent.)  causes  localized  or  diffuse 
peritonitis.  A  subacute  serofibrinous  peritonitis  rarely  results,  but  the 
author  has  seen  this  form,  as  well  as  an  encapsulated  serous  effusion, 
cover  the  convex  and  anterior  surface  of  the  liver,  (iv)  Rupture  into 
the  bowels  (colon  2  per  cent,  and  duodenum  1  per  cent.)  causes  pus  to  be 
voided,  sometimes  in  large  amounts,  by  the  stools,  (v)  Less  frequent 
are  ruptures  into  the  stomach,  pericardium,  pelvis  of  the  kidney,  portal 
or  hepatic  vein,  inferior  cava,  bile  vessels,  or  abdominal  wall,  (e)  Less 
frequent  complications  are  pyloric  obstruction  (from  abscess  of  the  left 
lobe),  pseudorheumatism  or  clubbed  fingers  (horn,  toxaemia),  cerebral 
abscess,  and  intestinal  obstruction. 

Diagnosis. — Diagnosis  is  based  on  (a)  an  etiological  factor;  (b) 
symptoms  of  sepsis;  (c)  hepatic  signs,  localized  enlargements,  pain,  and 
tenderness;  the  a'-rays  may  be  useful  when  there  is  bulging  of  the 
convexity  covered  by  the  lung;  (d)  exploration  -^"ith  the  aspirating 
needle,  which  is  usually  without  danger.  The  author  has  seen,  as  a 
result  of  ptmcture,  two  deaths  from  peritonitis  and  one  from  an  enor- 
mous hemorrhage  into  the  peritoneal  cavity  in  a  case  of  abscess  with 
intense  icterus;  puncture  should  be  performed  only  when  an  operation 
can  be  done  immediately  after  pus  is  found;  pus  is  far  less  often  found 
in  multiple  small  abscesses  than  in  the  large  solitary  form. 

Differentiation. — Five  types  of  hver  abscess  are  often  described; 
(a)  the  latent,  (b)  typhoid  (see  Typhoid  Table,  including  Sepsis  and 
Malaeia),  (c)  malarial,  intermittent,  (d)  phthisic,  and  (e)  a  type 
declared  by  rupture,  either  pulmonary,  peritoneal,  or  pletiral. 

Subphrenic  abscess  simulates  pneumothorax  (q.v.)  rather  than  liver 
abscess,  because  of  the  presence  of  tympany;  in  its  etiology  and  treat- 
ment (see  Localized  Peeitoxitis")  it  resembles  liver  abscess.  In  gall- 
stones, with  or  without  suppuration,  the  fever  usually  occurs  in  par- 
oxysms separated  by  fairly  long  intervals,  jaundice  (if  present)  is  apt 
to  become  more  intense  with  the  fever,  the  historv  is  different,  and 


TUMORS  OF  THE  LIVER  711 

marasmus  is  rare.  Abscess  of  the  abdominal  wall  shows  no  respiratory 
excursion  in  the  exploratory  needle  introduced  into  the  abscess.  Differ- 
entiation from  pleurisy,  echinococcus,  and  cancer  of  the  liver,  is  consid- 
ered under  these  topics  and  also  in  the  differential  table  (page  724), 
Prognosis  and  Treatment. — Ninety-three  per  cent,  of  unoperated 
cases  die  from  unfavorable  ruptures  (peritoneal,  pleural,  pulmon- 
ary), sepsis,  marasmus,  and  amyloid  disease,  which  may  occur  after 
weeks  or  months.  It  is  possible  for  an  abscess  to  desiccate  or  to  heal 
after  breaking  into  the  lung  or  bowel  but  this  cannot  be  depended 
upon.  The  treatment  is  solely  operative;  Solonoff  (1903),  quoted  by 
Rolleston,  in  a  collection  of  1,094  cases  estimates  the  mortality  at  30  per 
cent. 

(E.)   TUMORS  OF  THE  LIVER. 

Tumors  of  the  liver  are  chiefly  carcinoma.  Benign  tumors  possess 
little  clinical  interest,  as  fibroma,  lipoma,  teratoma,  adenoma,  or 
angioma,  which  latter  is  more  frequent  in  the  liver  than  in  any  other 
organ.  Single  adenoma  may  develop  from  the  liver  cells  or  bile  ducts; 
multiple  adenomata  occur  chiefly  in  cirrhosis.  (Three  cases  are  re- 
ported of  adrenal  "rests.")  Sarcoma  is  rarely  primary,  there  being 
hardly  twenty  clear  cases  on  record;  it  may  develop  from  the  connec- 
tive tissue,  endothelium  of  the  lymph  or  bloodvessels  or  Kupfer's  cells, 
as  a  single  primary  tumor,  multiple  primary  tumors,  diffuse  infiltration, 
or  possibly  as  a  primary  melanotic  growth,  which,  however,  is  almost 
always  secondary  to  melanotic  sarcoma  of  the  eye  or  skin. 

Cancer  of  the  liver  occurred  in  2.7  per  cent,  of  Virchow's  autopsies,  and 
ranks  third  among  internal  cancers:  the  frequency  of  cancer  locali- 
zation varies  somewhat;  the  usual  order  of  frequency  is  cancer  of  the 
uterus,  stomach,  mamma,  and  liver;  Eichhorst's  order  is  uterus, 
stomach,  mamma,  oesophagus,  and  liver,  (a)  Primary  cancer  is  20  to  48 
times  as  infrequent  as  secondary  cancer;  66  per  cent,  occurs  in  males. 
It  originates  from  the  liver  cells  (88  per  cent.)  or  bile  vessels  (12  per 
cent.).  The  main  forms  are  observed  (i)  as  sharply  outlined  massive 
local  swelling  (in  23  per  cent,  of  Eggel's  163  cases  reported  in  1901); 
(ii)  as  sharply  demarked  multiple  nodes  of  moderate  size  (in  65  per 
cent.)  of  which  one  of  the  tumors  is  primary  and  the  rest  secondary;  and 
(iii)  as  diffuse  infiltration,  fusing  with  the  parenchyma  (in  12  per  cent.) ; 
(iv)  there  is  a  fourth  form,  which  develops  in  hepatic  cirrhosis. 
The  writer  has  seen  primary  cancer  develop  from  an  hepatic  cyst. 
Metastases  occur  in  66  per  cent  (Eggel).  (6)  Secondary  cancer 
results  from  primary  cancer  in  the  stomach  (33  per  cent.),  in  the  colon 
(12  per  cent.),  oesophagus,  pancreas,  gall-bladder,  uterus,  ovaries,  and 
mamma,  by  metastasis  or  extension  by  contiguity;  cancer  cells  may 
enter  by  the  portal  vein  and  hepatic  artery,  or  much  less  frequently  by 
retrograde  metastasis  through  the  hepatic  vein;  the  lymph  vessels  do 
not  carry  cancer  infection,  as  their  current  flows  from  within  to  without 
the  liver.    Their  structure  is  that  of  the  primary  type. 


712  DISEASES  OF  THE  LIVER 

Sjnnptoms. — 1.  Hepatic  Symptoms. — (a)  The  liver  enlarges  rap- 
idly; it  may  increase  to  six  or  eight  times  its  normal  size  and  may  weigh 
30  to  40  pounds.  Its  edge  is  uneven  though  fairly  sharp;  on  its  surf  ace 
are  lumps  which  may  present  a  central  umbilication.  Great  unevenness 
is  more  characteristic  of  secondary  than  of  primary  tumor  in  which  the 
liver  is  more  uniformly  swollen.  The  enlargement  is  chiefly  downward 
though  the  liver  is  sometimes  high  because  of  ascites,  tympanites,  or 
adhesions.  Nodules  in  the  falciform  ligament  may  be  felt  near  the 
navel  or  linea  alba.  Sudden  increase  in  size  occasionally  results  from 
hemorrhage  which  is  due  to  icterus.  There  is  no  enlargement  when  the 
nodules  are  few  and  small,  and  the  liver  is  smaller  than  normal  in  10  per 
cent,  of  cases  (liver  cirrhosis  plus  malignant  adenomata),  (b)  Hepatic 
pain  is  Tnore  conspicuous  than  in  any  other  liver  lesion.  It  may  be 
caused  by  capsular  tension,  increased  weight,  perihepatitis,  pleuritis,  or, 
less  frequently,  from  rupture  of  tumor  particles  into  the  bile  passages, 
which  may  simulate  the  pain  of  gall-stones,  (c)  The  liver  is  often 
tender,  (d)  Exceptionally  pulsation  may  be  transmitted  from  the 
aorta,  or  there  may  be  a  venous  hum  over  the  liver. 

2.  Cachectic  Symptoms.— These  are  adynamia,  marasmus,  anor- 
exia, secondary  anaemia,  leukocytosis  (in  any  carcinoma,  but  especially 
in  hepatic),  insomnia,  stupor,  and  illusions.  Cachexia  probably  results 
from  the  katabolic  toxins  elaborated  by  the  tumor,  and  possibly  also 
from  hepatic  insufficiency  (v.  Cirrhosis).  Fever  may  result  from  the 
tumor  alone,  from  cholangitis,  and  from  secondary  or  terminal  in- 
fection. The  rare  peripheral  neuritis  and  some  of  the  urinary  findings 
may  be  referred  to  cachexia.  In  some  rare  cases  there  may  be  no 
cachexia. 

3.  Compression  Symptoms. — (a)  Jaundice  occurs  in  50  to  90  per 
cent,  and  more  frequently  in  secondary  than  in  primary  cancer.  It 
usually  results  from  mechanical  pressure  on  the  larger  bile  ducts  by  the 
tumor  or  by  carcinomatous  glands.  Pressure  on  the  ducts  within  the 
liver  often  produces  moderate  jaundice,  and  some  bile  then  appears  in 
the  stools;  complete  icterus  may  result  from  catarrhal  or  calculous 
obstruction  (especially  significant  when  there  is  no  ascites)  or  from 
pressure  by  enlarged  lymph  glands.  Exceptionally  the  tumor  grows  into 
and  along  the  bile  ducts,  thereby  totally  obstructing  them,  (b)  Ascites 
is  present  in  50  per  cent,  of  cases.  It  is  usually  moderate  in  degree  and 
results  from  pressure  on  the  portal  vein  or  its  larger  branches,  periton- 
itis, or  portal  vein  thrombosis  (pylethrombosis) ;  occasionally  it  is  due 
to  the  cirrhotic  form  of  cancer,  growing  of  the  tumor  into  the  hepatic  or 
portal  vein,  rupture — perhaps  with  syncope  and  great  hemorrhage — 
of  a  cancer  nodule  into  the  peritoneum,  or  rarely  to  plugging  of  the 
liver  capillaries  by  the  pigment  of  a  melanosarcoma  (Hektoen  and 
Herrick).  A  collateral  circulation  may  develop.  Friction  from  peri- 
hepatitis may  be  noted.  The  fluid  is  usually  serous  or  hemorrhagic,  less 
often  adipose,  chylous,  or  opaque  (v.  Cirrhosis ) ,  and  very  rarely  contains 
melanin  (sarcoma),  (c)  Other  compression  symptoms  include  splenic 
tumor  from  marantic  pylephlebitis  or  pressure  on  the  splenic  vein  (11  to 


TUMORS  OF  THE  LIVER  713 

17  per  cent.),  hydronephrosis,  vomiting  from  pyloric  obstruction, 
dyspnoea  from  pressure  on  the  heart  and  lungs,  and  oedema  from  pres- 
sure on  the  cava  inferior. 

4.  Other  Symptoms. — The  cervical  glands  are  seldom  swollen  unless 
there  is  coincident  gastric  cancer.  Carcinomatous  nodes  may  appear 
at  the  navel  or  even  in  the  skin  over  the  liver,  which  is  due  to  regional 
extension.  In  liver  cancer  combined  with  cirrhosis  any  cirrhotic 
symptom  may  occur.  The  urine  shows  increased  destruction  of  the 
tissue  nitrogen;  the  nitrogenous  extractives  are  increased  from  the 
normal  0.6  or  0.8  per  cent,  to  13  or  23  per  cent.  Acetone,  and  diacetic, 
lactic,  beta-oxybutyric  acids,  and  indican,  are  not  infrequently  present. 
The  urine  is  decreased,  high-colored,  and  is  often  icteric.  Albuminuria 
is  due  to  stasis  and  toxaemia  (Teissier  speaks  of  hepatogenous  albu- 
minuria). The  urea  may  be  decreased;  leucin  and  tyrosin  are  some- 
times present.  Mel  anuria  (sarcoma)  is  sometimes  detected  by  adding 
to  the  urine  a  solution  of  ferric  chloride;  the  pigment  exists  in  the  blood 
as  melanin  or  melanogen,the  latter  of  which  is  precipitated  as  the  urine 
stands,  or  by  the  addition  of  some  oxydizing  agent  as  nitric  acid;  its 
presence  nearly  always  indicates  involvement  of  the  liver  by  a  melanotic 
tumor;  melanuria  has  often  been  confounded  with  indicanuria  and  al- 
kaptonuria. 

Diagnosis. — The  chief  features  are  rapid  enlargement  of  the  liver, 
irregular  tumors,  pain,  icterus,  ascites,  cachexia,  and,  in  50  per  cent,  of 
cases,  the  recognition  of  the  primary  tumor.  Other  causes  of  liver 
enlargement  must  be  considered  as  in  cirrhosis.  (See also  Differential 
Table,  page  724.)  Icterus  with  ascites  is  always  suggestive.  In  some 
cases  liver  involvement  is  not  suspected.  The  differentiation  is  as 
follows:  (a)  Cirr/io^is  (see  both  forms),  (b)  Syphilis  (q. v.),  as  a,  rule, 
produces  smaller,  harder  tumors,  of  less  rapid  growth,  which  are  more 
often  associated  with  splenic  tumor  and  albuminuria,  much  less 
often  complicated  by  ascites  or  icterus,  and  respond  to  mercury  and 
iodide,  (c)  The  amyloid  liver  is  equally  large  and  but  seldom  causes 
confusion  except  when  complicated  by  gummata;  amyloidosis  of  the 
spleen,  kidney,  and  intestines,  usually  co-exists  with  amyloid  liver,  (d) 
Hydatid  cysts  develop  more  slowly  and  earlier  in  life,  and  cachexia 
appears  late  if  at  all.  Multilocular  echinococcus  produces  enlarged 
liver,  ascites,  and  icterus,  but  the  spleen  is  also  enlarged ;  puncture  may 
give  characteristic  findings;  the  affection  is  very  rare,  (e)  Liver 
abscess  is  seldom  accompanied  by  icterus  and  ascites;  puncture  often 
excludes  those  doubtful  cases  of  cancer  in  which  there  is  fever,  leu- 
kocytosis, and  semifluctuation  of  the  necrotic  neoplastic  nodes.  (/)  In 
congested  liver  the  causal  heart  or  lung  disease,  the  symmetrical  liver 
swelling,  other  signs  of  stasis,  diffuse  tenderness,  and  subicterus  to- 
gether with  cyanosis,  are  distinctive,  though  the  writer  knows  of  four 
cases  of  nutmeg  liver  in  which  the  stasis  unaccountably  caused  more 
local  than  general  hepatic  enlargement,  (g)  The  corset  liver  can  be 
easily  differentiated.  The  general  symptoms,  such  as  cachexia,  and  the 
compression  symptoms  of  cancer,  are  duly  considered,     (h)   Cancer  of 


714  DISEASES  OF  THE  LIVER 

the  stomach  (q.v.)  is  readily  differentiated  by  its  peculiar  chemism  and 
its  signs  of  stagnation;  gastric  cancer  may,  of  course,  be  the  cause  of 
hepatic  involvement,  (i)  Renal  or  adrenal  tumors  are  covered  by  the 
inflated  colon,  encroach  less  upon  the  thorax,  evert  the  ribs  less,  have 
(less  or)  no  respiratory  excursion,  and  often  are  separable  from  the  liver 
by  an  intervening  strip  of  tympany. 

{j)  Differentiation  between  'primary  and  secondary  tumors  is  difficult, 
yet  is  somewhat  irrelevant  according  to  Leube,  as  the  causal  growth 
leading  to  hepatic  metastasis  is  latent  in  50  per  cent,  of  secondary 
tumors,  and  great  caution  should  be  exercised  in  diagnosticating 
primary  liver  tumor.  The  following  characteristics  of  primary  tumor 
are  of  relative  importance,  though  subject  to  many  exceptions:  the 
solitary  tumor,  its  rapid  growth,  infrequent  jaundice  and  ascites, 
lesser  emaciation,  and  more  rapid  course,  which  results  in  death,  ac- 
cording to  Hale  White,  in  less  than  four  months.  Secondary  tumors 
cause  death  within  seven  months,  from  cachexia,  ascites,  and  inter- 
current pneumonia. 

Treatment. — Treatment  is  entirely  palliative  for  the  pain  and 
ascites  except  when,  in  very  exceptional  cases,  early  operation  (for 
primary  growths)  can  be  performed.  Luecke  reported  the  first  recovery, 
which  afterward  proved  to  be  a  gumma;  his  operation  was  followed 
by  a  few  others,  the  cases  of  Xothnagel,  Keen,  Mayo  Robson,  Barde- 
leben,  D'Urso,  Israel,  Hochenegg,  Heidenhain,  von  Bergmann,  and 
others,  which  included  recovery  from  cancer,  sarcoma,  and  malignant 
adenoma. 

(F).  EOHINOCOOOUS  CYSTS  OP  THE  LIVER. 

The  parasite  will  be  considered  under  Animal  Parasites  and  we  will 
here  consider  the  symptoms  of  its  hepatic  localization,  which  consti- 
tutes about  60  per  cent,  of  echinococcus  disease;  though  the  adult 
parasite  occurs  in  the  intestine  of  the  dog,  wolf,  fox,  and  jackal,  its 
cystic  form  occurs  in  man  alone. 

Sjnnptoms. — Fidly  half  the  cases  of  liver  echinococcus  are  clinically 
latent.  Cases  with  symptoms  show  the  foil  o-^dng  Zirer /??i(im^5;  (i)  A 
cyst  on  the  lower  border  or  anterior  surface  may  produce  a  visible, 
palpable,  round  and  smooth  bulge  which  everts  the  costal  arch  or  much 
less  often  affects  the  left  lobe.  In  some  cases  cysts  in  the  right  lobe  lead 
to  compensatory  hypertrophy  of  the  left  lobe,  which  may  equal  the  size 
of  a  normal  liver.  The  tumor  is  as  large  or  larger  than  an  orange.  It 
is  tense,  elastic,  semi-solid,  and  on  percussion  is  dull ;  it  may  fluctuate 
and  give  the  "hydatid  thrill"  of  Briancon  and  Piorry,  a  vibration 
which  is  elicited  by  laying  three  fingers  over  the  cyst  and  tapping  with 
themiddle  one;  the  thrill  is  not  a  frequent  finding,  and  may  also  occur 
in  ascites  and  sarcoma.  The  cysts  rarely  contain  gas,  which  is  due  to 
the  Bacillus  coli.  In  large  cysts  (36  to  70  pints  are  reported  to  have  been 
found)  the  liver  may  tip  so  that  the  right  lobe  is  lower  and  the  left  higher 
than  normal,     (ii)   Cysts  on  the  convexity  crowd  the  diaphragm  up- 


ECHINOCOCCUS  CYSTS  OF  THE  LIVER  715 

ward,  may  cause  symptoms  resembling  those  of  pleurisy  (q.v.),  pro- 
duce a  dome-like  dulness  as  in  cancer,  and  may  compress  the  lung  or 
even  the  heart,  (iii)  Liver  pain  and  tenderness  are  rare  without  sup- 
puration, which  may  induce  perihepatitis;  pain,  as  in  cancer,  may  be 
referred  to  the  right  shoulder.  Pleuritic  pain  follows  rupture  into  the 
pleura,  (iv)  Exploratory  puncture  (Recamier  and  Cruveilhier)  is 
dangerous,  because  severe  nervous  toxaemia  and  cardiac  collapse  may 
follow,  as  described  under  echinococcus  of  the  lung  and  pleura,  where 
also  the  finding  of  pus,  the  characteristic  membrane,  chemical  contents, 
and  hooklets,  are  enumerated. 

Rupture  may  occur  into  the  lungs  (in  11  per  cent,  of  hver  echino- 
coccus); it  may  simulate  phthisis  or  gangrene  of  the  lungs;  cysts  may 
rupture  into  the  pleura,  peritoneum,  kidney,  stomach,  bowel,  bile 
passages,  pericardium,  portal  or  hepatic  vein,  and  cava  inferior;  heart 
embolism  or  external  rupture  may  occur. 

Pressure  symptoms  are  rare,  as  icterus  (5  per  cent.),  pyloric  ob- 
struction, ascites,  albuminuria,  caput  Medusce,  or  oedema  of  the  legs. 
Dyspnoea  may  result  from  pressure  on  the  lungs,  or  vomiting  from 
pyloric  stenosis.  In  some  cases  there  is  a  distaste  for  fat  or  meat. 
Hemorrhage  from  the  alimentary  tract  is  rare.  The  blood  is  usually 
normal,  though  the  eosinophiles  are  usually  increased  in  nonsup- 
purating  cysts.  Urticaria  may  occur  after  puncture  or  rupture,  or 
without  either  incident. 

Diagnosis. — Diagnosis  depends  on  (a)  the  history  of  the  case, 
including  close  contact  with  dogs;  (b)  the  smooth,  round  tumor;  (c) 
the  thrill;  ((^)  slow  development;  (e)  the  infrequency  of  constitutional 
disturbance,  pain  and  fever;  in  other  words,  the  predominance  of 
the  signs  over  the  symptoms. 

DifEerentiation. — (a)  From  other  liver  cysts;  the  small  cysts  which 
occur  in  cirrhosis  and  in  obstructive  icterus  are  of  no  clinical  im- 
portance. Simple  serous  cj'Sts  may,  in  exceptional  cases,  hold  several 
(even  13)  pints;  they  rarely  cause  symptoms,  rupture  or  hemorrhage. 
Diffuse,  congenital,  cystic  disease  may  cause  dystokia;  in  adults  also 
the  cysts  are  probably  congenital  or  developmental  in  origin,  and  are 
associated  with  cystic  kidneys,  in  4  to  27  per  cent,  of  cases  (Lejars, 
Luzatta,  and  Johnson).  Moschcowitz  (1906)  collected  85  cases  of 
non-parasitic  cysts  of  the  liver;  they  are  usually  multiple  and  sub- 
capsular and  are  often  associated  with  other  congenital  anomalies 
such  as  hare-lip,  spina  bifida,  hypospadias,  or  supernumerary  fingers. 
He  concludes  that  (i)  they  are  always  associated  with  congenitally 
aberrant  bile  ducts;  (ii)  they  are  embryonal " rests " ;  (iii)  the  cysts 
are  due  to  inflammatory  hyperplasia  of  these  ducts  or  to  congenital 
obstruction  in  them.  Hoffmann  reported  18  operated  cases.  (6) 
Malignant  disease  ca.\ises  cachexia  more  pain  (than  does  echinococcus), 
multiple  tumors,  ascites,  and  icterus,  (c)  Syphilis  of  the  liver  (q.v.) 
more  often  causes  albuminuria  or  splenic  tumor,  and  responds  to 
antisyphilitic  remedies,  (d)  From  pleurisy;  the  ar-rays  may  show  the 
localized  tumor  on  the  liver  convexity;  but  the  upper  line  of  pleuritic 


716  DISEASES  OF  THE  LIVER 

dulness  is  much  less  often  convex  upward;  there  may  be  thoracic 
symptoms,  as  haemoptysis,  when  there  is  rupture  into  the  lung;  care- 
ful examination  of  the  sputum  or  aspirated  fluid  shows  the  diagnostic 
hooklets.  (e)  In  rare  cases  a  pendulous,  pedunculated,  movable  cyst 
(v.  Frerichs)  may  necessarily  resemble  pancreatic  cysts,  enlarged 
kidney,  gall-bladder  or  ovarian  cyst.  Rupture  into  the  bile  passages 
may  simulate  the  pain  of  gall-stones.  (/)  Liver  abscess  is  usually 
distinguished  with  ease,  though  one  may  remain  in  doubt  in  cases 
of  suppurating  cysts;  the  eosinophiles  are  not  increased  in  liver 
abscess;   both  conditions  are  strictly  surgical.      (See  table  page  724.) 

Prognosis. — The  prognosis  depends  largely  on  whether  surgery  is 
invoked.  Cysts  may,  however,  calcify  or  indurate  spontaneously. 
According  to  Cyr,  the  mortality  of  rupture  into  the  peritoneum  is 
90  per  cent.,  into  the  pleura  80  per  cent.,  bile  ducts  70  per  cent., 
bronchi  57  per  cent.,  stomach  40  per  cent.,  intestines  15  per  cent., 
and  externally  10  per  cent. 

Treatment. — ^When  drainage  by  the  trochar  is  performed  (Hippoc- 
rates), it  is  said  that  45  to  77  per  cent,  of  cases  recover,  and  some 
are  benefited  by  injection  of  iodine  or  electrolysis.  A  few  die  sud- 
denly from  a  toxalbumin,  which  is  formed  when  the  parasite  dies; 
it  causes  urticaria,  convulsions,  cardiac  failure  and  other  symptoms 
similar  to  those  produced  by  myrtilotoxin  in  mussel-poisoning.  Direct 
surgical  intervention  is  attended  with  the  least  risk.  Prophylaxis  is 
necessary,  such  as  the  burning  of  slaughter-house  offal  and  avoiding 
close  contact  with  dogs. 


Multilocular  or  Alveolar  Echinococcus. 

This  form  is  due  (see  Animal  Parasites)  to  another  parasite;  it 
is  extremely  infrequent  and  only  about  100  cases  are  recorded. 

Symptoms. — The  right  lobe  of  the  liver  alone  is  involved  in  65 
per  cent,  of  cases,  and  the  left  alone  in  10  per  cent.  The  liver  is 
hard  (from  fibrosis),  nodular  and  seldom  fluctuates.  This  rare  affec- 
tion is  attended  by  splenic  tumor  (90  per  cent.),  icterus  (80  per  cent.), 
dyspepsia,  ascites  and,  less  commonly,  by  fever,  polyuria,  collateral  cir- 
culation, gastro-intestinal  hemorrhage,  late  emaciation  (cachexia),  and 
metastases  in  the  heart  and  lungs  by  way  of  the  lymph  or  blood- 
vessels ;  or  death  may  occur  after  a  number  of  years  from  cholaemia  or 
hemorrhages.  The  diagnosis  is  very  difficult,  though  it  is  sometimes 
aided  by  exploratory  pomcture,  and  the  most  frequent  confusion  is 
with  cancer  of  the  liver.  The  only  hope  of  recovery  is  in  extirpation, 
which  has  been  successfully  done  by  Terillon,  Bruns  and  others. 


FATTY  LIVER  717 


(G).  FATTY  LIVER. 

The  term  "fatty  liver"  {hepar  adiposum)  includes  fatty  infiltration 
and  fatty  degeneration;  as  a  distinction  between  them  is  of  more 
speculative  than  clinical  interest,  they  may  be  considered  together. 

Etiology. — (a)  Obesity  and  (6)  decreased  oxygenation  from  carcinosis 
or  any  other  cachexia,  rickets,  profound  or  pernicious  anaemia,  phthisis, 
cardiac  stasis  and  kindred  causes  may  produce  fatty  liver,  (c)  Tox- 
oemias,  as  tuberculosis,  the  acute  specific  infections,  infantile  diarrhoea, 
acute  yellow  atrophy,  and  suppuration,  id)  poisons,  as  phosphorus, 
alcohol,  arsenic,  or  chloroform,  and  (e)  local  diseases  of  the  liver,  as 
cirrhosis  or  nutmeg  liver  are  etiological  factors. 

Pathology. — The  fat,  which  is  normally  found  in  the  liver  up  to 
2  to  5  per  cent,  of  its  weight,  may  amount  to  over  40  per  cent.  The 
liver  is  enlarged,  and  may  weigh  as  much  as  12  pounds  or  4,500  gm. 
Its  surface  is  smooth,  its  edges  are  rounded,  its  consistence  is  decreased 
and  its  color  is  yellow.  On  section  it  is  ansemic,  yellow  and  smooth, 
though  the  lobules  may  be  slightly  prominent.  The  color  is  yellow 
when  oleic  acid  predominates,  and  pale  when  there  is  more  palmitin 
and  stearin.  Slight  quantities  may  be  detected  only  on  microscopic 
examination.  When  cut  with  a  warm  knife  the  fat  may  be  seen  on 
the  blade.  Microscopically,  fat  is  seen  which,  in  fatty  infiltration,  is 
located  principally  in  the  periphery  of  the  lobule  and  obscures  the 
liver  cells;  when  the  fat  is  dissolved  by  ether,  the  normal  liver  cells 
are  clearly  seen.  In  fatty  degeneration,  fat  forms  at  the  expense 
of  the  liver  cells,  i.e.,  the  percentage  of  albumin  is  decreased.  The 
statement  that  fatty  infiltration  occurs  in  large  globules  and  fatty 
degeneration  in  smaller  ones  is  not  wholly  correct.  Pathologists  have 
lately  been  inclined  to  consider  infiltration  of  more  importance  than 
degeneration. 

Symptoms. — (a)  The  positive  findings  are  as  follows:  the  liver  is 
symmetrically  enlarged  and  smooth  and  rarely  extends  below  the  navel. 
Its  edge  is  rounded,  soft  and  can  usually  be  palpated,  even  in  obese 
persons.  (6)  The  negative  findings  are  absence  of  pain,  tenderness, 
icterus,  splenic  tumor,  ascites  or  gastro-intestinal  hemorrhage.  The 
urobilin  may  be  decreased. 

The  diagnosis  is  easily  made,  and  liver  stasis,  amyloid  degeneration, 
and  cirrhosis  can  be  readily  excluded  (see  Differential  Table,  page 
724).  The  treatment  is  merely  that  of  the  causal  obesity  or  of  other 
factors  involved. 

(H).  AMYLOID  LIVER. 

Amyloid  degeneration  was  first  clearly  described  by  Rokitansky. 

Etiology. — (a)  Ulcerative  tuhercidosis  of  the  lungs  or  bones  causes 
over  50  per  cent,  of  amyloidosis.  (6)  Inveterate  syphilis,  particularly 
the  ulcerative  and  osseous  types,  produces  about  25  per  cent,  of  amy- 


718  DISEASES  OF  THE  LIVER 

loid  disease,  (c)  Chronic  suppuration,  in  connection  with,  or  inde- 
pendently of,  the  above  causes,  has  become  uncommon  since  the 
introduction  of  asepsis  and  antisepsis.  Krawkow  produced  amyloid 
degeneration  experimentally  by  inoculations  of  the  staphylococcus. 
(d)  As  exceptional  causes,  intestinal  ulcerations,  exhausting  diarrhoeas, 
rickets,  leukaemia,  pseudoleuksemia,  and  ulcerating  neoplasms  may 
be  mentioned.     Seventy-eight  per  cent,  occurs  in  males  (Frerichs). 

Pathology. — Amyloid  degeneration  is  much  less  frequent  in  this 
country  than  in  Europe.  Its  localization,  in  order  of  frequency,  is 
in  the  spleen,  kidneys,  liver  and  intestines.  The  liver  is  uniformly 
enlarged  and  may  weigh  13  to  16  pounds  (5  to  6,000  gm.),  even  in  a 
child.  It  is  hard,  smooth  and  very  pale.  Its  edges  are  more  blunt 
than  normal,  though  somewhat  sharp.  On  section  the  general  appear- 
ance is  waxy,  speckled,  somewhat  resembling  raw  ham,  the  edges  are 
slightly  translucent  and  the  lobules  are  indistinct.  If  a  thin  slice  is 
placed  in  diluted  Lugol's  solution,  the  amyloid  areas  assume  a  brown 
color  (Virchow),  the  name  (amyloid)  referring  to  this  starch-like 
reaction;  the  waxy  substance,  however,  is  a  proteid,  and  reaches 
the  liver  by  the  hepatic  artery,  whence  it  is  first  deposited  in  the  middle 
zone  of  the  lobule,  and  later  infiltrates  the  central  and  peripheral 
zones.  It  is  essentially  an  infiltration,  aiJecting  primarily  the  capil- 
laries of  the  hepatic  artery.  Slight  lesions  may  necessitate  the  use  of 
the  microscope  for  detection.  Amyloid  liver  may  co-exist  with  gumma, 
cancer,  or  cirrhosis. 

S3miptoms. — The  large,  tense,  symmetrical,  painless,  smooth  liver, 
with  rounded  edges,  is  characteristic.  Its  measurements  may  attain 
those  caused  by  cancer.  The  onset  and  development  are  usually 
slow,  but  acute  amyloid  has  developed  within  a  month.  Splenic 
amyloid  enlargement  is  usually  also  noted,  as  well  as  albuminuria 
from  renal  amyloidosis  (g.  v.).  In  only  0.8  per  cent,  of  amyloid  degener- 
ation is  the  liver  alone  involved  (Fehr).  Gastro-intestinal  symptoms, 
as  nausea,  vomiting  and  diarrhoea  may  result  from  amyloidosis  of 
the  alimentary  capillaries.  In  advanced  cases  cachexia,  cedema  and 
ascites  may  develop.     Hepatargia  is  rare. 

Diagnosis. — Diagnosis  depends  on  (a)  the  recognition  of  a  cause; 
(b)  the  characteristic,  smooth,  symmetrical  enlargement,  which  is  less 
hard  than  that  of  cirrhosis;  (c)  the  association  with  amyloid  disease 
of  the  spleen,  kidney,  and  alimentary  tract;  {d)  the  absence  of  icterus 
(which  very  rarely  results  from  amyloid  portal  glands)  and  of  portal 
stasis  (ascites  is  infrequent,  is  a  late  symptom  and  results  from  renal 
implication) ;  and  (e)  the  small  amount  of  urobilin  in  the  stools. 
Differentiation  from  cirrhosis  (q.v.)  and  cancer  (q.v.)  presents  no 
difficulties.  Gummata  in  the  liver  plus  amyloid  disease  may  cause 
confusion.  No  diagnosis  is  possible  in  the  exceptional  cases  in  which 
the  liver  is  slightly  enlarged,  because  it  is  only  slightly  diseased,  or 
in  those  cases  in  which  splenic  tumor  and  albuminuria  are  absent. 
Other  diffuse  and  focal  hepatic  diseases  are  differentiated  in  the  table 
on  page  724. 


ANOMALIES  OF  FORM  AND  LOCATION  OF  THE  LIVER       719 

The  prognosis  of  pronounced  eases  is  unfavorable,  though  light 
grades  may  exceptionally  regress  (Budd,  Bamberger,  Frerichs,  Graves). 

Treatment  is  unavaihng;  it  is  solely  that  of  the  causal  condition 
and  of  the  symptoms  as  they  arise. 


(I).  ANOMALIES  OF  FORM  AND  LOCATION  OF  THE  LIVER. 

In  situs  viscerum  inversus  the  liver  lies  on  the  left  side,  which  in 
pathological  conditions  may  lead  to  serious  diagnostic  error.  Fenger 
and  Billings  mention  a  case  of  icterus  and  gall-stones  in  situs  inversus 
which  was  diagnosticated  as  acute  yellow  atrophy! 

Tilting  of  the  liver  (ante-  and  retroversion),  dislocation  downward 
by  pleuritis,  pneumothorax  or  tumors,  or  upward  luxation  require  but 
passing  mention. 

The  liver  may  be  found  in  the  thoracic  cavity  as  a  result  of  con- 
genital malformation  or  severe  trauma. 

"  Wandering  liver "  (hepar  migrans  s.  mobile)  occurs  in  women, 
(in  88  per  cent.)  and  usually  after  several  pregnancies.  Its  causes  are 
those  of  enteroptosis,  with  which  it  usually  occurs,  viz.,  flaccid  abdom- 
inal walls,  possibly  congenital  laxness  of  the  suspensory  ligaments, 
tight  lacing,  or  very  rarely  from  traction,  as  by  a  tumor.  J.  Dutton 
Steele  collected  100  cases,  which  Clark  and  Dolley  (1905)  increased 
to  118;  they  report  one  case  with  a  mesohepar  attached  to  the  dia- 
phragm and  with  absence  of  the  coronary  and  right  lateral  ligaments. 

Symptoms. — Symptoms  may  be  entirely  lacking.  In  5  per  cent, 
the  onset  is  acute  (Graham),  though  usually  gradual.  Subjectively, 
vague  pain  or  oppression  over  the  liver,  gastro-intestinal  disorders 
or  nervous  symptoms  may  be  present.  Objectively,  the  liver  is  lower 
and  is  more  mobile  than  normal;  there  is  sometimes  cardioptosis 
(Einhorn),  usually  gastroptosis,  and  in  20  per  cent,  nephroptosis 
(J.  D.  Steele).  Its  notch  can  be  distinctly  felt,  often  also  its  con- 
vex surface  and  sometimes  the  tense,  stretched  ligaments.  It  can 
be  replaced.  The  entire  liver,  in  extreme  instances,  may  be  below 
the  costal  arch,  and  tympany,  due  to  the  bowel,  may  exist  between 
it  and  the  lung.  In  a  recent  case  seen  with  Dr.  DeLee  there  was 
tympany  between  the  left  costal  arch  and  the  prolapsed  spleen,  and 
tympany  between  the  right  arch  and  the  liver,  even  though  the  patient 
was  five  months  pregnant.  In  very  rare  instances  there  may  be  pain 
similar  to  that  of  gall-stones;  ascites,  or  splenic  tumor,  result  from 
torsion  of  the  portal  vein. 

Treatment. — The  treatment  is  (a)  mechanical,  which  consists  of 
replacing  and  supporting  the  liver  with  appropriate  binders  or  pads; 
(b)  symptomatic,  with  due  consideration  of  the  neurasthenic  manifes- 
tations; (c)  dietetic,  in  order  to  increase  the  body-weight  and  {d) 
operative,  in  which  the  liver  is  sewed  to  the  diaphragm  or  abdominal 
wall.    In  39  cases,  hepatopexy  cured  about  75  per  cent. 


720  DISEASES  OF  THE  LIVER 

The  corset  liver  is  found  in  25  per  cent,  of  female  cadavers  (Leube), 
though  it  is  much  less  frequent  in  the  United  States  than  in  foreign 
countries.  Corsets  cause  pressure-atrophy  of  the  liver  substance, 
which  is  followed  by  induration,  peritoneal  thickening  and  deformity; 
these  changes  are  most  conspicuous  and  usual  in  the  right  lobe.  The 
liver  may  be  merely  constricted,  or  dislocated  upward;  or  the  part 
below  the  constricting  zone  may  hang  loosely  as  upon  a  hinge;  this 
may  cause  diagnostic  confusion  with  floating  kidney,  enlarged  gall- 
bladder or  other  tumors.  The  gall-bladder  is  said  to  be  dilated  in 
60  per  cent,  of  cases,  though  icterus  is  quite  infrequent.  Subjective 
manifestations  are  often  absent,  though  there  may  be  a  sense  of  pres- 
sure over  the  part.  Sometimes  paroxysmal  syncope  and  vomiting 
may  occur;  they  are  due  to  congestion  of  the  snared-off  portion  of  the 
liver.  Physical  examination  often  determines  the  condition,  especially 
when,  by  careful  palpation,  the  hinged  and  hard  part  can  be  proven 
directly  continuous  with  the  liver's  known  margins.  Respiratory 
excursion  is  naturally  imparted  to  it  in  most  cases.  Confusion  neces- 
sarily arises  when  a  loop  of  gut  causes  a  small  zone  of  tympany  be- 
tween the  hinged  segment  and  the  liver  proper,  but  even  then  careful 
palpation  frequently  demonstrates  its  continuity  with  the  liver.  Con- 
genital tongue-like  lobes  may  be  confused  clinically  with  corset  liver; 
they  are  often  cirrhotic  and  relatively  often  the  seat  of  malignancy, 
suppuration  or  syphilis.  Corset  liver  is  regarded  as  a  disposing  factor 
in  gall-stone  formation.  Treatment  is  seldom  possible  nor  is  it  im- 
portant, though  prophylaxis  and  perhaps  resection  should  be  men- 
tioned. 


(J).  AFFECTIONS  OF  THE  BLOODVESSELS  OF  THE  LIVER. 

I.  Active  Hypersemia  of  the  Liver. 

A  degree  of  arterial  hyperajmia  is  physiological  during  digestion, 
when  an  excess  of  blood  is  found  in  the  portal  circulation.  An  accen- 
tuation of  this  condition  is  common  in  heavy  eaters  and  drinkers,  in 
trauma  and  acute  infections,  in  the  latter  of  which  it  may  be  combined 
with  venous  hypersemia.  Heat  is  probably  not  a  cause,  though  some 
physicians  in  the  tropics  speak  of  tropical  hyperemia.  The  alleged 
vicarious  hypersemia  from  suppressed  menstruation,  the  menopause, 
or  diseases  of  the  internal  female  genitalia,  is  based  wholly  on  theory. 
The  symptoms  resemble  those  of  passive  hypersemia  (v.i.),  viz.,  some 
hepatic  enlargement,  moderate  discomfort  in  the  right  hypochondrium, 
and  also,  it  is  alleged,  slight  icterus.  Treatment  is  seldom  indicated, 
save  in  cases  of  dietetic  excesses,  where  gastro-intestinal  symptoms 
also  obtain.  Then  a  simple,  moderate,  or  milk  diet,  together  with 
calomel  and  saline  purgation,  is  indicated. 


PASSIVE  HYPEREMIA  OF  THE  LIVER  721 


II.  Passive  Hyperasmia  of  the  Liver. 

Etiology. — Passive  congestion  of  the  liver  results  from  various 
kinds  of  stasis,  the  stress  in  all  of  which  is  felt  in  the  efferent  hepatic 
(sublobular)  veins  within  the  liver.  It  results  (a)  from  cardiac  insuffi- 
ciency, which  is  caused  by  valvular  diseases,  particularly  mitral,  myo- 
cardial maladies  or  pericardial  lesions  (effusion  or  synechia;)  (b)  from 
pulmonary  stasis,  due  to  emphysema,  chronic  bronchitis,  asthma, 
induration  or  obliterative  pleurisy;  (c)  from  stasis  caused  by  spinal 
deformity,  aneurysm,  mediastinal  tumor,  perihepatitis,  or  pressure  on 
the  cava  inferior. 

Pathology. — The  essence  of  passive  congestion  is  over-filling  of  the 
sublobular  or  the  hepatic  venous  circulation,  malnutrition  of  the  liver 
cells  (fatty  degeneration)  and  in  some  advanced  cases,  increased  con- 
nective tissue.  The  liver  is  usually  symmetrically  enlarged,  firmer,  and 
a  darker  red  than  normal,  though  hepatic  hypereemia  lessens  after 
death.  The  capsule  is  often  thickened  or  oedematous.  On  section 
the  so-called  nutmeg  appearance  is  noted,  but  this  seldom  occurs 
over  the  entire  liver.  The  central  veins  with  their  radiating  offsets 
are  dark,  cyanotic,  and  sometimes  sclerotic  from  stasis,  while  the 
periphery  of  the  lobule  is  yellow-white  from  cloudy  or  fatty  change 
(malnutrition  or  impaired  oxygenation).  The  nutmeg  appearance  is 
not  pathognomonic  of  passive  congestion.  Long-standing  congestion 
results  in  atrophy  and  pigmentation  of  the  cells  in  the  periphery  of  the 
lohu\e(Yirchow's  red  atrophy);  there  is  usually  increased  connective 
tissue  with  fine  granulations;  this  is  the  atrophic  cyanotic  liver  or  the 
cardiac  cirrhosis  of  the  French;  fibrosis  is  probably  for  the  most  part 
relative  or  apparent,  for  the  liver  parenchyma  atrophies;  true  cir- 
rhosis may  co-exist  with  cardiac  disease. 

Symptoms  and  Diagnosis. — (a)  The  causal  heart  (or  lung)  lesion 
has  its  appropriate  symptoms,  (b)  The  liver  is  evenly  enlarged,  both 
on  percussion  and  palpation,  sometimes  also  on  inspection;  if  ascites 
is  present,  thrusting  palpation  with  the  finger-tips  usually  outlines  the 
organ;  the  liver  may  reach  to  the  navel  or  even  lower  and  may  evert 
the  ribs.  Its  edges  are  firmer  than  normal,  somewhat  rounded,  sen- 
sitive (from  capsular  tension)  and  descend  with  inspiration;  the  incisure 
is  clearly  felt.  If  there  is  relative  tricuspid  insufficiency,  a  systolic 
expansile  pulsation  is  detected  by  palpating  with  both  hands,  which 
are  separated  from  each  other  with  each  systole.  This  is  readily 
differentiated  from  the  non-expansile  pulsation  which  is  transmitted 
to  the  liver  from  the  aorta,  (c)  The  hepatic  intumescence  varies 
greatly,  as  the  heart  responds  to  rest  or  to  digitalis,  or  fails  in  com- 
pensation, {d)  The  skin  shows  cyanosis  and  is  also  tinged  with  slight 
icterus;  to  the  experienced  eye,  it  has  a  characteristic  appearance, 
which  is  probably  due  to  a  static  catarrh  of  the  finer  interhepatic 
bile  radicles,  (e)  For  other  symptoms,  see  Signs  of  Stasis  under 
Valvular  Disease.     The  spleen  is  seldom  enlarged  save  from  cardiac 

46 


^722  DISEASES  OF  THE  LIVER 

infarcts  or  complicating  liver  cirrhosis.  Hsematemesis  is  infrequent. 
Albuminuria  and  gastro-intestinal  symptoms  are  referable  to  the  heart. 
Ascites  is  usually  late  in  appearing  and  moderate  in  degree;  the  earlier 
statement,  that  an  ascites,  which  is  disproportionately  marked  in 
comparison  with  the  general  oedema,  indicates  the  atrophic  (indurated) 
nutmeg  liver,  is  incorrect,  because  a  cardiac  ascites  sometimes  oc- 
curs without  general  oedema.  Toward  the  end  of  the  course  there 
may  be  signs  of  renal  and  hepatic  insufficiency. 

Differentiation  is  seldom  complicated,  for  the  fundamental  heart 
lesion,  the  evenly  enlarged,  tender  liver,  which  varies  in  size  from 
time  to  time,  and  the  slight  icterus  with  the  cyanosis,  are  usually  un- 
mistakable. Certain  features  may  sometimes  mislead,  as  the  occasional 
unequal  distribution  of  the  liver  changes,  which  may  suggest  tumor; 
the  tenderness  in  two  cases  which  the  author  saw  was  thought  to  be 
suppurative.  (See  table  page  724.)  The  treatment  is  that  of  uncom- 
pensated valvular  disease  (q.  v.). 

III.  Pylethrombosis — Pylephlebitis. 

Thrombosis  or  phlebitis  of  the  portal  vein  is  practically  always 
secondary  to  compression  or  obstruction,  as  liver  cirrhosis  with  which 
33  per  cent,  of  pylephlebitis  cases  occur;  to  cancer,  ulceration,  abscess 
or  inflammation  of  contiguous  structures,  gall-stones,  cholangitis  and 
chronic  proliferative  peritonitis;  and  to  diseases  of  the  intima,  as 
phlebosclerosis  and  syphiHtic  endophlebitis;  all  cases  are  promoted 
by  slowing  of  the  portal  current.  Parasites  (distoma  and  bilharzia 
hsematobium)  and  embolism  are  rare  causes  (embolism  rarely  causes 
complete  liver  necrosis  unless  the  hepatic  arteries  are  simultaneously 
closed).  Pylephlebitis  and  thrombosis  occur  chiefly  in  males  over 
forty  years  of  age. 

A  fatal  obhterating  endophlebitis  exists  with  symptoms  very  closely 
resembKng  those  of  atrophic  cirrhosis;  Hess  in  1905  collected  23  cases 
from  the  literature. 

Symptoms. — These  may  be  entirely  absent  because  of  collateral 
compensation  through  the  hepatic  artery  or  Sappey's  accessory  portal 
vein.  The  onset  is  usually  sudden,  with  symptoms  of  acute  portal 
stasis.  The  spleen  is  enlarged  in  75  per  cent.,  unless  fibrous  changes  in 
its  pulp  or  capsule  prevent  its  swelling.  Ascites  develops  in  66  per  cent, 
and  rapidly  recurs  after  tapping.  Gastro-intestinal  symptoms  are  usual, 
as  hemorrhage  (44  per  cent.),  intense  sudden  epigastric  pain,  vomiting, 
diarrhoea  or  sometimes  acute  intestinal  obstruction.  The  portal  vein 
is  sometimes  varicose  below,  and  is  generally  obliterated  (pylephlebitis 
adhsesiva)  at  and  above  the  point  of  obstruction ;  this  leads  to  shrink- 
ing of  the  liver,  particularly  if  the  hepatic  artery  is  sclerotic,  in  which 
case  the  entire  liver  may  rarely  be  hemorrhagically  infarcted.  The 
liver  is  said  to  become  lobulated,  but  this  probably  results  from  ante- 
cedent syphilis.  Symptoms  of  hepatargia  (hepatic  insufficiency  or 
toxaemia)   may  develop.     Alimentary  glycosuria  is   fairly  frequent. 


AFFECTIONS  OF  THE  HEPATIC  ARTERY  AND  VEIN  723 

(Edema  of  the  abdominal  wall,  development  of  a  collateral  circulation, 
and  icterus  are  uncommon. 

Diagnosis. — Diagnosis  is  difficult,  unless  the  onset  is  typically  sud- 
den, in  which  case  pylethrombosis  may  be  considered.  Save  for 
their  acuity,  the  findings  are  those  of  atrophic  cirrhosis;  a  caput 
Medusae  rather  indicates  occlusion  of  the  portal  radicles  than  of  the 
portal  trunk.  The  ascites  may  suggest  carcinoma  or  peritonitis,  or 
the  hemorrhage  may  simulate  gastric  ulcer  or  hepatic  cirrhosis. 

Course  and  Treatment. — Death  may  occur  in  a  few  days  or  the 
patient  may  live  for  months  or  years  (six  to  twenty  years).  Treatment 
is  ineffectual,  save  in  early  syphilitic  cases.  Citric  acid  (5j)  may  be 
given  every  few  hours,  in  an  attempt  to  lessen  thrombosis.  Talma's 
operation  may  be  considered. 

Pylephlebitis  suppurativa  has  been  considered  under  liver  abscess. 
It  is  a  pyaemia  of  the  portal  vein;  metastasis  or  extension  occurs  in 
the  main  portal  trunk  and  its  branches  from  infection  of  its  radicles 
of  origin;  ulcerations  and  inflammations  in  the  gastro-intestinal  tract 
are  its  cause  in  75  per  cent,  of  cases;  appendicitis  causes  about  40 
percent.  (Dieulafoy's  "appendicular  liver")  and  gall-stones,  infected 
piles,  and  pancreatic  or  umbilical  suppuration  cause  most  of  the 
other  cases  (v.s.  Liver  Abscess,  Second  Variety). 

The  symptoms  are  those  of  the  original  disease,  those  of  sepsis  and 
those  of  portal  stasis.  In  very  rare  cases  the  thickened  vein  may  be 
palpated.  The  spleen  is  enlarged,  chiefly  from  sepsis,  though  sometimes 
from  stasis.  The  liver  is  tender  and  somewhat  enlarged,  icterus  occurs 
in  over  50  per  cent.,  and  the  usual  signs  of  sepsis  prevail.  The  diag- 
nosis is  always  difficult,  but  is  based  on  symptoms  suggesting  liver 
abscess  (though  without  the  findings  of  solitary  abscess)  on  the  one 
hand  and  those  of  sepsis  on  the  other.  The  treatment  is  practically 
futile,  being  supportive  and  rarely,  if  ever,  operative. 

rv.  Affections  of  the  Hepatic  Artery  and  Vein. 

These  are  of  more  pathological  than  clinical  interest.  Infarction 
of  the  hepatic  artery  with  complete  necrosis  of  the  liver  is  very 
rare. 

Aneurysm  (q.v.)  can  seldom  be  diagnosticated.  Pulsation  is  un- 
known; pain  is  nearly  always  present,  icterus  and  a  tumor  occur  in 
the  majority  of  cases,  ascites  is  uncommon  and  death  usually  results 
from  gastro-intestinal  hemorrhage. 

Thrombosis  of  the  hepatic  veins  is  very  infrequent,  only  12  cases 
being  reported.  It  may  follow  perihepatitis,  or,  less  often,  compres- 
sion by  a  neoplasm,  or  fibrous  obliteration  of  the  inferior  cava.  Ascites 
and  splenic  tumor  sometimes  result.  Suppurative  thrombosis  is  always 
secondary  to  liver  suppuration.  Retrograde  embolism  (Heller)  is 
mentioned  under  liver  abscess. 

Syphilis  of  the  Liver  (see  Syphilis). 


724 


DISEASES  OF  THE  LIVER 


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ICTEROXJS  725 

DISEASES  OF  THE  GALL-BLADDEE  AND  BILE 

VESSELS.     . 

(A).  ICTERUS. 

Icterus  or  jaundice  is  a  symptom  of  various  affections  of  the  liver 
and  bile  vessels;  it  usually  results  from  obstruction  to  the  bile  flow, 
and  is  characterized  by  staining  of  the  skin,  mucosae,  and  urine  by 
retained  bile  pigments. 

Etiology. — Most  cases  of  icterus  are  due  to  obstruction  either  within 
or  about  the  liver  and  biliary  system;  but  slight  obstruction  is  neces- 
sary because  the  bile  is  secreted  under  very  low  pressure,  (a)  It 
may  result  from  hepatic  diseases.  It  is  (i)  frequent  in  carcinoma, 
biliary  cirrhosis,  atrophic  cirrhosis,  multilocular  echinococcus  and 
passive  congestion;  (ii)  infrequent  in  unilocular  echinococcus,  abscess, 
and  syphilis;  (iii)  absent  in  fatty  and  amyloid  liver  and  in  simple 
pylephlebitis.  Pick,  Liebermeister,  and  Minkowsky  believe  that 
occasionally  functional  liver  disturbance  may  produce  icterus  (para- 
pedesis  of  bile,  "  diffusion -icterus  "  or  paracholia)  which  is  analogous 
to  transient  albuminuria  (in  its  relation  to  Bright's  disease).  (6)  Dis- 
eases of  the  biliary  tract  may  be  etiological  factors,  as  (i)  catarrhal, 
croupous,  or  purulent  inflammation;  (ii)  calculous  obstruction;  (iii) 
congenital  and  (iv)  cicatricial  occlusion;  (v)  malignant  growths;  (vi) 
parasitic  obstruction  by  ascaris,  distoma,  or  hydatid  vesicles,  (c)  It 
may  result  from  disease  in  contiguous  structures,  as  (i)  duodenal 
ulcer,  cicatrix,  catarrh,  or  malignancy;  (ii)  tumors  of  the  colon  or 
lymph  glands;  (iii)  tumors  or  inflammation  of  the  pancreas,  stomach, 
kidney,  omentum,  mesentery,  and  peritoneum,  and  (iv)  rarely  from 
visceroptosis,  or  aneurysm,  (d)  The  so-called  hcematogenous  or  uro- 
bilin icterus  is  a  possible  factor  in  the  etiology.  It  was  formerly  main- 
tained that  toxic  and  toxsemic  conditions  break  down  the  blood  cells 
(haemolysis),  and  thus  cause  icterus  (the  cytohsemolytic  icterus  of 
Senator).  It  is  now  thought  that  most  of  these  cases  are  essentially 
obstructive  (thickening  of  the  bile  or  cholangitis  of  the  smallest  rad- 
icles), though  the  obstruction  of  the  small  bile  ducts  within  the  liver 
is  not  complete.  From  a  recent  work  by  Eppinger,  it  appears  that 
the  smaller  bile  radicles  dilate  and  sometimes  rupture,  letting  the 
bile  into  the  lymph  vessels  which  absorb  it;  he  thinks  the  mechanical 
obstruction  lies  in  the  capillaries  which  were  blocked  by  fibrin  or  bile . 
thrombi.  The  jaundice  in  these  cases  is  slight,  bile  pigment  (bilirubin) 
is  not  found  in  the  urine,  and  the  stools  are  bile-stained.  This  type 
occurs  (i)  in  various  infections,  relapsing  fever,  septicopysemia,  etc., 
(ii)  in  pernicious  anaemia,  and  (iii)  in  toxic  conditions,  poisoning  by 
phosphorus,  chloroform,  felix  mas,  and  santonin. 

Icterus  neonatorum  may  be  considered  here,  (a)  The  physiological 
type  occurs  in  30  per  cent,  (to  80  per  cent.)  of  children;   it  appears 


726  DISEASES  OF  THE  GALL-BLADDER 

on  the  second  day,  lasts  two  weeks  and  is  never  fatal;  its  cause  is 
not  clear,  though  breaking  do^ni  of  the  blood,  increased  blood  pres- 
sure within  the  liver  and  persisting  patency  of  the  ductus  venosus 
are  suggested,  (b)  The  much  rarer  pathological  type  may  be  caused 
by  sepsis,  syphilis,  Winkel's  disease  or  still  more  exceptionally  by 
congenital  obstruction,  gall-stones  (10  cases  collected  by  Skormin), 
acute  yellow  atrophy  (7  cases)  or  catarrhal  icterus  (but  3  cases 
recorded).  Glaister  reported  a  family  in  which  6  cases  of  jaundice 
developed  after  birth.  Krannhals  recently  published  26  cases  of  con- 
genital "family  icterus''  most  of  which  had  an  enlarged  spleen. 

S3nnptoms  of  Icterus. ^Bilirubin,  found  normally  in  the  bile,  enters 
the  blood  in  biliary  obstruction,  by  the  lymph  vessels  and  possibly 
also  by  the  bloodvessels,  and  produces  the  following  symptoms: 

1.  Staining  of  the  skin  and  mucosce  occurs  in  two  or  three  days. 
The  sclerse,  skin  and  accessible  mucosae  are  yellow,  and,  in  cases  of 
long  standing,  dark  brown.  The  skin  itches  because  of  its  dryness, 
or  because  of  the  action  of  the  bile  on  the  nerves.  Eruptions  of  urti- 
caria or  xanthoma  may  occur. 

2.  The  urine  contains  bilirubin  before  icterus  is  seen  in  the  skin. 
Adding  nitroso-nitric  acid  to  the  urine  in  a  porcelain  dish  or  on  filter 
paper  gives  the  characteristic  play  of  colors,  of  green,  yellow,  violet  and 
red  (Gmelin  test).  If  the  urine  is  agitated,  the  yellow  color  appears  in 
its  foam.  Confusion  is  possible  with  melanuria,  heematuria,  urobili- 
nuria  or  staining  of  the  urine  with,  rhubarb,  picric  acid,  santonin,  senna 
and  chryosophanic  acid.  The  subject  of  urobilinuria  and  urobilin- 
icterus  has  caused  much  discussion ;  urobilin  is  formed  in  the  intestine 
by  the  reduction  of  bilirubin,  whence  it  is  absorbed  and  excreted  by 
the  urine;  it  never  stains  the  skin,  and  icterus  results  from  bilirubin 
alone.  To  reconcile  the  apparent  inconsistencies  in  the  urinary  findings 
and  in  various  statements,  it  may  be  said  that  there  are  three  classes 
of  cases;  (a)  in  complete  biliary  obstruction  with  icterus,  only  bili- 
rubin is  found  in  the  urine,  for  none  of  it  reaches  the  intestine  to  be 
converted  into  urobilin;  (b)  in  partial  obstruction,  bilirubin  is  found 
in  the  blood  and  urine  and  also  some  urobilin,  which  is  produced  in 
the  intestine  from  the  bilirubin,  for  there  is  much  intestinal  fermen- 
tation; (c)  in  slight  obstruction,  there  is  no  bilirubin  but  much  uro- 
bilin in  the  urine.  Albuminuria  may  occur  or  cylindruria  alone,  and 
the  hyaline  casts  or  desquamated  epithelium  are  then  bile-stained. 
The  sulphates,  which  normally  constitute  14  to  25  per  cent,  of  all  the 
sulphur  output,  may  be  increased  to  over  40  per  cent.  Indicanuria 
is  often  marked  and  is  due,  like  the  sulphate  increase,  to  greater  intes- 
tinal putrefaction. 

3.  The  digestive  tract  suffers  from  the  exclusion  of  bile.  The  tongue 
is  coated,  the  breath  has  a  disagreeable  odor  and  the  mouth  may  have 
a  bitter  taste,  which  is  due  to  toxaemia.  There  may  be  an  especial 
aversion  to  fats  and  sometimes  to  proteids,  and  there  may  be  nausea. 
The  abdomen  is  distended,  which  is  thought  to  be  due  to  the  absence 
of  the  antiseptic  action  of  the  bile,  though  the  importance  of  this 


ICTERUS  727 

action  has  been  overestimated.  Starchy  food  is  not  wholly  absorbed, 
albumin  digestion  is  somewhat  impaired  and  fat  is  fomid  in  large 
amounts  in -the  stools  (steatorrhoea).  The  function  of  the  pancreas 
in. this  respect  is  far  more  important  than  that  of  the  bile.  Vegetables 
are  absorbed  better  than  animal  fats.  The  normal  amount  of  fat 
found  in  the  faeces  is  7  to  10  per  cent.,  and  this  is  increased  in  icterus 
to  55  or  78  per  cent.  The  stools  are  clay-colored,  constipated  and  stink- 
ing; they  may  shimmer  when  the  fatty  soap  crystals  are  abundant; 
they  are  also  dry  (the  bile  in  the  faeces  amounts  normally  to  nearly  a 
quart  a  day).  If  the  obstruction  is  incomplete — as  in  many  intra- 
hepatic diseases — the  stools  are  merely  somewhat  lighter  than  normal ; 
a  nitrogenous  diet  may  impart  a  brownish  color  to  the  faeces.  The 
faeces  may  appear  deceptively  dark  if  voided  with  the  urine  which 
lends  a  yellow  color  to  their  surface. 

4.  Cholaemia  (hepatargia  or  hepatic  insufficiency)  may  finally  result. 
It  was  once  thought  to  be  due  to  the  cholestearin,  or  bile  salts,  but 
more  probably  results  from  injury  to  the  liver  cells  which  then  fail 
to  destroy  the  usual  intestinal  toxins  and  those  formed  in  excess  by 
the  increased  putrefaction.  Its  symptoms  rather  resemble  those  of 
acute  yellow  atrophy,  i.  e.  nervous  excitation  followed  by  sopor,  irregular 
breathing,  or  cutaneous  and  other  hemorrhages.  Most  subjects  of 
icterus  are  depressed,  irritable,  sleepless  and  somewhat  emaciated. 
The  hemorrhages  are  thought  by  Mayo  Robson  to  result  from  coin- 
cident pancreatic  involvement  (diminished  lime  salts  or  the  glycerine 
which  is  formed  by  fat  necrosis  of  the  pancreas). 

5.  There  may  be  other  symptoms,  (a)  The  heart  rate  is  slow,  par- 
ticularly in  catarrhal  forms  or  recent  cases  and  in  the  absence  of  pain, 
fever,  and  intoxication;  it  may  go  as  low  as  21  (Frerichs);  it  has  been 
said  that  this  is  due  to  degeneration  of  the  heart  muscle  or  action  of 
the  bile-salts  on  the  intracardiac  ganglia,  but  it  is  probably  caused 
by  vagus  stimulation,  for  atropine  will  raise  the  rate  (Weintraud). 
The  arterial  pressure  is  low  and  the  capillaries  wide.  A  functional 
heart  murmur  may  develop;  this  is  usually  caused  by  myocardial 
weakness.  Potain  holds  that  the  lung  capillaries  contract  reflexly, 
thereby  increasing  the  work  of  the  right  heart  and  causing  its  dilata- 
tion. The  respiration  rate  is  decreased,  even  to  7  or  9  a  minute;  the 
temperature  is  usually  normal.  (6)  The  hlood  shows  the  bile  stain, 
and  in  severe  cases  delayed  coagulation,  anaemia,  and  leukocytosis. 
The  undiluted  or  diluted  blood  may  give  a  partial  Widal  reaction 
(see  Typhoid),  (c)  The  liver  cells  may  suffer  mechanically  and  chem- 
ically from  bile  stasis,  and  may  be  smaller,  altered  in  form,  pigmented, 
necrotic  and  bile-stained.  The  gross  and  minute  anatomy  varies  wdth 
the  cause.  The  bile  vessels  are  often  dilated,  sometimes  thickened, 
and  occasionally  ruptured.  The  condition  of  the  gall-bladder  will  be 
discussed  under  gall-stones  and  pancreatic  cancer.  As  stated  under 
biliary  cirrhosis,  it  is  questionable  whether  simple  biliary  stasis  ever 
causes  induration  of  the  liver,  id)  The  spleen  is  occasionally  enlarged, 
especially  in  children,  from  infection  or  portal  stasis,  but  splenic  tumor 


728  DISEASES  OF  THE  GALL-BLADDER 

is  no  part  per  se  of  bile  stasis,  (e)  The  tissues  most  stained  are  the 
skin,  mucosae,  fasciae,  intima  and  connective  tissues;  the  fluids  most 
stained  are  the  urine,  serous  transudates  and  purulent  exudations. 
The  milk,  sweat  (the  foetus,  in  pregnant  women),  and  pneumonic 
sputum  are  sometimes  stained,  and  the  tears,  saliva,  mucus,  glandular 
and  epithelial  structures  (except  the  renal  cells  and  lowest  layers  of 
the  rete  Malpighii),  muscles  and  nervous  tissues  (except  in  the  more 
severe  type  of  icterus  neonatorum)  are  seldom  icteric.  (/)  Xanthopsia, 
yellow  coloring  of  objects  seen,  is  fairly  common,  and  is  due  to  the 
action  of  bile  pigment  on  the  nervous  tissues.  The  explanation  of 
nyctalopia  and  hemeralopia  is  uncertain,  {g)  Xanthelasma  multiplex 
develops  in  some  cases.  Twenty-three  cases  were  collected  by  the 
London  Pathological  Society  in  1882.  Futcher  in  1905  reported  three 
cases  in  women  about  forty  years  of  age;  80  per  cent,  of  reported 
cases  of  xanthelasma  occur  in  chronic  icterus  (in  women  more  fre- 
quently than  in  men),  due  to  gall-stones,  stricture  of  the  bile-ducts, 
cirrhosis,  hydatids,  and  cancer.  They  are  often  symmetrical,  often 
begin  on  the  eyelids  or  the  folds  and  creases  of  the  skin,  in  one  case 
were  found  in  the  bile  ducts,  rarely  disappear  and  are  probably  due 
to  some  toxic  substance,  though  Williams  believes  they  are  epithelial 
in  origin.  Some  few  cases  begin  before  puberty  and  are  probably 
hereditary. 

Diagnosis. — A  diagnosis  is  easily  made.  Icterus  may  not  be  noticed 
in  artificial  light,  for  daylight  is  absolutely  essential  for  its  certain 
detection.  It  is  seldom  confused  with  anaemia,  cachexia,  Addison's 
disease  or  the  pigmentation  of  vagabondism.  Pingueculae  are 
often  mistaken  for  scleral  staining,  but  only  on  superficial  examin- 
ation. 

The  'prognosis  and  treatment  cannot  be  considered,  as  icterus  is  but 
a  symptom.  The  details  depend  on  the  basic  affection.  (See  Catar- 
rhal Jaundice  for  treatment  in  general.)  The  patient  may  recover 
after  four  years  (Budd) ;  cases  of  icterus  lasting  six  years  (Murchison, 
Barth,  Bosnier),  ten  to  twenty-five  years  (Legendre,  Galliard)  or  even 
fifty-two  years  (Masing)  have  been  reported. 


(B).   CHOLELITHIASIS. 

Gall-stones  are  found  in  6  to  10  per  cent,  of  autopsies.  Among  the 
many  literary  contributions  to  this  subject  are  those  of  Naunyn, 
Langenbuch,  Kehr,  Riedel,  Lange,  Mayo  Robson,  Keen,  Fenger, 
Murphy  and  Mayo. 

Etiology. — 1.  Immediate  Cause. — The  actual  cause  is  catarrhal 
inflammation  of  the  gall-bladder  or  bile  vessels,  which  promotes  the 
formation  of  (or  actually  secretes)  cholestearin  and  lime.  Stagnation 
of  bile  is  merely  a  predisposing  cause.  Bacteria  play  an  important 
role,  especially  the  typhoid  (found  in  33  per  cent.)  and  colon  bacilli; 
they  have  been  found  in  calculi,  and  cholelithiasis  has  been  experi- 


CHOLELITHIASIS  729 

mentally  produced  by  their  inoculation;  the  Bacillus  typhosus  may 
live  seven  years  in  the  gall-bladder, 

2.  Predisposing  Factors. — (a)  Age;  50  per  cent,  of  cases  occur  in 
persons  over  forty  years  of  age;  the  affection  is  rare  in  those  under 
twenty  years  but  has  been  seen  in  the  young  and  even  in  the  new-born. 
(6)  Sex;  70  to  80  per  cent,  occur  in  women,  in  whom  pregnancy, 
menopause,  lax  abdominal  walls,  enteroptosis,  and  constipation,  seden- 
tary life,  and  lacing,  are  regarded  as  promoting  factors;  Bollinger  and 
Bother  found  that  40  per  cent,  of  women,  who  have  gall-stones,  also 
have  the  corset  liver.  According  to  Naunyn,  gall-stones  are  found  in 
25  per  cent,  of  autopsies  on  women  over  sixty  years;  90  per  cent,  of 
women  affected  have  borne  children,  (c)  Other  possible  factors  are 
sedentary  habits,  obesity,  splanchnoptosis,  luxurious  living,  insanity, 
cancer  of  the  stomach,  biliary  stasis,  and  foreign  bodies  in  the  biliary 
tract;  Kehr  holds  that  stone-formation  is  induced  by  long  intervals 
between  meals.  Cholelithiasis  is  more  common  in  cool  than  in  warm 
climates. 

Properties  of  Gall-stones. — (a)  Site;  they  are  almost  invariably 
formed  in  the  gall-bladder;  very  rarely  do  calculi  develop  in  the  intra- 
hepatic ducts  as  reported  in  McArthur's  recent  case,  (b)  Size;  they 
range  from  the  size  of  sand  or  gravel  to  that  of  an  egg;  a  calculus 
12  inches  in  length  is  recorded;  the  heaviest  weight  reported  is  over 
four  ounces  (135  gm.  Ritter).  (c)  Form;  they  are  usually  round 
and  rarely  spinous;  when  multiple  they  are  polygonal  and  facetted. 
Intrahepatic  calculi  may  be  cylindrical  or  branching  like  coral 
(Cruveilhier).  (d)  Their  number  probably  averages  a  dozen;  ac- 
cording to  Riedel  44  per  cent,  are  single;  Naunyn  reports  5,000 
in  one  case,  and  Otto  7,802  stones  in  another  case.  Chopart 
instances  a  case  in  which  the  liver  could  scarcely  be  cut  because 
of  the  numberless  stones  in  the  intrahepatic  ducts,  (e)  Consistence; 
gall-stones  can  usually  be  indented  by  the  finger.  (/)  The  time 
required  for  their  growth  is  about  six  months,  {g)  Chemistry;  the 
most  common  form  consists  of  cholestearin  and  bile-pigment  (bil- 
irubin and  biliverdin)  with  some  lime  as  a  cementing  substance; 
these  calculi  are  small,  numerous,  usually  yellow,  laminated  and  con- 
tain about  75  per  cent,  of  cholestearin.  Cholestearin  stones  are  not 
common;  they  are  translucent,  become  opaque  when  dry,  are  light 
in  weight  and  color,  and  are  combustible;  they  present  a  crystalline 
fracture  like  that  of  camphor,  they  dissolve  in  ether  and  alcohol, 
from  which  the  crystals  are  precipitated  and  produce  a  red  tinge  on 
addition  of  chloroform  and  sulphuric  acid;  cholestearin  comes  not 
from  the  bile  but  from  the  inflamed  mucosa  of  the  gall-bladder. 
Pigmentary  stones  are  also  uncommon;  bilirubin  imparts  a  brownish 
and  biliverdin  a  greenish  tint  to  them.  Calcium  carbonate  stones  are 
rare,  are  grayish  in  color  and  heavy.  Stones  in  the  liver  are  con- 
stituted of  calcium  and  bilirubin  as  in  Lewis  L.  McArthur's  recent 
case.  Traces  of  magnesium,  bile  acids,  fatty  acids,  iron,  and  copper 
have  been  found.    The  nucleus  may  consist  of  mucin,  bacteria,  epi- 


730  DISEASES  OF  THE  GALL-BLADDER 

thelium,  blood-clot,  cholestearin,  calcium,  bile  pigment  or  rarely  of 
foreign  bodies. 

Symptoms. — Kehr,  Riedel  and  Paulsen  assert  that  95  per  cent, 
of  cases  of  gall-stones  have  no  symptoms,  especially  in  elderly  subjects 
with  atrophic  gall-bladders.  Naunyn  states  that  gall-stones  are  found 
at  autopsy  in  25  per  cent,  of  women  over  sixty  years  of  age.  Stones 
may  be  felt  or  may  crepitate  in  the  gall-bladder,  or  be  found  in  the 
faeces,  especially  in  old  people  with  lax  tissues,  without  any  subjective 
symptoms. 

An  attach  of  biliary  colic  embraces  several  important  elements,  (a) 
Colic  is  usually  sudden  in  onset  and  very  frequently  begins  at  night. 
The  pain  is  great,  and  many  women  state  that  it  is  more  severe  than 
labor  pains.  It  begins  in  the  right  upper  abdominal  quadrant  and 
may  radiate  to  the  back,  navel,  hypogastrium,  left  side,  and  even  to 
the  arms,  legs,  testes,  or  chest.  Irregular  or  large  stones  cause  the 
greatest  agony  which  is  controlled  only  by  large  or  repeated  hypodermics 
of  morphine.  The  pain  usually  endures  for  minutes  to  a  few  hours, 
and  may  soon  recur.  According  to  Riedel  colic  is  absent  in  20  per  cent, 
of  cases,  which  implies  that  the  stones  are  small  or  the  tissues  are  lax. 
The  cause  of  biliary  colic  is  mechanical, — the  attempt  of  the  stone 
to  migrate  produces  the  spasm  of  the  cystic  and  common  ducts  during 
its  passage  but  some  consider  that  inflammation  is  the  chief  factor; 
Kehr  maintains  that  cholecystitis  starts  the  stones  moving  by  the 
exudation  it  induces.  The  author  has  seen  violent  colic  result  from 
this  mechanism  as  well  as  from  cholecystitis  without  stones.  It  is 
thought  that  quiescent  gall-stones  may  be  started  onward  by  palpation 
of  the  gall-bladder,  trauma,  muscular  exertion,  pressure  by  corsets, 
particularly  after  reduction  of  flesh,  menstruation,  or  delivery,  (b) 
Reflex  nausea  and  vomiting  are  frequent;  Kehr  thinks  that  they 
indicate  cholecystitis  (Mierzkowski  found  the  bile  sterile  in  only  22 
per  cent.).  Vomiting  relieves  the  pain,  and  this  frequently  causes  an 
erroneous  diagnosis  of  gastralgia.  Torsion  of  the  cystic  duct  may 
cause  vomiting  but  not  colic,  (c)  Chills  and  fever  occur  in  60  per  cent, 
and  probably  indicate  bacterial  inflammation  (though  they  are  possibly 
reflex),  (d)  The  gall-bladder  is  always  tender,  there  being  hypersesthesia 
over  the  ninth  costal  cartilage  or  over  a  point  two-thirds  of  the  distance 
between  it  and  the  navel.  In  33  per  cent,  of  cases  the  gall-bladder  is 
palpable.  The  right  rectus  muscle  is  rigid.  Boas  and  Gruh  describe 
a  right-sided  hypersesthetic  zone  which  lies  between  the  spine  and 
posterior  axillary  line  and  at  the  level  of  the  lower  dorsal  or  upper 
lumbar  vertebra,  (e)  Icterus,  which  is  so  often  emphasized  as  a 
diagnostic  point,  is  present  in  but  10  to  20  per  cent.  (Riedel  and  Kehr), 
and  in  but  14  per  cent,  of  Murphy's  series.  It  may  be  mechanical  or 
inflammatory;  Deaver  is  inclined  to  refer  it  to  inflammation  in  the 
pancreas  (v.  i.).  (/)  Other  symptoms  of  the  paroxysm  are  rapid  pulse, 
sweating,  prostration,  concentrated  urine,  constipation,  abdominal 
retraction  and,  after  the  seizure,  marked  prostration.  In  some  cases 
convulsions  or  other  hysterical  manifestations  may  be  precipitated. 


CHOLELITHIASIS  731 

Attacks  of  migraine  are  not  infrequent  (Kehr).  There  may  be  reflex 
coughing  or  reflex  contraction  of  the  pulmonary  capillaries,  which  puts 
extra  work,  on  the  right  heart  and  causes  its  dilatation.  The  patient 
may  suffer  actual  collapse,  and  in  nine  cases  death  has  occurred  in  the 
attack  (Naunyn).  Glycosuria,  albuminuria,  leukocytosis,  and  splenic 
swelling  are  probably  inflammatory  in  origin.  The  stone  may  fall 
back  into  the  gall-bladder  or  pass  into  the  bowel  if  it  measures  not 
more  than  1  cm.  It  is  detected  by  washing  of  the  stools  through  a 
cloth;  confusion  with  lumps  of  olive  oil,  which  may  have  been  given 
to  relieve  the  colic,  is  unnecessary.  The  passage  of  a  round  calculus 
suggests,  but  does  not  prove,  that  it  is  the  only  one.  Stones  passing 
into  the  bowel  may  be  dissolved,  unless  coated  with  cholestearin ; 
this  may  explain  why  stones  are  not  more  often  found  in  the  faeces. 
The  great  importance  of  gall-stones  lies  in  their  complications. 

Complications. — Complications  may  be  grouped  as  mechanical  or 
inflammatory  but  as  this  involves  descriptive  repetition,  both  forms 
may  be  combined  topographically.  Such  complications  as  liver  abscess 
or  pyaemia  may  develop  from  stones  which  were  without  any  clinical 
symptoms. 

1.  Gall-bladder. — Mechanical  complications  include  pressure  on  the 
duodenum  or  pylorus  and  rupture  of  the  gall-bladder,  which,  however, 
are  generally  inflammatory;  pressure  on  the  common  duct;  hyper- 
chlorhydria  and  hypersecretion;  and  cancer  of  the  gall-bladder  (q.v.). 
Inflammatory  complications  are  more  serious;  all  forms  and  sequences 
of  cholecystitis  (q.v.)  may  develop,  as  hydrops,  empyema,  gangrene, 
ulceration,  deformity,  hemorrhage,  atrophy,  calcification  or  liver 
abscess;  also  pylephlebitis,  adhesions  producing  pyloric  obstruction 
with  hyperchlorhydria,  dyspepsia,  and  sometimes  hemorrhage  into  the 
stomach;  adhesions  causing  duodenal  obstruction;  and  peritonitis, 
either  local  (near  the  gall-bladder,  or  subphrenic  abscess)  or  diffuse; 
Courvoisier  reported  49  cases  of  the  localized  and  70  of  the  diffuse 
type.  A  friction  rub  may  be  heard  over  the  gall-bladder  a  day  or  two 
after  the  colic.  The  distended  gall-bladder  rarely  exceeds  the  size  of 
the  fist,  is  pyriform,  can  be  moved  laterally  and  moves  with  the  liver, 
from  which  it  may  seem  to  be  separated  by  a  groove;  it  may  be  some- 
times confused  with  appendicitis,  the  kidney,  ovarian  cyst  or  ascites, 
and  has  even  been  found  in  a  femoral  hernia. 

2.  Cystic  Duct. — Mechanical  impaction  may  cause  icterus  by  induc- 
ing spasm  or  catarrh  of  the  common  duct  (in  10  to  15  per  cent.,  Riedel) 
or  by  directly  compressing  it.  The  duct  may  become  twisted,  stenosed, 
or  obliterated. 

3.  Common  Bile  Duct. — Its  mechanical  occlusion  is  usually  but 
not  invariably  preceded  by  colic,  and  impaction  occurs  oftenest  at 
its  lower  end  (50  per  cent.  Courvoisier,  or  67  per  cent.  Robson),  is 
caused  most  frequently  by  one  stone,  though  as  many  as  88  have  been 
found  (Mayo  Robson).  Permanent  occlusion  by  stone  in  the  common 
duct,  or  in  the  cystic  duct  pressing  upon  it,  causes  marked  icterus, 
usually  without  sepsis.    The  occlusion  may  be  partial  or  intermittent, 


732  DISEASES  OF   THE  GALL-BLAQDER 

by  a  ball-valve  action  of  the  stone,  described  by  Osier  and  Fenger, 
which  allows  some  bile  to  enter  the  gut  and,  unfortunately,  some 
bacteria  to  enter  the  duct,  thus  adding  bacterial  to  mechanical  injury. 
In  isolated  cases  there  is  no  icterus  but  usually  the  icterus  is  sudden  in 
onset  and  slow  in  subsidence.  In  partial  or  intermittent  obstruction 
there  is  often  the  intermittent  hepatic  fever,  which  was  first  described 
by  Charcot  and  later  clearly  defined  by  Osier.  Budd  well  compared  it 
to  urethral  fever.  During  the  paroxysms  the  fever  rises  to  103  or  105°, 
often  with  chills,  sweats,  leukocytosis,  vomiting,  and  increased  tender- 
ness, pain,  and  icterus.  The  spleen  may  swell  as  well  as  the  liver, 
from  cylindrical  or  saccular  dilatation  of  the  bile  channels  and  from 
cholangitis.  Osier  has  correctly  insisted  that  this  group  of  symptoms 
occurs  without  suppurative  cholangitis,  though  of  course  with  infection. 
The  gall-bladder  is  not  enlarged,  but  is  usually  shrunken,  following 
Courvoisier's  law;  Courvoisier  (1890)  found  the  gall-bladder  enlarged 
in  92  per  cent,  of  100  cases  of  non-calculous  obstruction  of  the  common 
duct,  and  shrunken  in  80  per  cent,  of  calculous  obstruction  (87  cases) ; 
this  is  caused  by  infection  (Hanot);  Eichhn  in  139  cases  of  non- 
calculous  obstruction,  found  the  gall-bladder  dilated  in  87  per  cent., 
and  contracted  or  normal  in  6.5  per  cent,  each;  in  172  cases  of  cal- 
culous obstruction,  the  gall-bladder  was  contracted  in  66  per  cent., 
normal  in  19  per  cent,  and  dilated  in  15  per  cent.  In  some  cases  sup- 
purative cholangitis  may  complicate  stones  of  the  common  duct  with 
remittent  fever  (rather  than  the  above  described  intermittent  fever), 
enlarged  liver,  septic  symptoms  and  more  intense  and  more  rapidly 
fatal  course.  Mechanical  dilatation  may  distend  all  the  bile-vessels 
and  these  may  be  seen  under  the  capsule;  ascending  cholangitis  may 
cause  subcapsular  abscess.  Cicatricial  stenosis  of  the  common  duct 
is  rare;  pylephlebitis  may  develop.  Malaria  is  excluded  by  examina- 
tion of  the  blood;  malignancy  will  be  considered  under  tumors  of  the 
pancreas,  though  in  obstruction  of  the  common  duct,  the  nutrition  is 
generally  but  little  impaired.  Practically,  special  stress  may  be 
placed  on  (a)  the  periodic  fever,  (6)  the  icterus  sudden  in  onset  and 
subsiding  slowly,  and  (c)  tenderness  (without  pain  over  the  liver). 

4.  Ampulla  of  Vater. — Calculous  retention  in  the  ampulla  may 
obstruct  the  flow  of  the  pancreatic  juice,  though  the  accessory  duct 
may  carry  it  into  the  intestine;  retention  may  allow  bile  to  enter  the 
pancreatic  duct,  and  result  (a)  in  acute  pancreatitis,  caused  by  bile 
in  the  pancreatic  ducts  (Opie) ;  (6)  in  chronic  induration  of  the  head 
of  the  pancreas,  resembling  malignancy  (Riedel,  Robson,  Barling); 
(c)  in  pancreatic  fibrosis  with  pancreatic  calculi  due  to  stasis  and  infec- 
tion;  or  {d)  rarely  in  glycosuria. 

5.  Intestinal  Obstruction  (q.v.). — Two  hundred  and  fifty  cases 
have  been  collected.  The  stone  usually  ulcerates  its  way  into  the 
bowel  from  the  biliary  channels  or  gall-bladder.  The  obstruction  is 
often  incomplete  and  may  not  occur  for  some  time,  sometimes  receiv- 
ing new  layers  of  magnesia  or  phosphates.  According  to  Courvoisier, 
the  obstruction  is  in  the  ileum  in  66  per  cent.,  duodenum  in  21  per  cent.. 


CHOLELITHIASIS  733 

ileocsecal  valve  in  10  per  cent,  and  sigmoid  in  3  p'er  cent.    About  50 
per  cent,  of  cases  die. 

6.  Fistulse. — Naunyn  assembled  384  cases.  The  external  form  con- 
stitutes about  50  per  cent,  of  cases  (Naunyn  and  Courvoisier) ;  they 
are  most  often  located  near  the  navel,  and  about  40  per  cent,  of  them 
heal.  In  the  duodenal  form  (28  per  cent.)  the  fistula  is  between  the 
duodenum  and  gall-bladder  and  less  often  between  the  common  duct 
and  the  gall-bladder.  In  13  per  cent,  there  is  a  fistulous  opening  into 
the  colon.  Courvoisier  and  Graham  collected  34  cases  of  bronchial 
fistula.  In  rare  cases,  stones  enter  the  stomach  (five  cases  recorded, 
Snively,  1903),  portal  vein,  hepatic  artery,  kidney,  urinary  bladder 
(200  gall-stones  were  evacuated  in  the  urine  in  the  case  of  Barraud- 
Palletan),  pericardium,  retroperitoneal  tissue,  vagina  or  even  the 
pregnant  uterus. 

7.  Renal  Calculus,  Glycosuria,  Etc. — In  700  cases  of  gall-stones, 
Kraus  found  the  following  complications:  renal  calculus  in  6  per 
cent.,  glycosuria  in  7  per  cent.,  diabetes  in  4  per  cent.,  and  gout  in  2 
per  cent. 

Diagnosis. — The  diagnosis  is  easily  made  when  colic,  vomiting, 
tenderness  of  the  gall-bladder  and  icterus  are  present,  but  icterus  is 
absent  in  at  least  80  per  cent,  of  all  cases.  The  a;-rays  may  produce 
no  shadow  in  cholestearin  calculi. 

1.  The  Colic. — This  is  most  apt  to  be  confused  with  (a)  gastralgia, 
for  both  conditions  are  relieved  by  vomiting;  due  regard  for  other 
symptoms  of  gall-stones,  and  the  habit  of  doubting  every  diagnosis 
of  gastralgia,  will  save  many  mistakes,  (6)  A  diagnosis  of  hepatic 
neuralgia  should  always  be  made  with  reserve,  though  pain  near  the 
liver  does  occur  in  neurotics,  (c)  Gastric  or  duodenal  ulcer  (q.v.), 
and  (d)  hyperchlorhydria  and  hypersecretion  (q.v.)  are  easily  dis- 
tinguished, (e)  Lead  colic  has  other  characteristic  symptoms,  such 
as  the  gingival  lead  line,  obstinate  constipation,  and  often  neuritic 
manifestations.  (/)  Tabetic  crisis  is  attended  by  the  Argyll-Robertson 
pupil,  absent  knee-jerk,  and  ataxia,  (g)  Renal  colic  (q.v.)  is  dis- 
tinguished by  pain  reflected  down  the  ureter,  hsematuria,  and  pyuria, 
and  Dietl's  crisis  in  floating  kidney,  by  bimanual  examination  of  the 
abdomen,  (h)  Mu/iou^  colic  (colitis)  is  differentiated  by  the  char- 
acteristic stools  and  neurasthenic  symptoms,  (i)  Appendicitis  is  char- 
acterized by  its  four  cardinal  symptoms  (q.v.);  Ochsner  finds  10  per 
cent,  of  his  appendicitis  cases  complicated  by  gall-stones  and  33  per 
cent,  of  his  gall-stone  cases  by  appendicitis,  (y)  Acute  pancreatitis 
(q.v.)  which  may  complicate  gall-stones,  causes  greater  collapse  and 
more  frequent  intestinal  obstruction,  (k)  Febrile  syphilis  may  simu- 
late gall-stones  (Riedel)  as  may  also  (I)  the  abdominal  crises  occasion- 
ally observed  in  angioneurotic  oedema. 

2.  Other  Affections  of  the  Gall-Bladder  and  Bile  Ducts  (see  Brew- 
er's Table). 


734 


DISEASES  OF  THE  GALL-BLADDER 


Brewer's  Diagnosis  op  Diseases 


Pathological  condition 

Pain. 

Fever. 

Vomiting 

Jaundice. 

Tumor    of    gall- 
bladder. 

I.  Calculous 

Disease. 

(a)  Stone   in   healthy 

No. 

No. 

No. 

No. 

May  be  present 

gall-bladder,     ducts 

from  large  num- 

free. 

ber  or  size  of 
stones. 

(6)  Stone   in    healthy 

May  be  absent;  generally 

No. 

May  be 

No. 

May  be  present 

gall-bladder,    cystic 

present  during  obstruc- 

present 

from    distention. 

duet        temporarily 

tion;  paroxysmal. 

when 

obstructed. 

colic 
occurs. 

(c)  Stone  impacted  in 

No. 

No. 

No. 

No. 

Present;  may 

cystic  duct. 

attain  large  size. 

(d)iStone   in    hepatic 

Frequently  present;  irregu- 

Occasion- 

May be 

Frequent. 

No. 

duct. 

lar  type. 

ally  pres- 
ent. 

present 
during 

(e)  Stone  in  common 

Present;  acute  paroxysmal 

Gener- 

pain. 
Present. 

Present. 

No. 

duct;  acute  obstruc- 

radiating to  back. 

ally  pres- 

tion. 

ent. 

(/)jsStone  in  common 

Periodic  attacks  of  acute 

Present 

Present. 

Present; 

Rarely  present. 

duct;    movable; 

radiating  pain. 

with 

intermit- 

chronic. 

chills  and 
sweats. 

tent. 

ig)  Stone  in  common 

May  be  absent;  frequently 

Maybe 

Often 

Present; 

Rarely  present. 

duct;    impacted; 

present   early;    may   be 

present; 

present. 

progress- 

chronic. 

intermittent;   variable. 

variable. 

ive;  may 
vary  in 
intensity. 

II.  Inflammatory 

i(    Disease. 

(o)  Cholecystitis   sub- 

Present; paroxysmal  dur- 

Present 

May  be 

No. 

Present  during 

acute. 

ing  periods  of  cystic  duct 

during 

present. 

attacks  of  cj^s- 

closure    from    stone    or 

attacks 

tic  duct  ob- 

swollen   mucous    mem- 

of cohc. 

struction. 

brane. 

(6)  Cholecystitis 

Acute  paroxysmal  radiat- 

Present, 

Present; 

No. 

Present;  tender- 

acute. 

ing  pain;    extending  to 

with 

often 

ness;  often 

back  and  shoulder;  may 

chills  and 

severe. 

muscular 

be  very  severe. 

sweats. 

rigidity. 

(c)  Cholecystitis 

Severe   radiating   pain   at 

Present; 

Present 

No. 

Present;  with 

chronic  (empyema 

first;      may      disappear 

severe  at 

at  first. 

tenderness; 

of  gall-bladder). 

later;  tendency  to  recur. 

first,  may 

diminish 

later. 

may  attain 
large  size. 

(d)  Cholecystitis  in 

Present;  often  severe;  par- 

Present; 

Present. 

No. 

No  (occasion- 

previously  diseased 

oxysmal. 

often 

ally    present! 

and  contracted 

with 

due  to  peri- 

gall-bladder. 

chills  and 
sweats. 

cystic  exudate). 

(e)   Cholangitis  of 

May  be  absent;  generally 

Present; 

Present. 

Present; 

No. 

hepatic  and  com- 

present when  obstruction 

chills; 

variable. 

mon  ducts 

exists,  or  severe  infection; 
tenderness  and  pain  over 
liver  in  intrahepatic  chol- 
angitis. 

sweats; 
severe 
prostra- 
tion; gen- 
eral sep- 
sis. 

III.  New  Growths. 

(o)  Carcinoma  of 

N'o;  may  occur  late  in  dis- 

No. 

No. 

Present 

Hard,  irregular, 

gall-bladder. 

ease. 

late  (por- 
tal 
glands). 

movable  tumor 
at  first,  later 

diffuse 
infiltration. 

(6)  Tumor  of  cystic 

fio;  may  occur  late. 

No. 

No. 

No. 

Present  when 

duct. 

obstruction 

exists. 

(c)  Tumor  of  hepatic 

No;  may  occur  late. 

No. 

No. 

Present; 

May  be  present 

or  common  iuct. 

progress- 
ive. 

from  distention 
with  bile. 

(d)  Tumor    of    neigh- 

No; may  occur  late. 

No, 

No. 

Present; 

Present;   gener- 

boring viscera  pro- 

progress- 

ally from  dis- 

ducing chronic  ob- 

ive; may 

tention  with 

struction  ofjCom- 

become 

bile. 

mon  duct. 

extreme. 

OTHER  AFFECTIONS  OF  THE  GALL-BLADDER  AND  DUCTS      735 

OF   THE    GaLIt-BlADDER    AND    DuCTS. 


Urine. 


Stools. 


Liver. 


Spleen. 


Ascites. 


Remarks. 


Negative     Normal 


Negative. 


Negative. 

Contains 
bile    pig- 
ment at 
times. 
Contains 
bile  pig- 
ment. 
Contains 
bile  pig- 
.ment. 

Contains 
bile  pig- 
ment. 


Negative. 


May  con- 
tain albu- 
min and 
casts. 


Negative. 


Negative. 


May  con- 
tain bile 
pigment, 
albumin, 
■and  casts. 


Negative 
(at  first). 


Negative. 


Contains 
bile  pig- 
ment. 
Contains 
bile  pig- 
ment. 


Normal. 


Normal. 

May  be  clay 
colored  if 
obstruction 
occurs. 
Clay  col- 
ored. 

Clay  col- 
ored. 


Clay  col- 
ored. 


Normal. 


Normal. 


Normal. 


Normal. 


May  be 

clay 
colored. 


Maybe 
clay 

colored 
late. 

Normal. 


Clay 
colored. 

Clay 
colored. 


Not  enlarged. 


Not  enlarged. 


Not  enlarged. 

Frequently 
enlarged. 


Not  enlarged. 


May  be  en- 
larged during 
attack. 

Enlarged. 


Not  enlarged. 


Not  enlarged. 


Not  enlarged. 


Not  enlarged. 


'Enlarged. 


Enlarged  late 
in  disease. 


Not  enlarged. 


May  be  en- 
larged. 

Enlarged. 


Not  enlarged. 
Not  enlarged. 

Not  enlarged. 
Not  enlarged. 

Not  enlarged. 


May  be  en- 
larged from 
pressure  of 
stone  on  vein. 
May  be  en- 
larged. 


Not  enlarged. 


May  be  en- 
larged (sepsis) 


Not  enlarged. 


May  be  en- 
larged (sepsis) 


Enlarged 
(sepsis). 


May  be  en- 
larged late 
(pressure  on 
vein). 

Not  enlarged. 
Not  enlarged. 


May  be  en- 
larged late. 


No. 

No. 

No. 
No. 

No. 
No. 

No. 


No. 


No. 


No. 


No. 


No. 


Present 
late. 


No.  (?) 


May  be 
present 

late. 
Present 

late. 


Generally    discovered    by    acci- 
dent; often  unrecognized. 


All  symptoms  promptly  relieved 
as  soon  as  obstruction  removed. 


Hydrops  of  gall-bladder  often 
unrecognized. 

Diagnosis  extremely  difficult; 
symptoms  generally  due  to  co- 
existing cholangitis. 

Symptoms  rapidly  disappear 
when  stone  passes  papilla. 

"Fievre  intermittente  h^pa- 
tique"  of  Charcot  resembles 
malaria;  all  symptoms  disap- 
pear during  interval. 

Condition  may  remain  for  many 
years;  may  only  be  jaundice 
with  digestive  disturbances 
and  loss  of  weight;  history  of 
previous  attacks  (?).  Ascites 
may  be  present  from  pressure 
of  large  stone  or  possibly  from 
hydraemia. 

Tenderness  over  gall-bladder; 
tendency  to  recurrence;  gener- 
ally associated  with  stones  in 
gall-bladder. 

May  follow  typhoid  or  other  sep- 
tic diseases;  onset  often  sud- 
den; rapid  development  of 
severe  symptoms  resembling 
appendicitis;  may  be  necrosis 
of  walls  of  gall-bladder  with 
perforation;  local  or  general 
peritonitis. 

Frequently  follows  acute  chole- 
cystitis; occasionally  becomes 
quiescent,  presenting  practi- 
cally no  symptoms. 

Generally  tenderness  over  gall- 
bladder area,  but  no  tumor; 
local  peritonitis;  diagnosis 
often  extremely  difficult. 

Often  follows  severe  infections 
of  gall-bladder;  generally  asso- 
ciated with  stones  in  common 
or  hepatic  ducts;  severe  sepsis; 
generally  fatal  in  virulent  in- 
fections (streptococcus). 


Digestive  disturbances,  progress- 
ive loss  of  weight  and  asthe- 
nia;  cachexia;   rapidly  fatal. 


Very  rare;  both  benign  and  ma- 
lignant growths  have  been  re- 
ported;    diagnosis  difficult. 

Very  rare;    diagnosis  difficult. 


Malignant  tumors  most  common; 
chronic  interstitial  pancreati- 
tis from  previous  infection  of 
biliary  passages  may  remain 
after  cause  has  disappeared; 
enlarged  portal  glands;  Hodg- 
kin's  disease. 


736  DISEASES  OF  THE  GALL-BLADDER 

Prognosis. — The  prognosis  is  difficult  to  formulate.  Stones  may 
pass  without  recurrence  of  colic  and  the  passage  of  smooth  calculi  may 
justify  some  hope  that  they  are  the  only  ones.  The  first  attack  is 
usually  the  worst.  Fever,  infection,  cancer,  and  obstruction  of  the 
common  duct  and  intestine  must  be  covered  in  forecasts  to  patients 
refusing  operation.  Riedel  held  that  10  per  cent,  recover  spontaneously 
under  expectant  treatment,  while  in  90  per  cent,  of  cases  surgical 
intervention  is  indicated. 

Treatment. — 1.  Prevention. — Exercise  and  deep  breathing  aid  the 
flow  of  bile.  Lacing  is  a  factor  to  be  regarded.  Plenty  of  water 
increases  the  secretion  of  bile.  Digestive  derangements  should  be 
corrected.  Alcohol  is  contra-indicated.  Kehr  believes  that  food  should 
be  taken  in  small  amounts  at  frequent  intervals  and  should  be  chiefly 
nitrogenous,  in  order  to  favor  the  secretion  of  bile.  The  predisposing 
gall-bladder  inflammation  seldom  comes  under  the  physician 's  care,  but 
in  suspicious  cases,  sodium  salicylate,  gr.  x  to  xv  t.  i.  d.  given  alternate 
weeks,  acts  as  a  cholagogue — increasing  the  bile  two  or  threefold— and 
antiseptic.  Mercurials  seem  to  stimulate  bile  formation  less  than  to 
aid  in  its  evacuation.  Potassium  iodide  and  mild  salines  (sodium 
phosphate,  5ss  to  j)  are  beneficial. 

2.  CoUc. — Hypodermics  of  morphine  must  be  given,  gr.  ^  being 
combined  with  nitroglycerine  gr.  ros  and  (for  the  first  injection  in  the 
attack)  with  atrophine  gr.  i^g;  repeated  doses  of  morphine  and 
nitroglycerine  are  often  necessary.  Inhalation  of  chloroform  is  indi- 
cated in  severe  cases  until  the  morphine  acts,  but  none  of  these  drugs 
should  be  left  in  the  possession  of  any  patient.  A  full  hot  bath  and 
hot  fomentations  over  the  liver  are  valuable  accessories.  Drinking 
freely  of  warm  water  makes  the  vomiting  easier,  which  in  turn  relieves 
the  pain. 

3.  Medical  Treatment. — This  in  no  way  influences  the  solution  of 
gall-stones.  Durande's  solvent  (oil  of  turpentine  1  part  to  ether  4 
parts)  is  useless,  and,  Hke  chloroform,  is  only  antispasmodic.  Olive 
oil  at  best  only  faciUtates  their  final  passage.  Salicylates,  calomel, 
salines  (v.s.)  and  various  "cures,"  as  at  Carlsbad,  Vichy,  Marienbad, 
Kissingen,  Las  Vegas  or  Bedford  Springs,  may  be  useful  in  quieting 
concomitant  or  causative  inflammation.  Local  massage  is  obviously 
injurious. 

4.  Surgical  Treatment. — ^The  author  believes  that  gall-stones  should 
be  operated  on  when  recognized,  thus  saving  time,  suffering,  and  danger. 
The  following  indications  are  given  by  Kehr :  "  (a)  I  recognize  that  the 
latent  state  ensues  in  many  cases  of  cholelithiasis  after  rest  cures  or 
alkalies  and  in  certain  cases  is  permanent.  Particularly  in  the  so-called 
cases  of  chronic  recurrent  cholecystitis  a  regular  rest  cure  carried  out  at 
Carlsbad,  Neuenahr,  or  even  at  home,  will  often  so  mitigate  the  colics 
that  all  reason  for  operation  will  be  absent.  But  I  doubt  whether  an 
absolute  cure  will  frequently  occur,  i.e.,  the  passage  of  all  the  stones, 
by  medical  means.  It  is  my  opinion  that  we  should  never  endeavor  to 
force  a  passage  of  the  stones;  it  is  much  better  to  seek  to  render  them 


OTHER  AFFECTIONS  OF  THE  GALL-BLADDER  AND  DUCTS      737 

quiescent  in  the  gall-bladder  and  secure  a  restitution  of  the  inflamma- 
tory processes.  The  continuous  use  of  hot  applications  for  weeks,  in 
conjunction  with  rest  in  bed  and  the  use  of  Carlsbad  waters,  will  give 
the  best  results,  "(h)  Riedel's  theoretical  justification  for  early 
operation — the  removal  of  the  calculi  while  they  remain  in  the  gall- 
bladder— holds  good  now  as  ever,  as  in  many  cases  an  early  operation 
is  the  only  salvation  for  the  patient  against  such  grave  dangers  as  per- 
foration, cholsemia  and  carcinoma.  Universal  application  of  early 
operation,  however,  in  general  practice,  is  absolutely  impossible,  and 
Riedel's  indications  for  operation  are,  for  this  reason,  without  practical 
value.  "  (c)  I  decline  operative  interference  if  the  attacks  run  a  mild 
course,  and  in  the  intervals  when  complete  latency  exists,  i.e.,  entire 
absence  of  sensitiveness  in  the  region  of  the  gall-bladder.  "  (d)  Acute 
obstruction  of  the  choledochus  is,  with  rare  exceptions,  to  be  treated 
medically.  Should  cholangitic  symptoms  appear,  or  should  the  jaun- 
dice be  prolonged  suflBciently  to  induce  loss  of  strength  and  absolute  loss 
of  appetite,  operation  should  be  performed.  "  (e)  Operation  is  nec- 
essary when  frequent  colics  occur,  even  without  jaundice  or  the  passage 
of  stones,  which  damage  the  general  health,  deteriorate  the  earning 
capacity,  and  destroy  the  pleasure  of  living.  "  (/)  Cases  of  jaundice 
which  are  always  accompanied  by  the  passage  of  stones,  belong  to  the 
physician;  should  the  attacks  multiply,  the  patient  become  vitally 
depressed,  and  no  hope  be  present  for  the  passage  of  all  the  stones, 
the  propriety  of  the  operation  is  established.  "  (g)  Hydrops,  empyema 
of  the  gall-bladder,  and  pericholecystitic  abscesses  belong  to  the  pro- 
vince of  surgery.  In  those  rare  exceptions  in  which  a  sterile  hydrops 
gives  rise  to  a  few  symptoms,  the  patient  may  be  ignorant  of  his  swollen 
gall-bladder  until  distress  begins  and  multiplies.  "  (h)  Surgical  treat- 
ment should  not  be  postponed  too  long  after  the  failure  of  a  Carlsbad 
cure.  "  (i)  Gall-stone  patients  who  have  become  addicted  to  the  use 
of  morphine  must,  under  all  circumstances,  be  operated  upon.  During 
the  after-treatment  the  best  opportunities  are  afforded  for  curing  the 
opium  habit.  "  (j)  Treatment  of  carcinoma  of  the  gall-bladder  can 
only  be  of  lasting  benefit  if  the  case  is  operated  upon  early.  Every  one, 
however,  dreads  an  early  operation,  and  late  operations  are  not  of 
much  use;  therefore  the  complete  cure  of  the  evil  will  but  rarely  be 
effected.  "  (k)  Those  suffering  with  chronic  jaundice,  which  is  not 
dependent  upon  stone  in  the  common  duct  or  incurable  disease  of  the 
liver,  must  be  operated  upon,  at  the  latest,  three  months  after  the 
appearance  of  the  icterus,  for  it  not  infrequently  occurs  that  in  place 
of  a  suspected  carcinoma  of  the  head  of  the  pancreas,  a  curable  chronic 
interstitial  pancreatitis  will  be  found.  "  (Z)  The  decision  for  operation 
will  be  rendered  easy  for  both  physician  and  patient  upon  demonstra- 
tion of  tumor  of  the  gall-bladder,  a  swollen  liver,  and  the  appearance  of 
jaundice  and  fever.  We  may  also  operate  on  cases  without  demon- 
strable local  lesions  of  the  gall-bladder  and  liver,  which  exhibit  severe 
and  continuous  symptoms  which  do  not  prove  amenable  to  internal 
medication.    We  find  in  such  cases,  particularly  often  in  men,  adhesions 

47 


738  DISEASES  OF  THE  GALL-BLADDER 

of  traumatic  origin  without  stones.  "  (m)  The  sequelae  of  choleHthiasis, 
purulent  cholangitis,  abscess  of  the  liver,  peritonitis  due  to  perforation, 
subphrenic  abscess,  severe  pyloric  and  duodenal  stenosis,  and  gall- 
stone ileus,  must  be  treated  surgically.  "  (n)  Concluding:  To  present 
general  indications  for  a  gall-stone  operation  is  not  readily  possible. 
One  must  decide  each  case  on  its  own  merits.  Men,  particularly 
corpulent  ones,  do  not  bear  the  operation  well.  Women  who  have 
borne  children  lend  themselves  particularly  well  to  this  surgical  pro- 
cedure. If  possible  one  should  refrain  from  operating  in  cases  of 
diabetes,  arteriosclerosis,  chronic  nephritis  and  diseases  of  the  lungs 
and  heart." 

In  Mayo's  1,000  operated  cases  (1905),  the  mortahty  was  but  1  per 
cent,  in  416  uncomplicated  cases,  while  those  complicated  by  suppura- 
tion or  cancer  brought  the  average  mortality  to  5  per  cent. ;  the  death 
rate  in  operations  on  the  common  duct  was  1 1  per  cent.  These  figures 
appear  to  the  writer  as  the  best  possible  argument  for  early  operation. 
Cholecystotomy  was  attended  by  a  2.5  per  cent,  mortality  and  it  is 
therefore  the  better  operation,  as  cholecystectomy  entailed  4.3  per 
cent,  of  fatalities.  In  Kehr's  last  500  cases  (1904),  the  mortality  was 
32per  cent,  in  uncomplicated  cases  and  13  per  cent,  with  cancer  and 
cholangitis;  stones  were  left  in  2.5  per  cent.,  hernia  developed  in  3  per 
cent,  and  adhesions  and  inflammatory  colic  occurred  in  5  per  cent. 
(versus  his  earlier  figures  of  4,  7  and  17  per  cent,  respectively). 

(C).  CHOLECYSTITIS. 

Etiology. — Inflammation  of  the  gall-bladder  may  occur  before, 
after,  with  or  without  inflammation  of  the  bile  passages,  (a)  Predis- 
posing factors  are  gall-stones  (especially  large  ones  which  cannot  pass, 
which  cause  65  per  cent,  of  cholecystitis  and  cholangitis  (Dominici)  or 
90  per  cent,  in  other  statistics),  bile  stasis,  trauma,  foreign  bodies,  or 
previous  attacks.  (6)  The  exciting  cause  is  bacterial;  the  colon, 
typhoid,  pyogenic,  pneumococcus,  cholera  or  influenzal  organisms  may 
be  responsible.  They  may  ascend  the  bile  channels  or  enter  with  the 
blood  current.  Inflammation  from  typhoid  infection  (Louis  and 
Andral)  may  occur  without  actual  typhoid,  or  may  develop  even  twenty 
years  later  (Osier). 

Symptoms. — The  symptoms  vary  with  the  intensity  of  infection, 
which  is  almost  synonymous  "wdth  the  type  (simple,  membranous, 
suppurative,  phlegmonous,  ulcerative,  or  gangrenous).  In  light  forms 
the  symptoms  may  not  be  recognized;  this  corresponds  to  post  mortem 
adhesions  in  cases  with  no  history  of  cholecystitis.  In  other  cases, 
perhaps  more  severe  ones,  symptoms  are  obscured  by  the  causative 
typhoid,  or  by  gall-stones.  In  the  average  case,  there  is  (a)  fain  over 
the  part,  which  may  be  severe  or  paroxysmal  and  may  radiate  toward 
the  appendix  or  back,  (b)  Tenderness  as  in  gall-stones;  it  is  often 
first  general  and  then  local,  and  the  right  rectus  is  tense;  it  is  clearly 


CHOLANGITIS,  CATARRHAL  ICTERUS,  CONGENITAL  OCCLUSION   739 

elicited]by  a  jab  over  the  part  during  inspiration,  (c)  Fever,  increased 
pulse  rate,  vomiting  or  nausea;  fever  is  absent  in  mild  infections:  in 
typhoid,  cholecystitis,  may  be  confused  with  typhoid  relapse  (Musser). 
(d)  There  may  be  a  palpable  gall-bladder.  Its  contents  may  be  puru- 
lent (empyema  cystidis  fellese)  or  serous  (hydrops  cystidis  fellese). 
Hydrops  may  enlarge  the  gall-bladder  to  the  size  of  the  fist,  or  in 
extreme  cases  so  that  it  weighs  50  to  60  pounds,  contains  thirty  to 
forty  quarts,  and  fills  the  entire  abdomen ;  experienced  observers  have 
mistaken  such  cases  for  ascites;  the  fluid  is  alkaline  or  neutral,  serous 
or  mucoid.  If  very  tense  the  gall-bladder  may  not  fluctuate  or  if  very 
lax  may  not  be  palpable  (see  Floating  KroNEY).  There  may  be  pus 
in  the  gall-bladder  without  enlargement.  In  chronic  cases  it  may 
shrink,  {e)  Severe  sepsis  may  intervene  when  there  is  diffuse  sup- 
purative cholangitis  or  pylephlebitis;  this  is  evidenced  by  septic  fever, 
chills,  leukocytosis,  colon  bacilli,  pneumococci  or  other  organisms  in  the 
blood,  swollen  liver  and  spleen,  nephritis,  and  ulcerative  endocarditis. 
Icterus  is  inconstant. 

Prognosis. — Many  cases  with  cholangitis  die  in  spite  of  operation. 
Mild  cases  may  subside,  but  recurrence  and  formation  of  gall-stones  are 
frequent.  Under  expectant  therapy,  the  outlook  is  serious  in  severe 
cases,  for  perforation,  localized  or  general  peritonitis,  adhesions  (in 
75  per  cent.),  and  duodenal  or  pyloric  obstruction  may  result. 

Treatment. — Rest,  milk  diet,  local  heat  and  morphine  may  suffice 
for  light  cases,  but  in  the  more  severe  infections  drainage  is  indicated. 

(D).  CHOLANGITIS,  CATARRHAL  ICTERUS,  CONGENITAL 
OCCLUSION. 

Suppurative  cholangitis  usually  is  diffuse,  co-exists  with  suppurative 
cholecystitis  and  results  from  gall-stones  with  infection.  It  may  occur 
in  cancer  or  foreign  bodies  in  the  tracts  and  in  pylephlebitic  liver 
abscess.  The  infection  is  usually  ascending  but  may  follow  infection  of 
the  portal  vein  into  which  their  bloodvessels  empty.  The  symptoms 
of  cholangitic  sepsis  have  been  described  under  cholecystitis.  Drain- 
age is  indicated. 

Acute  catarrhal  jaundice  (cholangitis  catarrhalis,  icterus  simplex 
seu  gastroduodenalis)  results  from  gastroduodenal  catarrh  which 
causes  swelling  with  obstruction  of  the  papilla,  and  probably  catarrhal 
inflammation  of  the  lower  portion  of  the  common  duct;  as  few  cases 
come  to  autopsy,  the  latter  point  is  not  entirely  proven,  though  a  small 
plug  of  mucus  usually  occludes  the  opening.  Its  usual  causes  are 
practically  those  of  acute  gastritis  or  enteritis.  Favoring  factors 
include  passive  congestion  (cardiac  or  portal),  acute  infections,  toxic 
causes  (as  phosphorus),  nephritis,  other  diseases  of  the  liver  or  bile 
tracts  (cirrhosis,  cancer,  stones,  parasites),  and  very  rarely  psychic 
disturbance  or  menstrual  derangement.  Epidemic  forms  occur  or 
forms  whichseem  to  be  a  separate  type  of  infection  (v.  Weil's  Disease). 


740  DISEASES  OF  THE  BILE  TRACTS 

Symptoms. — Gastro-intesiinal  catarrh  occurs  first  in  many  cases 
and  after  a  few  days  to  a  week  or  so  icterus  appears,  with  its  usual 
symptoms  {v.  Icterus),  sudden  decolorization  of  the  stools,  and  bright 
yellow  staining  of  the  skin  and  urine.  However  the  physician  must 
not  expect  to  always  find  an  antecedent  gastroduodenitis,  because 
a  primary  infectious  catarrh  of  the  bile  ducts  is  equally  frequent. 
Other  findings  are  inconstant;  the  liver  is  not  enlarged  at  first,  but 
may  become  sHghtly  swollen  later;  there  is  no  pain  over  the  Uver  or 
ducts,  emaciation  if  present  is  slight,  the  spleen  and  gall-bladder  are 
seldom  enlarged,  and  the  diagnosis  depends  entirely  on  the  mode  of 
onset  in  young,  healthy  subjects,  sequence  of  symptoms  and  exclusion 
of  other  causes  of  obstruction.  In  advanced  life,  catarrhal  jaundice  is 
uncommon  and  gall-stones  and  cancer  are  always  to  be  thought  of  first. 

Prognosis. — The  prognosis  is  almost  always  good,  the  jaundice 
lasting  four  to  eight  weeks.  The  author  has  seen  cases  clear  in  a  week 
and  others  last  five  months,  though  a  course  of  over  four  to  eight  weeks 
renders  the  diagnosis  uncertain.  Cases  with  fever  may  run  a  pro- 
longed course.  Death  rarely  occurs.  Cases  of^f atal  hemorrhage  (Toelg 
and  Neusser),  and  in  the  aged,  of  exhaustion  (Leichtenstem),  and 
of  sudden  death  -^ath  symptoms  of  sudden  heart-failure,  are  reported. 

Treatment. — (a)  Caizsative  factors,  as  gastritis  or  cardiac  failure, 
should  be  appropriately  treated;  dyspeptic  symptoms  yield  most 
readily  to  gastric  lavage;  a  diet  of  skimmed  milk,  which  contains  least 
fat,  and  fractional  doses  of  calomel  at  night  followed^by  a  mild  saline 
in  the  morning,  should  be  given;  but  it  should  be  remembered  that 
active  catharsis  augments  or  indeed  initiates  catarrh. 

^  .     . 

Acidi  hydrochlorici  diluti Sj. 

TinctursB  nucis  vomicse 5iv. 

Tincturse  gentian^e  co qs.  ad  §iv. 

M.  et  S.— One  teaspoonful  after  meals  in  half  a  glass  of  water. 

Calomel  was  formerly  given  because  it  produced  green  "bilious 
stools";  this  color  is  not  due  to  bile  but  to  mercuric  sulphide,  (b) 
In  the  diet,  fats  are  particularly  to  be  avoided,  as  neither  the  stomach 
nor  intestine  can  digest  them;  tea,  coffee,  alcohol  and  coarse  foods 
should  be  interdicted;  as  above  mentioned,  skimmed  milk  is  given  and 
well-cooked  carbohydrates  are  gradually  added  to  the  diet;  toast, 
eggs,  mealy  soups  and  possibly  some  lean  meat  may  be  given,  though 
meat  is  often  poorly  tolerated,  seemingly  because  of  exclusion  of  the 
pancreatic  secretion,  (c)  As  long  as  acute  dyspepsia  exists,  rest  in  bed 
is  indicated,  in  order  to  maintain  nutrition  on  the  lowest  possible  diet. 
(d)  The  bowels  should  be  regulated  by  copious  injections  of  water 
which  are  thought  to  incite  peristalsis  and  therefore  dislodge  the 
obstructing  mucus  plug,  (e)  The  itching  is  allayed  by  1  per  cent. 
carboHc  solution,  the  use  of  which  requires  care,  as  the  urine  some- 
times becomes  cloudy;  acetanilide,  gr.  v  q.i.d.;  potassium  bromide, 
5ss,  well  diluted,  by  rectum  once  or  twice  daily;  an  occasional  hypo- 
dermic of  pilocarpin  hydrochlorate  gr.  ^,  warm  baths  to  relieve  the 


CANCER  OF  THE  GALL-BLADDER  741 

dryness  of  the  skin  and  calcium  chloride  gr.  x  to  xx  t.i.d.  for  a  few 
days  are  indicated. 

Chronic  catarrhal  cholangitis  rarely  follows  the  acute  form  but  more 
often  results  from  occlusion  of  the  common  duct  by  calculus,  cancer, 
stricture  or  pressure  from  without  {v.  gall-stones,  pancreatic  cancer  and 
icterus) . 

Congenital  Occlusion  of  the  Bile  Ducts. — Sixty-four  cases  are  re- 
corded, according  to  Rolleston,  who  thinks  that  some  poison  possibly 
initiates  cholangitis,  which  results  in  a  mixed  cirrhosis  and  obliteration 
of  the  ducts.  Icterus  develops  within  a  month  after  birth  and  death 
results  in  a  few  weeks  or  months — nearly  always  within  a  year — from 
cholsemia  or  hemorrhages. 


(E).  TUMORS  OF  THE   GALL-BLADDER  AND  BILE  VESSELS. 
Cancer  of  the  Gall-Bladder. 

Tumors  other  than  cancer  are  rare  and  of  purely  anatomical  interest 
as  papilloma,  fibroma,  lipoma,  or  adenoma.  Rolleston  states  there  are 
but  9  recorded  cases  of  sarcoma.  Fiitterer  (1901)  collected  268  cases 
of  cancer,  though  it  is  certainly  much  more  frequent  than  these  figures 
indicate. 

Etiology. — The  most  striking  etiological  factor  is  gall-stones, 
present  in  70  per  cent.  (Musser,  Fiitterer)  to  85  per  cent.  (Zenker, 
Courvoisier) ;  it  is  estimated  that  4  to  14  per  cent,  of  cases  of  gall-stones 
result  in  cancer  of  the  gall-bladder,  but  this  seems  a  very  high  percent- 
age considering  the  great  number  of  cases  of  gall-stones  and  the  small 
number  of  cases  of  cancer  of  the  gall-bladder.  Eighty  per  cent,  occurs 
in  women,  caused  by  lacing  (Fiitterer);  the  average  age  of  subjects  is 
fifty-eight  years. 

Pathology. — The  tumor  may  be  scirrhus  or  medullary,  but  histo- 
logically is  usually  of  the  columnar  type  (adenocarcinoma);  the 
spheroidal  and  squamous  types  are  rare. 

Symptoms. — (a)  Gall-stones  which  irritate  the  mucosa  and  cause 
most  cases,  usually  produce  no  symptoms  though  previous  colic  may  be 
noted  in  the  history,  (b)  A  tumor  of  the  gall-bladder  is  palpable  in  over 
66  per  cent.,  first  as  a  smooth  oval  swelling,  and  later  as  a  larger  and 
more  nodular  one;  it  is  usually  due  to  the  growth,  for  the  gall-bladder 
itself  is  generally  shrunken.  The  fundus  is  the  usual  point  of  origin, 
being  most  irritated  by  calculi;  much  more  rarely  the  neck  of  the  gall- 
bladder, or  least  frequently,  the  cystic  duct,  is  the  point  of  origin.  The 
tumor  appears  below  the  edge  of  the  liver  with  which  it  moves  and  with 
"which  it  is  consecutive  on  palpation,  percussion,  and  on  inflation  of  the 
colon.  There  may  be  local  discomfort  and,  in  rare  cases,  severe  pain 
like  that  of  gall-stones,  (c)  Cachexia  appears  with  all  its  attendant 
symptoms. 


742  DISEASES  OF  THE  BILE  TRACTS 

Complications. — Secondary  growths  in  the  liver  occur  in  58  per  cent, 
by  lymphogenous  routes  or  by  invasion  from  contiguity  and  sometimes 
cause  hepatic  enlargement;  from  the  liver,  extension  by  the  hepatic 
veins  may  occasion  systemic  metastases.  Icterus  occurs  in  69  per  cent. 
(Musser)  from  mahgnant  or  inflammatory  involvement  of  the  bile 
ducts;  cholsemia  is  a  common  termination.  Using  Musser's  figures, 
growths  in  the  peritoneum  occur  in  12  per  cent.,  in  the  lungs  or  pleura 
in  10  per  cent.,  in  the  abdominal  lymph  glands  in  16  per  cent,  and 
ulcerative  fistula  into  the  colon  in  10  per  cent.  Warthin  records  adrenal 
metastases  with  pigmentation  like  that  of  Addison's  disease  and  with 
vitiligo.  Pressure  on  the  pylorus  may  cause  its  stenosis,  vomiting,  or 
dyspepsia.  Ascites  occurs  in  25  per  cent.,  and  is  due  to  mechanical 
compression  of  the  portal  vein  or  to  malignant  peritonitis.  Suppurative 
cholecystitis  and  cholangitis  may  develop,  and  the  case  then  terminates 
by  sepsis,  ulcerative  endocarditis,  etc.  The  differential  diagnosis  is  con- 
sidered under  gall-stones.  The  clinical  course  averages  six  months. 
Treatment  is  merely  palliative,  unless  the  affection  is  diagnosticated 
early  enough  for  operation  or  is  accidentally  found  in  operating  for 
other  conditions.  Removal  of  the  gall-bladder  cancer  has  resulted 
in  a  few  permanent  cures  (Hochenegg,  Robson,  Warren).  Part  of 
the  liver  also  must  usually  be  removed. 


Tumors  of  the  Extra-Hepatic  Bile  Ducts. 

RoUeston  states  that  about  80  cases  are  reported.  These  tumors  are 
usually  small,  show  little  tendency  to  infiltrate  and  are  cancers  of  the 
columnar  type.  The  common  duct  is  most  often  affected,  the  hepatic 
duct  much  less  frequently,  and  the  cystic  duct  least  frequently;  these 
tumors  usually  occur  between  the  years  of  sixty  and  seventy  and  two- 
thirds  occur  in  males  (Devic  and  Gallaverdin).  The  salient  symptom 
is  icterus,  which  develops  early,  increases  steadily,  is  intense,  occurs  in 
nearly  all  cases,  causes  icteric  necrosis  of  the  liver  cells  in  the  central 
zone  (Fiitterer)  and  precipitates  early  cholsemia  before  metastases  have 
time  to  develop.  The  gall-bladder  is  almost  always  dilated  anatomi- 
cally in  tumors  of  the  common  duct  and  is  felt  clinically  in  over  50  per 
cent.  Pain  is  not  common,  though  that  of  gall-stones  may  be  simulated. 
Ascites,  dyspepsia  and  gastro-intestinal  hemorrhages  (from  cholsemia) 
may  develop.  Death  results  most  often  from  chol^mia,  and  less  often 
from  cholangitic  sepsis.  Differentiation  from  duodenal  or  pancreatic 
tumors  (q.v.)  is  always  diflBcult,  indeed  usually  impossible.  Confusion 
with  gall-stones  (q.v.)  is  possible.  Palliative  treatment  consists  of 
draining  the  gall-bladder  to  relieve  the  icterus;  radical  treatment' is 
extirpation  of  the  deeply  located  tumor  (Kehr,  Halsted). 


ACUTE  PANCREATITIS;  FAT  NECROSIS  743 

DISEASES  OF  THE  PANCREAS. 

(A).  ACUTE  PANCREATITIS;  FAT  NECROSIS. 

Etiology. — Infection  ascending  from  the  intestines  is  the  leading 
cause,  (a)  Calculus  obstructing  the  common  du£t,  though  allowing  bile 
to  regurgitate  into  Wirsung's  duct,  may  cause  acute  pancreatitis  (Opie), 
especially  when  the  gall-bladder,  the  natural  reservoir  for  obstructed 
bile,  is  shrunken.  Japha  found  gall-stones  in  38  per  cent,  of  76  cases  of 
acute  fat  necrosis  of  the  pancreas.  According  to  Quenu  and  Duval 
(1906)  118  cases  are  recorded  in  which  pancreatitis  occurred  in  the 
course  of  cholelithiasis.  Flexner  concludes  that  gastric  juice,  and  Opie 
that  bile  alone  may  initiate  inflammation  and  fat  necrosis,  even  when 
there  is  no  infection.  Though  the  accessory  duct  of  Santorini  may 
carry  off  the  pancreatic  juice  when  there  is  obstruction  of  Wirsung's 
duct,  it  is  too  small  for  much  compensation  in  66  per  cent,  of  cases 
(Opie);  (6)  metastatic  infection  is  an  infrequent  cause;  in  one  case  the 
author  observed  acute  pancreatitis  in  which  acutely  inflamed  ulcers  of 
the  leg  may  have  been  the  atrium  of  infection;  it  rarely  follows 
mumps;  (c)  in  some  cases  suppuration  or  ulceration  in  contiguous 
tissues  is  causative. 

Predisposing  Factors. — (a)  Age  and  sex;  in  Koerte's  collection  of 
41  cases,  90  per  cent,  occurred  in  males  beyond  middle  life;  McPhedran 
observed  a  case  in  a  child  nine  months  old.  (6)  Obesity;  (c)  alcohol- 
ism; (d)  trauma;  and  (e)  gastro-intestinal  catarrh  are  factors.  (/) 
Parturition  appeared  to  be  a  factor  in  6.6  per  cent,  of  Peiser's  collection 
of  128  cases. 

Symptoms. — The  symptoms  were  clearly  described  and  the  clinical 
picture  defined  by  Fitz  (1889),  though  cases  were  reported  earher 
(Oppolzer).  The  onset  is  sudden  in  adult  stout  males  who  have  enjoyed 
previous  good  health,  or  who  have  a  history  of  alcoholism  or  of  gall- 
stones. 

1.  Epigastric  pain  is  the  initial  symptom;  it  is  very  sudden  and 
severe,  is  often  agonizing,  may  be  constant  or  paroxysmal,  and  may  be 
confused  (or  coincident)  with  gall-stone  colic,  though  it  is  even  more 
intense;  it  may  be  central,  diffusely  epigastric,  to  the  right  or  left  of  the 
median  line,  or  rarely  directly  over  the  head  of  the  pancreas.  The 
author  has  seen  cases  in  which  it  radiated  into  both  lower  axillae.  The 
intensity  of  the  pain  is  referable  to  pressure  on  the  coeliac  plexus 
(neuralgia  or  possibly  neuritis  coeliaca).  Much  less  often  the  pain  is 
gradual  in  onset. 

2.  Epigastric  tenderness  is  usual,  often  over  the  head  (Elliot)  or 
sometimes  more  to  the  left  and  over  the  tail  of  the  pancreas,  whence  the 
inflammation  may  extend  to  the  left  pleura  with  tenderness  and  friction, 
as  in  one  of  the  author's  reported  cases.  The  recti  are  tense  r.nd  the 
epigastrium  is  swollen. 


7I4T  DISEASES  OF  THE  PANCREAS 

3.  Vomiting  is  early  and  severe,  and  brings  up  food,  mucus  and 
sometimes  blood. 

4.  Collapse  soon  follows;  it  is  often  very  severe,  threatens  im- 
mediate dissolution  and  too  often  prevents  surgical  interference.  It  is 
due  to  pressure,  on  or  actual  inflammation  of,  the  closely  contiguous 
coeliac  plexus  and  semilunar  ganglia.  There  may  be  marked  cyanosis. 
In  one  of  the  author's  cases  there  was  relapsing  shock  with  cyanosis 
and  a  pulse  of  140,  which  was  so  weak  that  no  surgeon  would  operate 
during  the  two  weeks  before  recovery.  Collapse  usually  causes  death 
in  2  to  4  days  in  unoperated  cases, 

5.  Fever  is  not  constant;  there  may  be  no  elevation  or  an  irregular 
rise  to  103  or  104  degrees.  Chills  are  more  common  in  late  suppuration 
than  at  the  onset. 

6.  The  pancreas  can  rarely  be  felt  because  of  its  deep  position  behind 
the  colon  and  stomach,  and  because  the  epigastrium  is  tense,  swollen, 
and  tympanitic.    If  palpable  it  is  small  and  immobile. 

7.  The  bowels  are  constipated,  simulating  obstruction.  Operation 
or  autopsy  at  this  stage  shows  an  acute  pancreatitis,  with  swelling,  a 
variegated  yellow-red  or  black  color,  exudation  of  fibrin,  pus  cells, 
blood  (hemorrhagic  pancreatitis)  and  areas  of  acute  fat  necrosis  (Balser, 
1882).  Fat  necrosis  is  caused  by  the  fat-splitting  steapsin  (Langerhans, 
Hildebrand,  Dettmer  and  Flexner),  which  produces  glycerine  and  in- 
soluble fatty  acids  from  the  pancreas  and  contiguous  adipose  tissues, 
i.e.,  omentum,  mesentery,  and  peritoneum;  the  glycerine  is  absorbed, 
the  fatty  acids  are  precipitated  with  lime  and  become  opaque  white 
areas  of  necrosis  as  large  as  a  pinhead  or  saucer,  and  some  of  the  fer- 
ments occasionally  escape  into  the  blood,  producing  toxsemic  symptoms 
or  necrosing  fatty  tissue  elsewhere,  as  in  the  pericardium  or  skin. 

8.  If  the  patient  lives,  the  symptoms  of  localized  peritonitis  develop 
in  the  upper  half  of  the  abdomen  and  sometimes  more  to  the  left  side; 
a  pus  sac  may  fill  the  lesser  peritoneal  cavity;  the  localized  pain  may 
become  general  from  diffused  fat  necrosis.  In  one  of  the  author's  cases 
great  dyspnoea  attended  diaphragmatic  pleurisy. 

9.  Septicopycemic  symptoms  may  appear,  as  rigor,  hectic  fever, 
delirium,  pleurisy,  hiccough,  icterus,  diarrhoea,  and  loss  of  weight  and 
strength;  in  one  case  the  author  saw  acute  splenic  tumor,  acute  nephri- 
tis and  universal  swelling  of  the  lymph  nodes. 

9.  Acute  glycosuria  is  not  common,  though  present  in  one  of  the 
author's  cases. 

In  the  third  week  rupture  into  the  colon  may  occur;  this  is  attended 
by  lancinating  pain,  intestinal  hemorrhage,  even  passage  of  the  pan- 
creas by  the  bowel  (Chiari)  and  relief  from  all  symptoms. 

Suppurative  types,  of  which  Koerte  collected  46  cases,  may  begin 
gradually,  without  acute  gangrene,  fat  necrosis,  or  hemorrhage.  The 
symptoms  are  less  acute  and  severe  than  those  of  the  acute  type.  The 
suppuration  is  localized  or  there  is  a  diffuse  purulent  infiltration;  it 
may  cause  pylephlebitis,  liver  abscess,  subphrenic  abscess,  burrowing 
of  pus  into  the  peritoneum,  loin  (which  Koerte  considers  rather  char- 


ACUTE  PANCREATITIS;  FAT  NECROSIS  745 

acteristic),  peripheral  tissues,  or  alimentary  tract.  Protracted  suppura- 
tion sometimes  is  said  to  cause  glycosuria,  skin  pigmentation,  and 
anasarca.    -Koerte  found  40  cases  of  acute  gangrenous  pancreatitis. 

Diagnosis. — The  cardinal  features  are  (a)  the  sudden  onset,  (6) 
violent  epigastric  pain  and  tenderness,  (c)  vomiting,  (d)  collapse,  (e) 
epigastric  distention.  The  absence  of  indican  under  circumstances  in 
which  it  usually  is  increased  is  suggestive  of  pancreatic  lesions,  because 
trypsin  converts  albumin  into  peptone,  which  in  turn  becomes  partly 
converted  into  indol,  the  source  of  indican  in  the  urine.  Since  leucin 
and  tyrosin  are  formed  in  the  normal  intestine  as  a  result  of  the  action 
of  the  pancreatic  juice  upon  proteids,  Ulrich  attaches  much  importance 
to  their  absence  from  the  urine  (with  glycosuria),  as  indicative  of 
disease  of  the  pancreas.  Robson  finds  calcium  oxylate  crystals  in  30 
per  cent,  of  all  varieties  of  pancreatic  disease. 

The  pancreatic  reaction  of  Robson  and  Cammidge  is  a  test  for  gly- 
cerine in  the  urine;  it  is  complicated  and  recent  reports  show  it  is 
neither  constant  nor  reliable. 

Differentiation. — (a)  Acute  poisoning  is  eliminated  by  the  history 
and  by  the  gastric  contents,  (b)  Intestinal  obstruction  is  less  severe 
in  onset;  collapse  is  usually  attended  by  distention  and  often  by 
intestinal  rigidity  or  peristalsis  above  the  obstruction,  and  rectal 
injections  often  show  its  impermeability;  indicanuria  is  usual;  epi- 
gastric distention  alone  is  unusual;  in  one  pancreatic  case,  the  author 
saw  obstruction  lasting  nine  days.  Operation,  indicated  in  either 
instance,  may  be  necessary  for  diagnosis,  (c)  Gall-stone  colic  is  some- 
times hard  to  differentiate  but  is  rarely  as  severe  as  pancreatic  pain; 
collapse  or  epigastric  distention  is  infrequent,  (d)  In  perforating 
duodenal  or  gastric  ulcer,  the  later  collapse,  pain,  and  the  history,  are 
significant,  (e)  Mesenteric  embolism  and  appendicitis  (without  in- 
duration) must  be  considered. 

Prognosis. — Mild  cases  may  occur,  though  the  malady  generally 
evinces  a  severe  progressive  tendency.  A  fatal  attack  may  be  the 
last  of  several  milder  seizures.  Fitz  has  found  at  autopsy  fibrous 
tissue  and  crystals  or  granules  of  hsematoidin  which  he  regards  as 
evidence  of  previous  hemorrhage  and  inflammation.  Death  may  occur 
within  a  few  hours  to  three  days  from  collapse,  in  two  or  three  months 
from  sepsis,  or  in  six  months  from  diabetes  (Fitz).  Death  at  an  even 
later  period  may  result  from  sepsis  or  diabetes.  Koerte  and  Osier 
report  cases  of  recovery  after  coeliotomy  had  first  revealed  the  true 
cause  of  the  obstruction.  The  pancreas  may  slough  into  the  intestine, 
as  in  Trafoyer's  and  Chiari's  cases,  and  recovery  may  result. 

Treatment. — Rectal  feeding  and  stimulation,  morphine  hypoder- 
matically,  and  heat  are  indicated  during  the  initial  shock,  from  which 
some  surgeons  consider  that  a  rally  is  necessary  before  operation  can 
be  safely  performed.  Though  early  operation  is  dangerous  because  of 
shock  and  hemorrhage,  the  author  considers,  with  Robson,  that  it 
is  indicated  lest  local  extension  or  general  toxaemia  develop.  In  21 
cases  (Quenu  and  Duval),  62  per  cent,  of  the  acute  cases  died  after 


746  DISEASES  OF  THE  PANCREAS 

operation,  100  per  cent,  of  the  hemorrhagic,  and  45  per  cent,  of  the 
acute  suppurative  cases. 


(B).  CHRONIC  PANCREATITIS. 

Etiology  and  Pathology. — (a)  Gall-stones  in  the  common  duct  may 
induce  chronic  catarrh  of  Wirsung's  duct,  thus  leading  to  chronic 
pancreatitis  (Robson).  (6)  Cancer,  gastroduodenal  catarrh  and  ulce- 
ration (alcoholism,  syphilis,  and  pancreatic  calculi)  may  produce  the 
same  results.  In  these  instances  ascending  infection  appears  to  be  the 
patent  factor,  causing  interlobular  fibrosis  (Opie)  i.e.,  fibrosis  around 
the  pancreatic  lobules;  diabetes  is  a  late  and  uncommon  sequence, 
(c)  In  liver  cirrhosis  and  hoemochromatosis  (see  Diagnosis  Portal 
AND  BiLiAEY  CiRRHOSis)  an  intcracinar  fibrosis  (Opie)  occurs,  develop- 
ing in  the  lobules,  diffusely  invading  the  islands  of  Langerhans  and 
causing  glycosuria ;  it  does  not  result  from  obstruction  of  the  common 
duct.  The  opposite  of  this  condition  was  described  by  J,  C.  Ohlmacher 
in  a  case  of  degeneration  of  the  liver;  there  was  a  compensatory  hyper- 
trophy of  Langerhans'  islands,  proving  for  the  first  time  the  mutual 
relation  of  the  pancreas  and  liver,  in  diabetes,  and  in  the  disposition 
of  carbohydrates. 

Symptoms. — Symptoms  may  be  lacking.  Moynihan  states  that 
chronic  inflammation  increases  in  frequency  with  increasing  thorough- 
ness of  operations  for  gall-stones.  They  vary  with  the  cause.  In 
catarrh  due  to  gall-stones  there  is  a  history  of  colic,  jaundice,  and  some- 
times intermittent  fever.  Tenderness  in  the  epigastrium,  a  fulness 
above  the  umbilicus,  and  loss  of  flesh  are  noted,  and  if  the  pancreatic 
symptoms  predominate,  the  pain  passes  from  the  epigastrium  to  the 
left  side,  to  the  scapular  or  renal  regions.  If  gall-stones  are  not  the 
cause,  there  may  be  merely  aching  or  painful  attacks  which  are  not 
at  all  pronounced;  pain  may  be  absent.  The  gall-bladder  may  enlarge 
from  obstruction  of  the  common  duct,  when  the  liver  becomes  enlarged 
and  frequently  cirrhotic  (Robson).  According  to  Robson  marked 
enlargement  of  the  spleen  is  frequent,  bile  is  found  in  the  urine  in  60 
per  cent.,  calcium  oxalate  crystals  in  40  per  cent,  and  glycosuria  in 
but  5.5  per  cent.  (90  cases).  Opie  found  glycosuria  but  once  in  22 
cases.  Riedel,  Koerte,  Robson,  Moynihan,  and  others  have  described 
a  tumor-like  induration  of  the  head  of  the  pancreas,  which  simulates 
cancer  because  of  the  emaciation  and  icterus  which  it  produces; 
differentiation  may  be  impossible,  even  during  laparotomy ;  it  is  more 
common  in  subacute  than  in  chronic  cases.  As  in  tumor,  excessively 
copious,  pale  stools,  laden  with  fat  and  undigested  muscle-fibers,  are 
noted.     Polyuria  has  been  reported. 

Differentiation  from  stone  in  the  common  duct  and  from  cancer 
is  very  difficult. 

Prognosis. — ^Without  surgical  intervention,  death  is  likely  to  occur 
from  emaciation,  cholsemia,  diabetes,  or  hemorrhagic  diathesis. 


PANCREATIC  LITHIASIS  747 

Treatment. — In  severe  clear  cases  and  doubtful  cases  drainage  of 
the  gall-bladder  or  anastomosis  is  indicated.  Robson  operated  on 
62  cases  with  13  per  cent,  mortality,  Quenu  and  Duval  on  62  cases 
with  13  per  cent,  mortality,  and  Moynihan  on  14  cases  without  a 
death.  Hemorrhage  is  a  dreaded  complication;  Robson  and  Moyni- 
han recommended  calcium  chloride  gr.  xx  to  5  j  t.i.d.  before  operation 
to  increase  the  coagulability  of  the  blood. 


(0).  PANCREATIC  APOPLEXY. 

Pancreatic  hemorrhage  has  been  described  by  Spiess  (1866),  Klebs 
(1870),  and  Zenker  (1876).  Draper  found  19  instances  in  4,000  autop- 
sies and  Anders  (1899)  collected  40  cases.  The  anaemias,  syphilis, 
alcoholism,  obesity,  acute  infections  and  local  lesions  of  the  pancreas, 
seem  to  be  predisposing  causes.  Sixty-six  per  cent,  of  cases  occur  in 
men.  Doubtless  many  reported  cases  are  acute  hemorrhagic  pan- 
creatitis. Sudden  onset,  severe  collapse,  epigastric  pain,  intestinal 
obstruction,  vomiting,  restlessness,  and  normal  or  subnormal  tem- 
perature, mark  the  affection.  The  course  is  said  to  be  even  more 
acutely  fatal  than  that  of  acute  pancreatitis;  death  sometimes  occurs 
within  a  few  hours.  If  the  patient  survives  the  initial  stage,  suppura- 
tion may  develop  in  the  pancreas,  peritoneum,  and  retroperitoneal 
tissues  into  which  the  hemorrhage  sometimes  burrows.  Hemorrhagic 
cysts  may  form,  which  should  not  be  confused  with  cysts  into  which 
secondary  hemorrhage  has  occurred.  The  diagnosis  from  acute  pan- 
creatitis is  rarely  made,  and  the  treatment  of  both  affections  is  iden- 
tical. 

(D).  LITHIASIS. 

Few  more  than  100  cases  of  sialolithiasis  pancreatica  are  recorded. 
The  etiology  is  probably  like  that  of  gall-stones,  infection  of  Wirsung's 
duct  (wirsungitis) ;  stagnation  of  secretion  is  a  predisposing  factor, 
whence  the  occasional  association  with  gall-stones,  pancreatic  inflam- 
mation and  tumor. 

Symptoms  and  Diagnosis. — Confusion  with  gall-stones  is  often 
inevitable,  for  colic  without  icterus  is  equally  indicative  of  either 
condition  and  their  co-existence  is  not  uncommon.  The  pain  maj- 
radiate  to  the  left  side  and  shoulder;  Lancereau,  Lichtheim,  Leichten- 
stern,  Minnich,  Holtzmann,  Moynihan,  and  Kinnicutt  have  recognized 
cases.  In  some  of  them  the  stones  were  found  in  the  faeces  during  life, 
in  others  at  autopsy.  Salivation  is  reported.  In  Lichtheim's  case 
there  was  cohc,  glycosuria  (found  in  33  per  cent,  of  the  cases)  and 
diarrhoea.  The  stones  are  single  or  multiple  (even  300),  white-gray, 
round,  oval,  irregularly  outlined  or  branching,  hard  or  friable,  and 
vary  in  size  from  that  of  almost  impalpable  gravel  to  that  of  a  hazel- 
nut.    They   consist   largely   of   calcium   carbonate   and   phosphate. 


748  DISEASES  OF  THE  PANCREAS 

Shattuck  described  an  oxalate  calculus.  Their  sequelae  are  (a)  ob- 
struction and  inflammation  of  Wirsung's  duct,  (b)  acute  suppurative 
pancreatitis  and  possibly  pancreatic  cancer.  The  treatment,  in  the 
cases  which  are  fortunately  diagnosticated,  is  surgical;  Moynihan 
both  recognized  and  successfully  operated  on  a  case.  Gould  also 
operated  on  a  case  which  did  not  recover. 


(E).  PANCREATIC  CYSTS. 

To  Nicholas  Senn  (1885)  belongs  the  credit  of  establishing  their 
clinical  picture.     Bessel-Hagen  (1900)  collected  149  cases. 

Etiology  and  Pathology. — Probably  many  reported  cases  are  extra- 
pancreatic,  especially  (a)  the  traumatic  cysts  of  which  Honigmann  in 
1905  collected  69  cases,  (b)  Duct  obstruction  (janula  pancreatica, 
Virchow)  by  calculi,  strictures,  parasites,  tumors,  or  inflammation  in 
the  smaller  ducts,  is  an  etiological  factor,  (c)  Cystadenoma  is  the 
cause  of  most  cysts  (Lazarus),  (d)  Cysts  rarely  result  from  an  old 
hemorrhage.  In  all  forms  the  cyst  causes  considerable  parenchy- 
matous atrophy,  (e)  Sex.  Traumatic  and  inflammatory  forms  are 
most  frequent  in  men  and  the  cystadenomatous  type  in  women. 
(/)  Age;  over  50  per  cent,  are  found  in  persons  in  the  third  decade 
of  life,  though  a  congenital  form,  sometimes  with  cystic  liver  and 
kidneys,  is  found  (Richardson). 

Symptoms  and  Diagnosis. — 1.  In  cysts,  (a)  a  deep  retroperitoneal 
swelling  is  found,  (b)  the  location  of  which  is  more  or  less  central, 
but  is  above  the  navel  in  87  per  cent.,  where  other  cysts  are  most 
uncommon;  it  lies  behind  or  between  the  stomach  and  colon;  it 
sometimes  lies  below  the  colon  but  rarely  above  the  stomach;  very 
large  cysts  (which  contain  10  to  20  quarts)  may  fill  almost  the  entire 
abdomen.  A  cyst  may  in  rare  cases  develop  in  the  tail  of  the  pancreas, 
when  it  points  toward  the  spleen  or  left  kidney,  (c)  Its  form  is  round, 
oval,  and  smooth;  {d)  its  consistence  often  varies;  (e)  it  is  immobile 
on  palpation  and  on  inspiration,  or  at  the  most  can  be  moved  slightly 
in  a  vertical  direction.  (/)  The  fluid  is  alkaline,  1,010-25  specific 
gravity,  usually  mucoid,  blood  stained  in  82  per  cent.  (Koerte),  and 
in  45  per  cent,  contains  one  or  more  pancreatic  ferments  (diastatic, 
saponifying,  or  tryptic)  of  which  the  latter  is  alone  characteristic,  for 
the  other  ferments  occur  in  various  exudates.  The  fluid  sometimes 
contains  fat  and  cholestearin ;  aspiration  is  dangerous,  because  the 
tension  of  the  cyst  is  great  and  fat  necrosis  or  peritonitis  may  result 
from  leaking  after  exploratory  puncture. 

2.  The  so-called  pancreatic  symptoms  are  rare,  as  emaciation,  sali- 
vation, stools  laden  with  undigested  fat  or  muscle-fibers  or  glyco- 
suria,     i^^-^ii 

3.  Symptoms  of  peritonitis  or  of  intestinal  obstruction  may  occur  in 
traumatic  or  inflammatory  types  and  after  rupture.  The  author  saw 
a  case  of  Murphy  and  Wittwer  in  which  the  picture  after  rupture 


PANCREATIC  CYSTS  749 

was  exactly  that  of  subacute  tuberculous  peritonitis;  after  two  rup- 
tures the  case  was  successfully  operated  on. 

4.  PaiV  like  that  of  cholelithiasis  may  be  present,  but  it  more  often 
radiates  to- the  left  side,  shoulder  and  neck.  Pressure  symptoms  in- 
clude dyspnoea,  vomiting,  icterus,  emaciation,  and  polyuria. 

Dijferentiation  from  ovarian,  renal  and  other  cysts  is  largely  a 
topographical  question.  Ovarian  cysts  have  their  pelvic  origin  and 
connection,  but  hydronephrosis  is  movable  and  originates  in  the  flank 
to  which  pancreatic  cysts  seldom  penetrate.  Fluid  in  the  lesser  peri- 
toneal sac  or  mesenteric,  omental,  and  retroperitoneal  cysts  are  difficult 
to  distinguish.  Cysts  of  the  liver  present  respiratory  excursion  and  other 
obviously  hepatic  symptoms. 

Treatment.^Aspiration  is  never  permissible.  Enucleation  of  the 
sac  is  more  difficult  and  more  dangerous  than  simple  drainage.  In 
Bessel-Hagen's  149  cases,  the  operative  mortality  was  6.7  per  cent. 
Diabetes  has  followed  operation  (Bull  and  Kroenig). 


(F).  TUMORS  OF  THE  PANCREAS. 

Cancer  of  the  pancreas  constitutes  67  per  cent,  of  all  pancreatic 
diseases  but  possibly  this  estimate  must  be  discounted  because  con- 
fusions with  benign  induration  have  been  frequent  until  of  late  years. 
It  occurs  in  0.6  per  cent.  (Eppinger)  to  1  per  cent.  (Soyka)  of  autopsies. 
In  132  cases  of  pancreatic  tumors  (Segre)  127  were  cancer,  2  sarcoma, 
2  cysts  and  1  gumma.  Sarcoma  is  usually  secondary  from  contiguous 
lymphosarcoma  in  the  retroperitoneal  glands. 

Cancer  is  usually  scirrhus,  less  often  of  the  medullary,  colloid,  or 
adenomatous  type.  It  most  often  begins  in  the  head  of  the  organ.  In 
some  cases  it  may  be  secondary  to  pyloric  cancer. 

S3miptoms. — (1)  Tumor  is  the  commonest  and  surest  symptom, 
occurring  in  25  to  50  per  cent. ;  it  lies  deep,  beside  the  spine  at  the  level 
of  the  navel  and  between  the  pylorus  and  colon.  It  is  tender,  prac- 
tically immobile,  and  varies  from  the  size  of  a  walnut  to  that  of  a  child's 
head  though  small  tumors  are  commonest;  in  some  instances  it  may 
show  propagated  pulsation  from  the  aorta  or  a  bruit  from  its  com- 
pression. Palpation  should  be  made  with  the  stomach  and  bowels 
empty.  (2)  Icterus  occurs  in  72  per  cent.,  increases  gradually,  and 
is  more  often  continuous  than  remittent.  In  some  cases  there  may  be 
rigors  and  pain  as  in  biliary  calculi;  occasionally,  just  before  death, 
the  growing  anaemia  seems  to  lessen  the  jaundice.  There  may  be  the 
slightly  enlarged  "icterus  liver,"  but  Bard  and  Pic  state  the  liver  is 
usually  rather  small.  (3)  The  gall-bladder  is  usually  enlarged  (Bat- 
tersby.  Bard  and  Pic);  see  differentiation.  Cochez  holds  that  it 
shrinks  when  the  hepatic  or  cystic  ducts  are  obstructed.  (4)  Pain 
and  early  vomiting  are  usual.  The  pain  is  epigastric,  severe,  and 
sometimes  neuralgic  (neuritis  cceliaca)  or  radiating  as  in  pancreatitis 
or  lithiasis.     (5)  Cachexia  is  marked  and  rapid;  ^ great  prostration, 


750  DISEASES  OF  THE  PANCREAS 

emaciation,  and  a  syncopal  tendency  occur  in  tumor  as  in  other  pan- 
creatic lesions.  The  temperature  is  usually  subnormal.  (6)  The 
stools  may  contain  much  fat  (Kuntzmann,  1827  and  Bright,  1833); 
in  steatorrhcea  the  fatty  acids  and  neutral  fats  (^Mueller)  are  more 
abundant  than  the  fatty  soaps;  its  significance  grows  if  diarrhoea  and 
icterus  are  not  present.  The  stools  also  contain  many  undigested 
muscle-fibers  {lientery)  and  sometimes  blood  is  present.  (Sahli's 
test  for  albumin  digestion  is  made  by  giving  salol  in  divided  doses  in 
glutoid  capsules;  as  the  glutoid  is  not  dissolved,  no  carbolic  acid 
appears  in  the  urine).  (7)  The  urine  may  contain  sugar;  Miralli^ 
holds  that  glycosuria  occurs  in  26  per  cent.,  though  in  Robson's  15 
cases  it  was  absent.  It  is  said  to  be  an  early  symptom  and  to  disappear 
before  death  or  with  the  increasing  icterus.  Albuminuria  is  more 
frequent  than  glycosuria.  The  indican  is  decreased.  Peptone,  maltose 
(once,  by  v.  Ackeren),  and  fat  (Clark  and  Bowditch),  have  been  found. 
Polyuria  and  bronzing  of  the  skin  are  rare  findings.  Complications 
include  pyloric  or  duodenal  obstruction;  compression  of  the  aorta 
or  cava;  retention  cysts  of  the  pancreas;  and  extension  by  contiguity 
to  the  portal  vein,  colon,  peritoneum,  ureter  or  lungs. 

Differentiation. — 1.  Chronic  pancreatitis  with  icterus  and  tumor 
may  not  be  differentiated  even  by  laparotomy  (Riedel)  though  ascites 
indicates  neoplasm,  and  recovery  means  inflammation.  The  pan- 
creatic cachexia  of  French  writers,  occurring  in  many  lesions  of  the 
pancreas,  may  be  confused  with  the  cachexia  of  cancer. 

2.  In  duodenal  cancer  (q.  v.)  the  growth  is  also  fixed  and  is  attended 
by  icterus,  but  cancer  above  the  papilla  causes  rather  the  picture  of 
pyloric  stenosis;  in  cancer  below  the  papilla,  pancreatic  juice  may  be 
recovered  from  the  stomach. 

3.  Liver  disease,  with  the  frequent  icterus,  ascites,  and  splenic 
enlargement,  causes  Httle  difficulty  in  differentiation. 

4.  Calcto.us  in  the  Common  Duct. — vs. — Compression  of  Common  Duct  bt 

Pancreatic  Tumor. 

1.  History  of  colic  usual.  Absent. 

2.  Tenderness  of  gall-bladder  usual.  Absent. 

3.  Icterus,  often  remittent.  Permanent. 

4.  Liver  less  large  than  in —  pancreatic  tumor. 

5.  Intermittent  fever,  and  rigors.  Subnormal  temperature. 

6.  Gall-bladder  (see  gall-stones)  shrunk-        Dilated  in  92  per  cent.  (Courvoisier's 

en  in  80  per  cent.  law). 

7.  Slower  course.  Very  rapid  emaciation. 

According  to  Bard  and  Pic,  the  icterus,  enlarged  gall-bladder,  rapid 
emaciation,  cachexia,  subnormal  temperature  and  normal  or  smaller 
liver  of  pancreatic  cancer  can  only  be  confused  with  some  few  cases 
of  gall-stones,  cancer  of  immediately  adjacent  parts,  primary  cancer 
of  the  liver  or  bile-passages,  and  primary  duodenal  or  gastric  cancer 


ACUTE  DIFFUSE  PERITONITIS  751 

with  early  diffuse  generalization  in  the  liver.  Kehr  states  that  obstruc- 
tion of  the  common  duct  is  cancerous  in  70  per  cent.,  (chronic)  pan- 
creatitic  in  20  per  cent,  and  calculous  in  10  per  cent. 

Treatment  is  largely  symptomatic;  morphine  should  be  given  for 
pain,  the  gall-bladder  should  be  drained  (cholecystotomy)  or  it  should 
be  sutured  to  the  intestine  (cholecystduodenostomy).  Koerte  reports 
ten  operations  with  six  permanent  recoveries,  and  Ruggi  reports  a 
successful  operation. 


[DISEASES  OF  THE  PEEITONEUM. 

(A).  ACUTE  DIFFUSE  PERITONITIS. 

Acute  inflammation  of  the  peritoneum  was  at  one  time  far  more 
important  as  an  independent  affection  than  at  present;  we  now  regard 
it  as  chiefly  symptomatic  of  some  other  disease,  e.g.,  appendicitis, 
salpingitis,  puerperal  sepsis,  etc. 

Etiology. — The  actual  cause  is  probably  always  mycotic.  Some 
writers  classify  peritonitis  as  bacterial  (especially  suppurative  forms), 
chemical  (serous  and  sero-hemorrhagic  forms)  and  mechanical  (adhe- 
sive forms).  The  Streptococcus  pyogenes  (puerperal  and  traumatic 
forms),  and  Bacillus  coli  (forms  due  to  intestinal  lesions)  are  the  two 
most  frequent  organisms.  The  staphylococcus,  pneumococcus,  and 
tubercle  bacillus  are  fairly  frequent  and  less  often  the  Bacillus  pyo- 
cyaneus,  proteus,  anthracis,  typhosus,  aerogenes  encapsulatus,  the  ray 
fungus,  Bact.  lactis,  gonococcus,  Amoeba  coli,  and  pseudodiphtheria 
organisms.  Generally  speaking,  mono-infections  are  less  common 
than  mixed  infections. 

Factors  causing  lessened  physiological  resistance  include  nephritis 
(in  10  per  cent,  of  cases),  alcoholism,  cardiac  disease,  scurvy  or  gout; 
in  other  words  peritonitis  may  be  a  terminal  infection,  fatal  to  reduced 
subjects. 

Atrium. — Compared  with  pleurisy  and  pericarditis,  peritonitis  is 
seldom  primary.  Though  it  may  follow  inflammation  of  every  abdom- 
inal viscus,  it  is  most  commonly  a  secondary  manifestation  of  intestinal 
disease  (e.g.,  appendicitis),  or  of  pelvic  diseases  in  women,  (a)  Infec- 
tion may  occur  through  the  alimentary  tract;  appendicitis,  bowel 
ulceration  (typhoid,  carcinomatous,  tuberculous),  bowel  obstruction, 
perforation,  traumatism  and  infarction  may  cause  it.  Gastric  are  less 
frequent  than  intestinal  lesions  and  ulcer  and  cancer  range  first.  (6) 
The  internal  female  genitalia;  it  may  result  from  gonorrhoea  (Noeger- 
rath),  extra-uterine  pregnancy,  puerperal  infections  and  septic  abortion ; 
peritoneal  infection  from  diseases  of  the  male  genitalia  is  rare,     (c) 


752  DISEASES  OF  THE  PERITONEUM 

Liver  and  bile  vessels;  local  or  general  peritonitis  may  result;  perito- 
nitis is  more  common  as  a  result  of  hepatic  abscess  and  syphilis  than  of 
echinococcus,  cancer,  pylephlebitis,  or  cholecystitis,  (d)  Pancreas; 
acute  pancreatitis,  (e)  Kidney  and  bladder;  pyonephrosis,  calculi,  or 
ulcerations  of  the  bladder.  (/)  Rarer  causes  are  splenic  affections, 
retroperitoneal  adenopathies,  spinal  or  costal  caries,  lesions  of  the 
thoracic  duct,  or  the  abdominal  parietes,  or  extension  through  the 
diaphragm,  (g)  Metastatic  peritonitis  is  not  common,  though  it  is 
observed  in  septicopysemia  and  in  acute  infections,  (h)  In  children 
foetal  peritonitis  has  been  observed  by  transplacental  infection;  in 
the  new-born  the  umbilical  vein  may  convey  infection,  though  perito- 
nitis occurs  in  but  8  per  cent,  of  fatal  cord  infections.  It  occurs  more 
commonly  through  the  lymphvessels  of  the  cord;  congenital  syphilis 
may  in  this  way  cause  peritonitis. 

Age  and  Sex. — Most  cases  occur  between  the  ages  of  fifteen  and 
forty  and  women  are  more  often  affected  than  men. 

Symptoms. — Symptoms  are  local  and  general. 

1.  Local  or  Abdominal. — (a)  Pain,  the  usual  initial  symptom,  is 
almost  invariable,  is  continuous,  begins  near  the  navel  and  remains 
greatest  there;  a  causal  gastric  ulcer  may  produce  pain  in  the  back, 
salpingitis  is  attended  with  early  pelvic  pain,  and  appendicitis  has  its 
own  initial  localization,  but  the  pain  of  diffuse  peritonitis  is  felt  at 
or  below  the  navel.  (6)  TencZerness  accompanies  pain ;  the  tenderness 
is  deep  rather  than  superficial;  tenderness  and  pain  are  very  rarely 
absent  and  are  caused  by  inflammation;  at  the  operation  or  autopsy 
both  the  visceral  and  parietal  investments  are  injected,  reddened,  lustre- 
less, covered  with  a  thin  film  of  fibrinous  exudate  which  binds  the  in- 
testinal coils  together;  not  infrequently  the  peritoneum  is  dotted  with 
minute  petechiee.  (c)  The  attitude  is  characteristic;  the  knees  are 
drawn  up  and  the  head  lifted  to  relieve  tension  and,  in  marked  cases, 
to  keep  the  bedclothes  from  contact  with  the  abdomen,  (d)  Vomit- 
ing is  reflex;  it  occurs  early  and  greatly  aggravates  the  pain;  the 
vomitus  contains  food  and  later  bile;  it  may  be  green  (the  vomitus 
herbaceus  of  the  older  writers),  rarely  dark  brown  or  fsecal.  It  is 
accompanied  by  redness  and  dryness  of  the  tongue,  great  thirst  and 
singultus  which  is  a  sensory  phrenic  symptom;  toward  the  fatal 
issue  vomiting  and  singultus  cease,  (e)  The  abdomen  on  inspection  and 
palpation  is  at  first  tense,  retracted,  and  scaphoid,  but  later  becomes  tym- 
panitic from  paresis  of  the  inflamed  intestinal  coils  (Stokes)  and  decom- 
position of  their  contents;  the  diaphragm  stands  high  and  its  movement 
is  restricted;  in  some,  especially  muscular,  subjects,  the  abdomen 
may  be  retracted  throughout  the  course.  Exploration  by  percussion 
may  elicit  dulness,  which  is  usually  due  to  serous,  seropurulent,  or 
perhaps  serohemorrhagic  exudation,  which  may  be  effused  in  small 
pockets  between  fresh  adhesions  or  may  fill  the  entire  cavity,  amounting 
to  even  30  or  40  quarts  and  sometimes  fluctuating  to  the  hand;  as 
a  rule  a  tympanitic  note  prevails;  in  some  cases  dulness  suggests  the 
presence  of  fluid  which,  however,  is  not  found  on  exploration;  because 


ACUTE  DIFFUSE  PERITONITIS  753 

of  adhesions,  the  fluid  changes  but  little  on  change  of  posture.  On 
auscultation  a  friction  rub  is  sometimes  heard  (Beatty  and  Bright), 
chiefly  over  the  liver.  (/)  Constipation  is  usual  and  results  from  in- 
flammatory infiltration  of  the  intestine  (Stokes);  in  the  puerperal 
(streptococcic)  and  in  pneumococcic  peritonitides,  diarrhoea  is  com- 
mon. 

2.  General  Symptoms. — (a)  Shock  is  a  conspicuous  symptom. 
Collapse  may  occur  early  and  directly  from  perforation  or  later  from 
toxaemia.  The  pulse  is  frequent,  hard,  wiry,  and  averages  about  120 
or  more;  later  it  becomes  thready  and  runs  to  140  or  170.  The  fades 
Hippocratica  is  pronounced,  with  its  anxious  expression,  wrinkled, 
clammy,  cyanotic,  lead-colored  skin,  pointed  nose,  hollowed  temples, 
and  sunken  eyes.  The  voice  whispers  (vox  cholerica)  to  avoid  move- 
ment of  the  diaphragm  and  the  breathing  is  costal,  shallow,  difiicult, 
and  rapid.  (6)  Fever  is  usually  but  not  always  present.  It  may  rise 
abruptly  with  a  chill  at  the  onset  but  follows  no  one  type;  it  may  be 
continuous  or  remittent,  and  there  is  usually  elevation  of  temperature 
by  rectum,  even  during  collapse.  The  fever  and  pulse  curves  may 
run  parallel  in  peritonitis  with  a  slow  course,  (c)  The  lungs  and 
heart  are  crowded  upward  by  the  abdominal  distention.  The  apex- 
beat  is  high  and  further  to  the  left  as  the  heart  lies  more  horizontally 
than  in  normal  conditions,  (d)  The  urine  is  scant  from  lessened  ab- 
sorption and  from  cardiac  weakness;  albuminuria  is  frequent;  indi- 
canuria  is  constant  from  increased  putrefaction  in  the  paretic  bowel; 
dysuria  is  usual;  tenesmus,  due  to  involvement  of  the  vesical  serosa, 
is  less  common  than  retention. 

Course. — Though  recovery  is  possible,  the  issue  is  fatal  within  two 
days  in  the  rapidly  fatal  toxcemic  form  in  which  there  is  only  roughening 
of  the  peritoneum  without  exudation ;  the  slower  cases  rarely  last  more 
than  five  days.  Consciousness  is  usually  preserved  to  the  end,  though 
stupor  or  delirium  occasionally  intervenes;  the  pulse  becomes  thready, 
the  breathing  shallow  and  sighing,  the  superficial  temperature  is  low 
though  rectal  registration  is  high,  and  the  patient  succumbs  to  gradual 
or  sudden  cardiac  failure  from  toxaemia.  In  exceptional  cases  death 
occurs  within  a  few  hours,  or  relative  recovery  results  with  encapsula- 
tion of  pus.  Treves  found  inhalation  pneumonia  in  17  per  cent,  of 
his  cases  and  Tilger  found  serous  pleurisy  in  25  per  cent.;  of  the 
latter,  63.3  per  cent,  was  right-sided,  3.3  per  cent,  left-sided,  and  33.3 
per  cent,  bilateral. 

Types. — (a)  Peritonitis  serosa  usually  follows  the  fibrinous  form; 
the  fluid  is  yellow  or  light  green,  its  specific  gravity  is  1,015  or  more, 
it  contains  2  to  3  per  cent,  of  albumin  and  flocculi  of  fibrin,  epithelial 
cells,  red  cells,  and  leukocytes.  (&)  P.  purulenta  may  occur  in  pockets 
or  as  a  massive  pyoperitoneum,  amounting  to  30  or  40  quarts,  (c) 
P.  putrida  occurs  in  septicopysemia  and  puerperal  fever,  but  espe- 
cially in  perforating  carcinoma;  Obermeyer  and  Schnitzler  have 
proven  that  foetid  peritonitis  may  occur  without  perforation,  (d) 
P.  perforativa  is  characterized  by  two  groups  of  symptoms,  (i)  those 

48 


754  DISEASES  OF  THE  PERITONEUM 

of  peritonitis  and  (ii)  those  of  gas  in  the  peritoneal  sac  (pneumoperi- 
toneum, pneumatosis  peritonei);  there  is  often  (but  not  always)  the 
■initial  subjective  sense  of  perforation,  sudden  pain,  collapse  and 
retracted  abdomen;  in  four  to  twelve  hours  diffuse  peritonitis  sets 
in,  unless  death  occurs  from  the  initial  shock;  free  gas  may  obliterate 
the  dulness  of  the  liver  and  spleen  though  this  also  results  from  great 
tympanites  without  perforation;  the  liver  dulness  may  be  found  only 
in  the  posterior  axilla,  but  when  the  patient  is  turned  on  his  left 
side  the  free  gas  entirely  obscures  it;  the  abdominal  contents  may  be 
putrid  or  faecal,  though  when  due  to  perforating  gastric  ulcer  (q.v.) 
there  is  seldom  any  odor  (Czerny).  The  diaphragm  is  pushed  to 
its  highest  possible  level;  a  succussion  splash  may  be  elicited,  and  the 
intestines  may  be  compressed  against  the  spine.  It  has  been  held 
that  gas  may  develop  in  peritonitis  without  perforation  through  the 
action  of  the  Bacillus  pyogenes  foetidus  and  Bac.  aerogenes  encapsulatus 
but  pneumoperitonitis  without  perforation  is  rare,  (e)  P.  puerperalis, 
usually  streptococcic,  is  described  under  septicopysemia ;  it  is  char- 
acterized by  moderate  pain,  enormous  tympanites,  diarrhoea,  and  the 
usual  septic  manifestations.  (/)  P.  pneumococcica  has  been  described 
by  Sevestre,  Moizard,  Galliard,  and  Dieulafoy.  Von  Brunn  has  col- 
lected 72  cases,  and  these  have  been  increased  by  Jensen  to  106. 
It  may  be  primary  or  secondary.  Most  cases  occur  in  girls  between 
three  and  twelve  years  old.  The  lower  abdomen  is  especially  involved, 
thereby  often  simulating  appendicitis,  which  it  also  resembles  in  its 
abrupt  onset,  pain,  fever,  and  vomiting;  pneumococcic  peritonitis  is 
nearly  always  attended  by  early,  continuous,  foetid  diarrhoea.  It  often 
points  at  the  navel,  through  which  a  creamy,  greenish  pus  may  rupture. 
Sometimes  it  ends  by  crisis;  an  encysted  pus  sac  often  remains.  The 
inflammation  is  usually  purulent,  and  rarely  serofibrinous.  The  pneu- 
mococcus  may  be  found  in  the  blood,  (g)  The  streptococcic,  colon, 
and  staphylococcic  peritonitides  are  described  under  appendicitis. 

Diagnosis. — Peritonitis  is  usually  diagnosticated  with  ease  from  the 
cause  (appendicular,  salpingitic,  gastric  ulcer,  septic  abortion),  the 
febrile  onset,  pain,  tenderness,  vomiting,  distention,  effusion,  and 
collapse.  Puncture  with  an  aspirating  needle  is  dangerous.  In  certain 
cases  only  the  fact  of  peritonitis  can  be  established,  perhaps  even  at 
operation,  though  the  autopsy  usually  demonstrates  a  cause. 

Differentiation  is  necessary  (a)  from  intestinal  obstruction  (q.v.); 
(b)  from  the  pain  of  biliary  or  renal  calculi;  (c)  from  acute  pancreatitis 
(q.v.);  id)  from  ruptured  tubal  pregnancy,  in  which  the  menstrual 
history,  pelvic  localization,  and  symptoms  of  acute  anaemia  and  shock 
are  present;  (e)  from  ruptured  abdominal  aneurysm;  or  infarction  of 
the  superior  mesenteric  artery  in  which  a  cause  for  embolism,  acute 
obstruction,  and  bloody  vomiting  or  diarrhoea  with  later  peritonitis 
are  often  distinctive;  (/)  from  acute  enterocolitis,  which  is  attended 
by  less  pain  and  tenderness  and  by  more  diarrhoeal  colic,  tenesmus,  and 
collapse,  due  to  dessication  of  the  tissues  and  to  toxaemia;  {g)  from 
hysteria  (q.v.),  which  may  simulate  peritonitis,  as  it  may  resemble 


CHRONIC  DIFFUSE  PERITONITIS  755 

every  other  disease:  the  first  cases  seen  by  young  practitioners  may 
be  very  deceptive;  if  its  presence  is  once  suspected,  the  other  stigmata 
are  usually-  definitive,  (h)  The  referred  abdominal  pain  of  thoracic 
disease  (pleurisy  and  pneumonia)  is  not  accompanied  by  tenderness, 
and  is  easily  distinguished  by  examination  of  the  chest,  especially  of 
its  posterior  parts,  (i)  Mild  infections  with  much  exudation  may 
simulate  ascites  (q.v.). 

Treatment. — Surgical  treatment  alone  is  of  any  value.  In  most 
statistics  the  percentage  of  recoveries  is  not  large;  Koerte  estimates 
it  at  35  per  cent.,  Haenel  at  37  per  cent.,  and  Krogius  (680  cases)  at 
28.5  per  cent.  The  author  has  seen,  in  Murphy's  service,  35  out  of  36 
consecutive  cases  of  diffuse  purulent  peritonitis  recover  under  operation, 
the  last  one  being  a  case  of  streptococcic  peritonitis;  Murphy  institutes 
drainage,  puts  the  patient  in  Fowler's  semi-erect  posture,  and  admin- 
isters continuously  enemata  of  normal  salt  at  low  pressure.  Had  he 
not  seen  the  cases,  the  author  would  accept  no  one's  word  for  these 
remarkable  results,  which  were  obtained  chiefly  in  patients  apparently 
moribund.  Deaver  reports  a  series  as  large  as  Murphy's  and  Morton 
had  twelve  recoveries  in  fourteen  operations. 

Palliative  treatment  is  of  little  value,  (a)  The  opium  treatment  only 
controls  pain  and  though  suffering  must  be  relieved  by  drugs  or  opera- 
tion, the  doses  recommended  by  Alonzo  Clark  (more  than  1,000  grains 
of  opium  in  one  week!)  are  now  only  of  historical  interest.  Morphine, 
given  hypodermatically,  produces  the  best  results.  (6)  The  patient 
should  have  absolute  rest,  (c)  Tait's  method  of  saline  purgation  to 
increase  osmosis,  is  productive  of  more  harm  than  good,  (d)  Vomit- 
ing is  treated  as  in  acute  gastritis ;  the  stomach  should  be  washed  out ; 
then  all  medication,  food  and  water  by  mouth  should  be  withheld, 
and  given  only  by  rectum,  (e)  Tympanites  should  be  treated  by  the 
turpentine  stupe,  and  by  enemata  containing  tr.  asafoetida  5iijj  spts. 
chloroform  5j  and  spts.  turpentine  5ss. 


(B).   CHRONIC  DIFFUSE   PERITONITIS. 

Aside  from  tuberculous  peritonitis,  chronic  diffuse  peritonitis  is 
uncommon,  (a)  The  serous  or  serohemorrhagic  form  will  be  con- 
sidered under  ascites;  (6)  the  diffuse  adhesive  form  results  from  acute 
peritonitis  and  from  tuberculous  peritonitis;  in  this  form  the  peri- 
toneal sac  is  obliterated  and  at  operation  or  necropsy  the  knife  cuts 
directly  into  the  intestine,  (c)  Chronic  proliferative  peritonitis  may 
occur  in  peritoneal  cancer  or  tuberculosis,  chronic  alcoholism,  cir- 
rhosis of  the  liver,  or  cardiac  disease.  It  may  develop  with  or  with- 
out adhesions,  as  a  diffuse  sclerosis  of  the  peritoneum  and  as  a 
subperitoneal  proliferation.  In  its  extreme  forms  it  was  described  by 
Virchow  (1885)  as  peritonitis  deformans.  The  peritoneum  is  white, 
lustreless,  and  diffusely  thickened,  though  in  some  places  more  than 
in  others.    The  omentum  is  retracted  upward,  so  that  it  lies  as  a  hard, 


756  DISEASES  OF  THE  PERITONEUM 

transverse  roll  above  the  navel,  and  the  mesentery  is  indurated  (mes- 
enteritis  retrahens)  as  described  under  tuberculous  peritonitis.  As  the 
mesentery  retracts,  it  may  gather  the  intestinal  coils  into  a  ball  no 
larger  than  a  child's  head,  lying  centrally  or  to  the  right  of  the  median 
line.  Here  and  there  may  be  found  multilocular  serous  encapsula- 
tions, or  there  may  be  no  serous  exudation,  at  least  when  the  case 
comes  under  observation.  There  may  be  palpable  tumor-like  thick- 
enings. The  spleen,  liver,  stomach,  caecum,  or  colon  may  be  partic- 
ularly indurated.  In  some  cases  it  is  but  part  of  a  multiple  cirrhosis 
(polyserositis,  polyorrhomenitis),  invading  also  the  pleura  and  peri- 
cardium. Miliary  fibromata,  resembling  miliary  carcinosis  or  miliary 
tuberculosis,  may  sometimes  form  around  parasitic  ova  or  cholestearin 
crystals. 

^  (C).  LOCALIZED  PERITONITIS. 

I.  Suppurative  Forms. 

1.  Subphrenic  Abscess  and  Pyopneumothorax  Subphrenicus. — 

Subphrenic  suppuration  was  first  diagnosticated  by  Barlow  (1845),  and 
was  especially  described  by  Leyden  (1879).  Maydl's  monograph 
(1894)  comprised  179  cases,  upon  which  the  following  figures  are 
based;  sixty  cases  are  described  by  Koerte  (1903). 

Etiology. — (a)  Gastric  ulcer  causes  19.5  per  cent.;  gastric  cancer 
is  less  frequent.  (&)  Appendicitis  causes  14  per  cent.;  (c)  trauma, 
14  per  cent.;  (d)  intestinal  ulceration,  7.3  per  cent.;  (e)  cholangitis 
and  cholecystitis,  11  per  cent.;  echinococcus,  7.3  per  cent.;  liver 
abscess;  (/)  metastatic  abscess,  6  per  cent.;  (g)  perinephric  abscess, 
6  per  cent.;  (h)  occasionally,  ulcerative  lung  lesions,  5  per  cent.; 
(i)  splenic  infarct,  abscess  or  echinococcus,  diseases  of  the  spine,  ribs, 
pericardium  or  uterus  are  uncommon. 

Sjnnptoms. — Pus  is  always  present,  is  ensacculated  beneath  the 
diaphragm  (pyothorax  subphrenicus)  and  is  associated  in  26  per  cent, 
with  gas  formation  (pyopneumothorax  subphrenicus).  The  subphrenic 
abscess  is  usually  right-sided,  is  limited  by  the  suspensory  ligament  of 
the  liver  and  may  be  intra-  or  extraperitoneal;  in  the  latter  instance 
the  abscess  is  most  often  appendicular  or  perinephric  and  lies  well 
back  in  the  abdomen.  Cases  with  simple  pus  formation  are  often 
diflacult  to  locahze;  their  symptoms  are  those  of  sepsis  with  pain, 
tenderness,  or  dulness  on  the  liver  convexity,  which  suggest  liver 
abscess.  The  retroperitoneal  forms  give  most  dulness  posteriorly, 
but  in  intraperitoneal  forms  it  is  chiefly  located  anteriorly;  swelling 
and  cedema  of  the  chest  wall  are  unimportant  but  may  occur  without 
suppuration;  the  a;-rays  may  produce  a  subphrenic  shadow. 

In  pyopneumothorax  subphrenicus  there  are  signs  "of  a  cavity  be- 
neath the  diaphragm,  filled  with  gas  and  pus,  pushing  the  diaphragm 
upward  and  simulating  pyopneumothorax"  (Leyden).  (a)  Tympany 
and  absence  of  vesicular  murmur  and  of  vocal  fremitus  are  found  from 


ADHESIVE  OR  INDURATIVE  FORMS  757 

the  third  rib  downward,  above  which  is  the  compressed  lung,  and 
below  which  is  (6)  the  dulness  of  the  liver  whose  exposed  surface  and 
edge,  dislocated  downward,  are  easily  percussed  and  palpated.  Some- 
times the  tympany  entirely  covers  the  liver  dulness.  As  in  pneumo- 
thorax (c)  succussion  and,  on  change  of  posture,  the  clearly  shifting 
line  of  dulness  may  be  elicited,  (d)  Puncture  evacuates  gas  and  putrid 
pus;  sometimes  on  a  higher  puncture  serum  is  found  in  the  pleura 
for  pleurisy  develops  in  66  per  cent,  of  the  cases.  The  needle  ascends 
during  inspiration  and  descends  during  expiration,  which  is  the  con- 
verse of  the  findings  in  pleural  exudation  (Fuerbringer).  If  a  manom- 
eter is  attached  to  the  exploring  needle,  a  rise  in  the  indicating 
column  during  inspiration  and  a  fall  during  expiration  denote  a 
subphrenic  lesion  (Pfuhl).  (e)  The  x-rays  may  show  movement  of 
the  diaphragm  and  a  shadow  between  it  and  the  liver,  but  in  three 
cases  the  writer  found  no  respiratory  excursion.  (/)  Perforation  into 
the  lungs  occurs  in  16  per  cent,  (more  often  in  extra-  than  in  intra- 
peritoneal forms),  into  the  pleura  in  19  per  cent.,  and  into  the  peri- 
cardium in  1  per  cent.  At  the  beginning,  and  until  perforation,  there 
is  generally  an  entire  absence  of  such  thoracic  symptoms  as  cough 
or  sputum;  this  is  of  value  in  differentiation  from  true  pyopneumo- 
thorax, (g)  The  history  of  the  subphrenic  pyopneumothorax  is  usually 
that  of  some  abdominal  lesion  (v.  Etiology). 

Treatment  is  surgical.  In  Maydl's  series,  74  cases  were  operated 
on.  Koerte's  experience  with  60  operations  gives  66  per  cent,  of 
recoveries. 

2.  Suppuration  in  the  Lesser  Peritoneum. — This  may  result  from 
gastric  or  duodenal  ulceration,  acute  pancreatitis,  etc.  Closure  of  the 
foramen  of  Winslow  confines  the  pus;  a  tumor  appears  in  the  epi- 
gastric, umbilical  or  left  hypochondriac  region,  bounded  above  by 
the  stomach,  which  also  in  part  covers  it,  below  by  the  colon,  and 
behind  by  the  pancreas  and  retroperitoneal  tissues.  Its  relations  are 
like  those  of  pancreatic  cyst;  variability  in  its  size  occurs  when  the 
stomach  is  filled  with  gas  and  fluid.  When  gas  and  pus  co-exist  the 
diaphragm  and  liver  are  pushed  upward.    Treatment  is  surgical. 

3.  Other  Forms.- — The  appendicular  abscess  has  been  described. 
The  pelvic  abscess  occurs  especially  from  tubal,  but  also  from  uterine 
and  ovarian  inflammation;  it  follows  abortion,  puerperal  fever,  gonor- 
rhoea, tuberculosis,  and  pneumococcic  peritonitis  in  young  girls.  Other 
types  are  suppuration  around  the  gall-bladder,  colon,  and  sigmoid, 
and  in  other  rare  localizations. 


II.  Adhesive  or  Indurative  Forms. 

Local  thickening  or  adhesions  may  occur  over  any  abdominal  viscus 
but  especially  over  the  spleen,  next  over  the  liver,  and  less  commonly 
over  the  intestines;  it  may  bind  together  two  coils  or  form  bands 
under  which  loops  may  become  strangulated. 


758  DISEASES  OF  THE  PERITONEUM 

Perisplenitis  is  most  common  over  chronic  malarial,  leuksemic,  and 
pseudoleuksemic  enlargements  of  the  spleen  and  less  frequent  over 
acute  splenic  tumors. 

Perihepatitis  may  cover  small  areas  of  the  liver  like  soldier's  spots 
in  the  pericardium,  or  may  engross  its  entire  surface.  General  peri- 
hepatitis was  described  by  Budd  (1852),  by  Curschmann  (1884), 
who  called  it  the  "icing  liver"  (Zuckergussleber),  and  by  Fagge,  Hale 
White,  Nichols,  A.  O.  J.  Kelly  and  others.  It  is  frequently  associated 
with  deforming  proliferative  peritonitis.  Nichols  describes  it  as  a 
hyaline  degeneration,  hyaloserositis.  Following  Rolleston,  there  are 
apparently  three  groups  of  cases;  (a)  multiple  serositis  (polyorrho- 
menitis,  Concato's  disease);  this  borders  closely  on  Pick's  "pseudo- 
cirrhosis  pericarditica."  Kelly  has  assembled  27  cases  in  which 
perihepatitis  was  associated  with  adhesive  pericarditis,  (b)  Arterioscler- 
osis and  interstitial  nephritis  occurred  in  86  per  cent.,  in  Hale  White's 
series  of  22  cases,  (c)  Other  rarer  factors  are  syphilis,  tuberculosis, 
malignancy,  and  alcoholism.  Its  symptoms  may  be  those  of  cirrhosis; 
it  will  be  differentiated  under  ascites  iv.i.). 


III.  Chronic  Hemorrhagic  Peritonitis. 

This  is  a  rare  disease  and  was  described  first  by  Virchow,  who 
likened  it  to  pachymeningitis  hemorrhagica.  It  occurs  chiefly  in  the 
pelvis  and  is  most  often  circumscribed.  This  pachyperitonitis  is 
characterized  by  hemorrhagic  inflammation;  from  the  laminae  of  the 
resulting  fresh  connective  tissue,  which  is  deposited  layer  by  layer, 
repeated  fresh  hemorrhages  arise. 


(D).   CARCINOMA  OF  THE   PERITONEUM. 

Primary  malignant  growths  of  the  peritoneum  are  endotheliomata, 
and  are  very  rare. 

Cancer  is  most  frequently  secondary  to  cancer  of  the  stomach, 
ovaries,  intestines,  pancreas,  and  liver.  Histologically  it  is  that  of 
the  primary  growth.  Its  gross  forms  are  (a)  miliary  carcinosis,  re- 
sembling miliary  tubercles;  (6)  vegetative;  (c)  ulcerative;  (d)  cystic 
and  (e)  infiltrative.  The  primary  tumor  may  be  quite  latent  clinically, 
so  that  the  peritoneal  complication  is  apparently  primary.  The 
secondary  growths  spread  by  contact,  by  the  lymphatics,  and  by  im- 
plantation of  free  particles.  They  may  be  felt  in  the  omentum,  mesen- 
tery, and  Douglas'  cul  de  sac  and  in  some  cases  may  be  confused  with 
tuberculous  masses.  The  diagnosis  is  usually  reached  by  the  symp- 
toms and  signs  of  the  initial  growth  or  by  those  of  an  ascites,  which 
is  serous,  hemorrhagic,  pseudochylous,  or  adipose;  its  progress  is 
rapid  and  is  attended  by  cachexia.  Groups  of  cancer  cells  may  be 
found  in  the  aspirated  fluid,  and  secondary  cancer  may  develop  at 


ASCITES  759 

the  point  of  puncture.     Differential  features  are  tabulated  under  the 
next  topic. 

(E).  ASCITES. 

Ascites  (hydroperitoneum)  is  a  symptom  and  sometimes  the  chief 
symptom  of  various  diseases. 

Etiology. — (a)  It  may  result  from  stasis,  of  which  the  chief  varieties 
are  valvular  and  other  cardiac  lesions,  pulmonary,  mediastinal  or 
pleural  disease,  and  portal  stasis,  due  to  disease  of  the  liver  or  of  the 
portal  vein.  Stasis  causes  increased  pressure  in  the  portal  system, 
followed  by  malnutrition  of  the  vessels  and  pouring  out  of  serum.  (6) 
Hydrcemia  or  cachexia  causes  malnutrition  and  increased  permeability 
of  the  vessel  walls ;  it  occurs  in  amyloidosis,  chronic  nephritis,  marantic 
conditions,  profound  anaemias,  and  occasionally  in  acute  affections, 
(c)  Inflammation,  as  simple,  tuberculous,  suppurative  or  cancerous 
peritonitis,  may  be  an  etiological  factor,  (d)  Abdominal  tumors, 
leuksemic  spleen,  etc.,  may  cause  ascites.  In  many  cases  more  than 
one  factor  may  operate;  tuberculous  peritonitis  may  complicate  liver 
cirrhosis  or  ascites  may  be  due  to  the  hydrsemia  of  nephritis,  accentu- 
ated by  weakness  of  the  heart. 

Symptoms. — 1.  Inspection. — This  shows  a  symmetrical  enlargement 
of  the  abdomen,  which,  in  the  average  case,  presents  rather  more  lateral 
than  anterior  bulging.  The  abdomen  resembles  that  of  a  batrachian 
(ventre  de  hatracien).  The  skin  is  pale,  tense,  striated,  oedematous; 
the  'pouting  navel  and  diastasis  of  the  recti  muscles  are  noted.  A 
caput  Medusce  may  be  noted  in  the  cases  of  cirrhosis.  Dilated  veins 
over  the  ribs  and  sides  of  the  upper  abdomen  indicate  compression  of 
the  cava  inferior.  Sometimes  the  heart,  beating  upon  the  fluid,  im- 
parts systolic  waves  to  it. 

2.  Palpation. — Fluctuation  (ballottement) ,  due  to  the  transmission 
of  a  fluid  wave  from  side  to  side,  is  usually  present  but  may  be  absent 
because  of  tense  abdominal  walls  or  great  accumulation  of  fluid. 
Pseudofluctuation  may  be  caused  by  accumulation  of  fluid  other  than 
ascitic,  as  intestinal  contents,  or  by  lax,  obese  abdominal  walls;  in 
the  latter  condition  a  third  hand  placed  in  the  median  line  of  the 
abdomen  will  break  the  deceptive  wave,  which  is  due  to  superficial 
or  parietal  vibration.  Fluctuation  is  felt  in  ascites  even  where  great 
tympany  exists.  In  women  the  water-pilloiv  fluctuation  (I^randau), 
may  be  elicited  hy  vaginal  examination,  and  Tripier  remarks  that  the 
uterus  seems  remarkably  movable.  Thrusting  palpation  may  disclose 
the  outline  of  the  liver,  spleen,  or  possibly  some  neoplasm  even  through 
the  abundant  fluid:  it  is  performed  by  placing  the  fingers  vertically 
on  the  abdomen  and  suddenly  thrusting  them  inward,  thus  anticipating 
any  rigidity  of  the  muscles  and  pushing  aside  the  ascitic  fluid. 

3.  Percussion. — At  least  a  pint  to  a  quart  (500  to  1,000  c.c.)  of  fluid 
must  be  present  for  clinical  detection.  With  small  effusions,  the 
patient  should  be  examined  in  the  genupectoral  position — which  is 


760  DISEASES  OF  THE  PERITONEUM 

the  best  method,  according  to  Leube.  Elevation  of  the  buttocks 
causes  scanty  fluid  to  gravitate  to  the  flanks  where  its  presence  is 
more  easily  demonstrated.  Classically,  the  fluid  in  dependent  parts 
gives  dulness,  and  the  supernatant  intestines  are  located  by  tympany 
in  the  highest  parts  of  the  abdomen.  These  areas  vary  with  change 
of  position,  always  giving,  in  uncomplicated  cases,  tympany  above  and 
dulness  below,  in  any  posture  the  patient  may  assume.  When  the 
patient  lies  upon  his  back,  the  tympanitic  area  is  central  and  elliptical. 
This  rule  is  void  when  the  mesentery  is  retracted  and  does  not  allow 
the  gut  to  float,  in  which  event  there  is  dulness  over  the  highest  areas 
on  light  percussion,  though  tympany  can  be  elicited  on  deep  percus- 
sion over  the  same  area;  adhesions  between  the  intestinal  loops  pre- 
vent shifting  of  the  fluid;  two  Hues  of  tympany  in  the  flanks  mark 
the  ascending  and  descending  colon;  when  the  gut  is  adherent  ante- 
riorily,  there  is  permanent  tympany  in  that  location,  and  the  author 
knows  of  an  instance  of  ascites  in  which,  ignoring  this  possibility  as 
well  as  the  physical  signs,  a  physician  perforated  the  intestines, 
though  happily  without  unfavorable  issue;  immovable  tympany  in 
the  flanks  in  ascites  may  be  due  to  extensive  adhesions  of  intestinal 
coils  to  the  lateral  abdominal  parietes.  Light  percussion  is  employed 
in  the  determination  of  ascites,  because  heavy  tapping  elicits  tympany 
from  the  adjacent  or  more  deeply-situated  intestine. 

A  large  quantity  of  free  fluid  may,  in  very  rare  instances,  exist 
without  dulness.  The  author  has  withdrawn  two  gallons  of  ascitic 
fluid  from  a  patient  in  whom  no  dulness  could  be  elicited  in  any  position. 

(Edema  of  the  subcutaneous  tissues  renders  percussion  of  the 
abdomen  difiicult,  as  do  fatty  abdominal  walls,  fatty  omentum,  and 
fatty  mesentery.  The  manometric  pressure  in  the  abdomen  amounts 
to  20  to  40  mm.  of  mercury. 

Diagnosis.— Although  ascites  is  usually  one  of  the  most  easily 
demonstrable  physical  conditions,  nevertheless  many  excellent  clin- 
icians have  mistaken  it  for  other  affections.  Fcecal  accumulations 
cause  dulness  in  either  flank,  simulating  fluid,  but  the  history  of  the 
case,  the  immobility  of  the  dulness,  and  the  use  of  enemata  or  catharsis, 
preclude  error.  Large  quantities  of  semifluid  faeces  in  the  ascending 
and  descending  colon  may  closely  resemble  free  fluid;  on  thrusting 
palpation  a  splashing  sound  may  be  elicited  over  the  colon,  and 
Kuessner  publishes  a  case  in  which  a  large  quantity  of  fluid  in  the 
intestines  was  mistaken  for  ascites.  Leube  confused  ascites  with  an 
enormously  dilated  stomach.  Preperitoneal  lipoma,  hydronephrosis, 
hydatid  cyst,  pregnancy,  dilated  bladder,  ovarian  cyst  and  tympanites 
are  frequently,  though  unnecessarily,  sources  of  error. 

Rostan  (1837)  noted  that  tympany  might  be  absent  in  ascites  when 
the  intestines  contained  little  or  no  gas,  a  point  sometimes  forgotten 
in  differentiation  between  ascites  and  ovarian  cyst,  the  latter  of  which 
may  also  thrust  itself  in  between  the  coils  of  gut  and  simulate  ascites; 
ovarian  cyst  usually  produces  a  central  flatness  with  tympany  in  the 
flanks,  and  neither  the  dulness  nor  tympany  shifts  with  change  of  pos- 


ASCITES  761 

ture.     Adami  has  collected  42  cases  of  fatty  tumor  (fibroUpoma  and 
myxolipoma)  in  which  ascites  is  very  closely  simulated. 

Etiological  Diagnosis. — 1.  Stasis. — In  cardiac  disease  the  dyspnoea 
develops  early,  but  that  caused  by  ascites  pressing  upward  on  the 
diaphragm  is  a  late  symptom;  swelling  of  the  feet  usually  antedates 
the  ascites,  though  Striimpell  (1883)  pointed  out  that  pericarditis  and 
valvular  disease  may  exceptionally  produce  ascites  without  anasarca. 
It  must  be  borne  in  mind  that  a  marked  ascites  may  crowd  the  heart 
upward  and  outward.  The  liver  is  peculiarly  an  etiological  factor  in 
ascites  (see  Diffeeential  Chart  under  Liver  Diseases).  Portal 
ascites  commences  almost  invariably  in  the  peritoneum;  the  legs  swell 
secondarily  from  pressure  on  the  vena  cava  inferior  or  from  cardiac 
weakness  due  to  great  ascites  (Giovanni);  the  legs  may  swell  dis- 
proportionately, cicatrices  may  involve  the  portal  vein  and  cava  sim- 
ultaneously at  the  notch  in  the  posterior  surface  of  Hver,  and  finally 
the  legs  may  swell  first.  In  some  cases  the  ascitic  fluid  may  lie  between 
the  diaphragm  and  the  liver,  which  latter  is  then  pushed  downward 
and  may  appear  large  though  it  is  merely  dislocated.  An  attempt 
should  be  made  to  exclude  perihepatitis,  which,  according  to  Fagge, 
causes  one  death  to  every  five  fatal  cases  of  cirrhosis,  and  is  more 
apt  to  be  attended  by  albuminuria  (see  Table  given  below). 

2.  Hydrsemia.  (Cachexia,  Increased  Vascular  Permeability). — In  renal 
disease  the  eyelids  often  become  oedematous  before  other  symptoms 
develop  and  the  nephritic  ascites  is  seldom  great  unless  the  liver  and 
heart  are  involved.  Cachectic  ascites  is  not  uncommon  in  leukaemia 
and  kindred  affections.  Slight  serous  effusions  occurring  in  acute  infec- 
tious diseases  in  children  may  come  under  this  title.  The  author  has 
seen  three  instances  of  ascites  in  typhoid  convalescence. 

3.  Peritonitis. — The  specific  gravity  and  the  percentage  of  albumin 
in  the  fluid  are  important  factors  in  differentiating  between  exudate 
and  transudate.  Three  divisions  are  distinguished:  (a)  a  specific 
gravity  of  1,010  or  lower  indicates  a  cachectic  transudate,  e.g.,  in 
nephritis  with  less  than  1  per  cent,  albumin.  A  very  low  specific 
gravity  and  percentage  of  albumin  occurs  in  amyloidosis.  (6)  A 
hypostatic  transudate  has  a  specific  gravity  which  ranges  between 
1,010  and  1,014,  and  has  between  1  and  3  per  cent,  of  albumin,  (c) 
An  exudate  has  a  specific  gravity  of  more  than  1,015  (or  1,018)  and 
the  albumin  reaches  4  to  6  per  cent.  The  lower  strata  are  heavier, 
and  the  specific  gravity  should  be  measured  several  times  during  the 
paracentesis.  When  there  is  less  than  1  per  cent,  of  albumin,  no 
disease  of  the  peritoneum  or  portal  vein  exists.  Reuss'  formula  en- 
ables us  to  compute  the  albumin  percentage  from  the  specific  gravity. 
It  is  subject  to  an  error  of  less  than  ^  of  1  per  cent. ;  the  percentage 
of  albumin  =  |  (specific  gravity  minus  1,000)  minus  2.8.  A  specific 
gravity  of  1,017  to  1,020  positively  indicates  an  exudate.  There  are 
certain  exceptions  to  this  rule,  and  certain  confusions  may  arise; 
thus  an  ascites  due  to  a  carcinoma  in  the  liver  substance  has  a  low 
specific  gravity  and  albumin  is  present  to  1  or  2  per  cent.     If  the 


762  DISEASES  OF  THE  PERITONEUM 

carcinoma  spread  to  the  peritoneum  (carcinomatous  peritonitis),  the 
specific  gravity  rises  and  5  per  cent,  of  albumin,  or  more,  is  found. 
An  ascites  due  to  nephritis  has  a  low  specific  gravity  but  the  figures 
rise  when  stasis  due  to  weak  heart  or  intercurrent  inflammation  devel- 
ops. In  many  cases  of  simple  transudation  (ascites  and  hydrothorax), 
the  characters  of  an  exudate  may  develop,  due  to  the  long-continued 
irritation  of  the  serosa. 

Ascitic  fluid  always  contains  the  constituents  of  the  blood — albumin, 
globulin,  urea,  xanthin,  hypoxanthin,  guanin,  uric  acid,  sugar,  etc. 
(a)  Ascitic  fluid  due  to  stasis  is  clear  yellow  or  yellow-green,  opales- 
cent, and  alkaline,  and  microscopically  contains  some  lymph  cells, 
erythrocytes,  and  peritoneal  endothelium.  (6)  Exudates  show  a 
microscopic  picture  varying  with  the  cause;  fibrin  threads,  pus,  blood, 
adipose,  chylous  or  chyliform  fluid,  intestinal  contents,  cancer  cells, 
tubercle  bacilli,  diplococci  or  pyogenic  organisms,  may  be  found.  In 
exudates  are  found  the  polymorphonuclear  leukocytes  and  some 
erythrocytes;  lymphocytes  and  red  cells  are  detected  in  transudates 
and  tuberculous  exudates  (see  Pleurisy)  ;  the  fluid  must  be  examined 
at  once  or  formahn  should  be  added  for  the  cells  readily  degenerate 
and  shrink.  Rieder,Dock  and  others  describe  cells  in  carcinomatous 
peritonitis  in  which  asymmetrical  karyokinetic  figures  appeared. 
Quincke  states  that  red  disks,  lymph  cells,  and  peritoneal  endothelium 
are  found  in  every  ascites, 

Primavera  differentiated  between  transudates  and  exudates  by 
means  of  glacial  acetic  acid;  a  single  drop  will  leave  a  white  cloud 
as  it  falls  to  the  bottom  of  a  vessel  containing  an  exudate,  while  its 
addition  to  transudates  gives  no  reaction. 

The  French  authors,  especially,  assert  the  existence  of  a  primary 
ascites  due  to  cold,  excessive  catharsis,  drinking  freely  of  water, 
suppression  of  menses  or  checking  of  hemorrhoidal  bleeding.  This 
so-called  "essential"  ascites  is  usually  a  chronic  serous  or  tuberculous 
peritonitis. 

Differentiation  Between  Serous  and  Tuberculous  Peritonitis. — Henoch 
believes  that  chronic  serous  peritonitis  occurs  in  children  though  West 
and  Courtois-Suffit  think  such  affections  are  tuberculous.  In  tuber- 
culous peritonitis  (q.v.)  there  are  usually  temperature,  emaciation, 
and  bacilli  in  the  exudate.  According  to  Tepret  and  Vierordt,  chronic 
nontuberculous  peritonitis  occurs  especially  in  women,  the  causes  of 
which  are  Bright's  disease,  trauma,  portal  stasis,  alcoholism,  and 
heart  affections.  The  ascitic  forms  of  nontuberculous  peritonitis 
may  pass  into  the  membranous  or  adhesive  variety  (peritonitis  de- 
formans or  pachyperitonitis).  The  diagnosis  of  simple  nontuberculous 
peritonitis  is  most  difficult  to  establish,  even  at  autopsy,  and  the  diag- 
nosis in  doubtful  cases  of  a  tuberculous  peritonitis  is  by  fai*  more 
frequently  justified. 

Differentiation  Between  Tuberculous  Peritonitis  and  Ascites. — 
Mechanical  (portal)  ascites  is  accompanied  by  other  circulatory  dis- 
turbances, as  splenic  tumor,  piles,  or  caput  Medusae.     The  spleen  is 


ASCITES  763 

rarely  enlarged  in  tuberculous  peritonitis.  The  specific  gravity  and 
percentage  of  albumin  are  almost  final  in  determining  between  peri- 
tonitis and  ascites.  The  fluid  is  generally  clear  in  ascites  and  usually 
cloudy  in  peritonitis.  Pain  and  fever  usually  indicate  encapsulation. 
The  liver  is  small  in  the  terminal  stage  of  atrophic  cirrhosis,  which 
is  also  marked  by  various  urinary  changes;  these  are  evidences  of 
incomplete  discharge  of  the  hepatic  function.  In  tuberculous  peri- 
tonitis, the  hydrops  ascites  saccatus  gives  an  irregular  form  to  the 
abdomen  from  meteorism  produced  by  adhesions  and  from  irregular 
nodules  sometimes  simulating  carcinoma :  it  was  described  by  Hippoc- 
rates. Free  tuberculous  exudations  differ  according  to  Thomayer, 
from  simple  ascites  in  that  the  tympany  in  tuberculous  forms  is  often 
right-sided,  due  to  retraction  of  the  mesentery  (mesenteritis  retrahens) 
to  the  right  side,  carrying  with  it  the  small  intestine.  Mesenteritis 
retrahens  is  usually  either  tuberculous  or  carcinomatous,  but  may 
sometimes  be  due  to  simple  deforming  peritonitis.  The  author  recalls 
several  instances  in  which  right-sided  tuberculous  masses  pushed  to 
the  left  both  the  tympany  and  the  fluid.  Hemorrhagic  ascitic  fluid 
occurs  frequently  in  tuberculous  peritonitis,  and  rarely,  if  ever,  in 
cirrhotic  transudate. 

The  "apparent  tumors"  (Bamberger)  of  tuberculous  peritonitis  are 
always  suggestive  where  the  nature  of  an  ascites  is  in  question.  In 
two  instances  observed  personally,  the  omentum  was  so  retracted  and 
so  peculiarly  adherent  to  the  normal  liver  as  to  resemble  most  closely 
the  edge  of  an  enlarged  cirrhotic  liver.  Intestinal  or  pulmonary 
tuberculosis,  adhesive  pleuritis,  and  meteorism  from  intestinal  adhe- 
sions, or  an  irregular  form  of  the  abdomen  with  a  "doughy"  feel  on 
palpation,  indicate  tuberculous  peritonitis.  A  good  working  rule  is 
that  a  peritoneal  exudate  is  tuberculous,  when  cancer,  sarcoma,  and 
trauma  can  be  excluded.  Exploratory  incision  is  often  the  only  direct 
route  to  diagnosis  and  appropriate  therapy.  In  the  case  of  Heidenrich, 
in  which  the  fluid  was  encapsulated,  each  of  about  20  separate  sacs 
was  filled  with  fluid  differing  from  that  found  in  the  others;  in  one 
was  clear  serum;  in  another  paler  fluid;  in  others,  the  effusion  was 
brown,  purulent,  thick,  or  sanguinolent. 

Nichols,  in  an  excellent  monograph  ("A  Somewhat  Rare  Form  of 
Chronic  Inflammation  of  the  Serous  Membranes  [Multiple  Progressive 
Hyaloserositis],"  Royal  Victoria  Hospital  Reports,  vol.  i.  No.  3) 
gives  a  differential  table,  presented  on  the  following  page. 

4.  Tumors. — Tumors,  other  than  peritoneal,  may  cause  ascites. 
Uterine  fibromata  produce  hydroperitoneum,  which  is  not  usually 
great,  is  lenion-colored,  and  but  rarely  sanguineous.  There  is  no 
relation  between  the  size  of  the  tumor  and  the  amount  of  fluid  tran- 
suded, because  very  small  uterine  myofibromata  may  excite  consider- 
able peritoneal  effusion.  There  is,  nevertheless,  a  direct  relation 
between  the  malignancy  of  the  tumor  and  the  amount  of  the  fluid 
found  (Terillon).  As  a  general  statement,  ascites  is  infrequent  in 
uterine  tumors  (Cruveilhier)  but  when  observed  is  most  common  in 


764 


DISEASES  OF  THE  PERITONEUM 


"Zuckergtiss- 

leber|';     chronic 

perihepatitis. 


Atrophic  cirrho- 
sis of  liver. 


Chronic  tuber- 
cular peritonitis. 


Carcinoma  of 
peritoneum. 


Age. 

Sex. 

Previous     history. 

Alcoholism. 


Syphilis. 
Heredity. 


Incidence. 

Chronicity. 
Fever. 

Pain. 


Digestive. 

disturbance. 


Ascites. 


Anasarca. 
Jaundice. 

Liver. 


Spleen. 
Omentum. 


Occurs  about  mid-'Oftenest  about 
die  life  or  later,      i  middle  age. 


Commonest        be-  Occurs  late  in  life, 
tween   ages  of  20 
and  40. 


Both  sexes  equally^More    frequent    in  Predominates    in 
liable.  males.  ,  females. 


Often  a  history  of 
acute  pericarditis 
or     perihepatitis. 


No  influence. 


No  influence. 
No  influence. 


History  of  alco-  Often  a  chronic 
holism,  syphiUs  cough,  diarrhcea, 
or  digestive  dis-  or  genital  tuber- 
turbances.  culosis. 


More  frequent  in  fe- 
males. 

In  some  cases  a  his- 
tory of  cancer  _  of 
stomach  or  ovaries. 


Frequently 
ent. 

Occasionally. 
Unimportant. 


Insidious. 


pres-  Unimportant. 


Unimportant. 


Unimportant. 
May    be    family 
i  taint. 


Unimportant. 
Unimportant. 


Onset        may      be  Insidious, 
acute  or  insidious. 


Acute       becorning 
chronic  or  insid- 
ious from  first. 

Cases  last  for  2-10-  May  last  for  years.  Prolonged. 
16  years. 

Generally      absentMay    be    afebrile;  Usually  slight; 

except  "during  ex-|  when    present    is    often  absent, 
acerbationorsome    sUght. 
complication. 


Indefinite   and 
trifling. 

Trifling  or  none. 


'Trifling. 


Constant  'and  ex- 
treme; nutrition 
long  maintained 
— Osier's  case  tap- 
ped 121  times; 
may  resemble  per- 
itonitis, albumin  3 
per  cent.,  fibrin. 

Constant  but  slight. 

Absent    in   pure 
cases. 

Not    cirrhotic;     at 
first      enlarged, 
then    small; 
smooth. 


Fairly  rapid  course. 


I  Rarely    absent;  due 
to  complication. 


Apt  to  be  trouble- 
some. 


Constant;    dyspep-i  Fairly  common, 
sia,  nausea,  vom- 
iting, gastric  hem- 
orrhage, mekena. 


Variable. 
Often  marked. 


Constant. 


Relatively  slight. 

Occurs  in  27  per 
cent,  of  cases. 


Cirrhotic;     at  first' Often  enlarged, 
enlarged,         tnen 
small  and  warty. 


Never  extreme, 
may  be  absent, 
may  be  hemor- 
rhagic. 


Trifling. 


May     occur 
ceptionally. 


Moderate  grade; 
may  be  hemor- 
rhagic or  pseudo- 
chylous. 


'Slight. 

Common  when  Uver 
is  enlarged. 

May   be   enlarged, 
with  nodules. 


Gradual 
ment. 


enlarge-  Gradual 
ment. 


Thickened  and  con- 
tracted. 


Normal. 


enlarge-  Nothing     special. 
Often   matted   up. 


Nothing  special. 
Often  matted  up. 


adenomyoma  (Freund).  It  is  more  often  seen  in  papillomatous  cysts; 
in  glandular  cysts  whose  walls  rupture  by  fatty  degeneration  and  pour 
out  their  contents  into  the  abdominal  cavity,  serum  is  secreted  by  the 
peritoneal  surface  because  of  the  irritation,  even  though  the  ruptured 
cyst  be  very  small  (Quenu).  The  fluid  in  cysts  contains  more  solids 
(60  to  50  pro  mille)  than  does  the  ascites  of  renal  disease  (25  pro 
mille,  M^hu).  Ascites  is  most  often  observed  in  sohd  ovarian  tumors. 
In  an  ovarian  sarcoma  successfully  removed  by  operation,  an  ascites 


CHYLOUS  AND  ADIPOSE  ASCITES  765 

existed  whose  specific  gravity  was  1,024;  the  case  recovered  and 
remains  well  after  nine  years. 

Treatment. — The  treatment  of  ascites  varies  with  its  cause,  for 
which  reference  should  be  made  to  valvular  heart  disease,  atrophic 
cirrhosis,  tuberculous  peritonitis,  and  nephritis. 

Paracentesis  in  peritoneal  carcinoma  and  chylous  ascites  (v.i.) 
hastens  the  issue.  Hale  White  asserts  that  cases  of  cirrhosis  survive 
but  few  punctures,  while  cases  of  perihepatitis  may  be  punctured 
more  than  200  times.  Lecanu  reports  a  case  of  ascites  in  which  885 
tappings  were  performed  in  fifteen  years.  In  puncture,  surgical  anti- 
sepsis is  most  necessary,  for  reduced  subjects  are  easily  infected.  The 
bladder  should  be  emptied  by  catheterization.  The  trochar  should 
be  introduced  in  the  linea  alba  to  avoid  injury  to  the  bloodvessels. 
It  should  be  pushed  carefully  and  is  felt  to  penetrate  the  parietal 
peritoneum  by  the  sense  of  something  giving  away.  A  dull-pointed 
probe  should  be  sterilized,  with  which  to  push  back  the  omentum 
if  it  should  prolapse  against  the  canula.  The  fluid  should  be  evacuated 
slowly  to  obviate  collapse  which  may  result  from  dilatation  of  the 
abdominal  veins,  if  they  are  suddenly  relieved  of  the  pressure  of  the 
effusion.  A  cat-o '-nine-tails  bandage  may  be  applied  as  the  tapping 
progresses,  to  compress  the  abdominal  contents. 


Chylous  and  Adipose  Ascites. 

The  peritoneal  cavity,  much  more  frequently  than  any  other  serous 
sac,  is  the  seat  of  those  unusual  exudates  and  transudates  known  as 
chylous,  chyliform,  lactiform,  oily,  or  adipose  ascites.  The  first  au- 
thentic case  is  Poncy's  (1699).  During  the  last  two  centuries  the  litera- 
ture gives  about  200  cases.  Seven  have  come  under  the  author's 
observation. 

Much  confusion  has  arisen  from  inaccurate  nomenclature.  Chylous 
ascites  properly  designates  an  effusion  of  chyle.  Adipose  ascites 
contains  a  large  percentage  of  fat  with  no  chylous  admixture.  Some 
authors  use  the  terms  "adipose,"  and  "chyliform"  interchangeably. 
Boulengier  prefers  the  term  "chyliform"  and  "lactiform"  to  "chy- 
lous" on  the  ground  that  the  fluid  is  rarely  chyle.  Chyliform  ascites 
is  a  chyle-like  fluid  in  which  lymph  or  chyle  is  mixed  with  exudates 
or  transudates. 

1.  Chylous  Ascites. — Straus'  case  is  the  clearest  example,  in  which 
chemically  typical  chyle  was  extravasated  through  two  fistulse.  In- 
gested butter  was  recognized  in  the  fluid  withdrawn  by  paracentesis. 
Senator's  latest  case  gave  similar  results  with  the  administration  of 
olive  oil.  Chylous  ascites  contains  sugar,  which  is  said  to  be  diagnostic 
when  diabetes  is  excluded.  Sugar  when  primarily  present  may  dis- 
appear later  (Whitla).  Its  presence  is  very  rare  and  very  suggestive; 
it  has  been  detected  not  more  than  two  dozen  times.  Of  late  many 
clinicians  discount  the  importance  of  the  presence  of  sugar  as  a  diag- 


766  DISEASES  OF  THE  PERITONEUM 

nostic  test;  Bock  found  sugar  (0.04  to  0.07  per  cent.)  in  all  cases  of 
hydrops,  and  Eichhorst  in  ten  out  of  seventeen  cases  of  pleural  exudate. 
A  small  amount  of  fat  (0.9  per  cent.)  indicates  chyle.  Chylous  ascites 
is  rich  in  solids,  mineral  salts,  and  albumin.  Albumin  and  fat  occur 
in  small  punctiform  granules,  susceptible  of  chemical  differentiation. 
The  escape  of  chyle  may  occur  through  a  visible  rupture  or  by  transu- 
dation through  the  walls  of  the  chyle  vessels ;  among  the  most  frequent 
causes  of  lymph  or  chyle  obstruction  are  compression  of  the  thoracic 
duct  or  lymph  system  by  glands,  neoplasms,  peritonitis,  occlusion  of 
left  subclavian  vein,  pressure  efforts,  lifting  or  coughing,  filarial 
disease,  or  occlusion  of  the  thoracic  duct.  Rupture  may  occur  in  any 
part  of  the  lymphatic  system;  in  the  thoracic  duct,  receptaculum, 
lacteal  vessels,  lymph  glands,  and  chylous  cysts.  Chyle  may  extrav- 
asate  into  a  serous  effusion  by  mural  alteration  of  the  lymphatic 
vessels. 

2.  Adipose  or  Chyliform  Ascites. — Adipose  ascites  is  characterized 
by  the  absence  of  sugar  and  a  higher  percentage  of  fat.  The  degree 
of  opacity  is  no  index  of  the  amount  of  fat,  because  turbidity  may  be 
due  to  emulsionized  albumin.  Fat  is  found  in  most  cases;  its  greatest 
amount  is  5.25  per  cent.  (Schmidt),  and  in  one  of  the  author's  cases 
6.5  per  cent.  The  granules  of  albumin  and  fat  are  much  coarser  in 
adipose  than  in  chylous  ascites.  Hydropic  and  fatty  carcinoma  cells 
may,  if  numerous,  cause  a  creamy  layer,  and  their  microscopic  detec- 
tion^favors  the  diagnosis  of  hydrops  adiposus.  Red  blood  disks  may 
occur,  also  fibrin,  filaria,  casein,  mucin,  sodium  alkali  albuminate, 
bile,  acetone,  hydropsin,  peptone,  lecithin,  cholestearin,  fibrinogen, 
diastatic  ferments,  urea,  and  various  inorganic  compounds.  Among 
the  numerous  etiological  conditions  are  tuberculosis  of  the  peritoneum 
and  glands;  carcinoma  of  the  glands,  peritoneum,  and  lymph  vessels; 
chronic  peritonitis;  liver  cirrhosis,  heart  disease,  and  sarcoma  of  the 
omentum  or  mesentery. 

Diagnosis. — ^A  diagnosis  has  never  been  made  prior  to  puncture, 
except  in  Morton's  early  case.  The  local  signs  and  symptoms  do  not 
differ  from  those  of  serous  ascites.  It  is  probable  that  some  cases 
diagnosed  as  the  vulgar  ascites,  healing  without  treatment,  are  in- 
stances of  chylous  hydrops;  this  explains  the  increasing  frequency  of 
these  affections.  It  is  not  easy  to  differentiate  between  chylous  and 
adipose  effusions,  even  at  necropsy. 

Prognosis. — About  90  per  cent,  of  both  types  die.  Continuous 
chylous  fistulse  are  always  fatal.  The  immediate  prognosis  is  seem- 
ingly more  favorable  in  the  adipose  form. 

Treatment. — Surgical  interference  is  chiefly  indicated  in  tuberculous 
peritonitis.  Paracentesis  should  be  avoided  as  much  as  possible  for 
it  is  weakening,  and  precipitates  the  fatal  issue. 


SECTION  V. 


DISEASES  OF  THE  KIDNEY. 


(A).  ACUTE  NEPHRITIS. 

Etiology. — (a)  Acute  nephritis  may  result  from  infections.     The 
scarlatinal  nephritis  (q.v.)  is  the -most  frequent  type,  and  develops 
during  the  third  week  after  desquamation.     It  also  occurs  in  diph- 
theria, at  the  height  of  the  disease;   it  is  found  in  a  large  percentage 
of  cases  of  acute  enterocolitis  in  children;  it  may  result  from  malaria, 
variola,  sepsis,  ulcerative  endocarditis,  or  pneumonia;  there  is  scarcely 
an  infection  in  which  acute  nephritis  may  not  occasionally  develop, 
as  typhoid,  typhus,  measles,  tonsillitis,  or  epidemic  meningitis;   it  is 
rare  in  German  measles,  varicella,  or  purpura.    It  may  develop  in 
tuberculosis  and  syphilis.     Infections  operate  (i)  more  often  by  their 
toxins  than  (ii)  by  the  causal  microbe,  though  the  typhoid  bacillus, 
recurrens   spirillum,  pneumococcus,  streptococcus,  and  others,  have 
been  found  in  the  kidneys  and  urine;   (iii)  in  some  instances  (nephritis 
hgemoglobinurica)  hsemolysins  develop   and   apparently  cause  acute 
nephritis.     (6)   Toxic  substances,  taken  internally  or  applied  to  the 
skin,  may  induce  acute  nephritis;   as  turpentine,  salicylic  compounds, 
carbolic  acid,  potassium  chlorate,  cantharides,  and  kindred  substances, 
(c)  Exposure  to  cold  and  dampness  (with  alcoholism)  is  frequently  the 
sole  apparent  cause,  though  its  mechanism  is  obscure;    possibly  it 
lessens  the  tissue  resistance  or  acts  as  a  htemolysin,  as  in  the  hsemo- 
globinuric  type,     (d)  Skin  diseases,  burns,  eczema,  and  psoriasis,  may 
be  etiological  factors,  either  by  lessening  the  skin  functions,  by  pro- 
ducing hsemolysins,  or  by  too  active   medical   treatment  (nephritis 
medicinaHs).    (e)  Pregnancy  (v.i.)  may  result  in  nephritis.     (/)  The 
cause  is  often  obscure;    chronic  Bright's  disease,  cardiac  affections, 


767 


768  DISEASES  OF  THE  KIDNEY 

and  the  dyscrasiae,  predispose  to  acute  nephritis,  (g)  Acute  nephritis 
may  occur  independently  of  any  known  cause;  this  primary  form 
may  be  epidemic. 

Pathology. — Gross  changes  may  not  be  apparent  in  mild  cases, 
though  in  some  the  kidneys  are  swollen  from  marked  interstitial 
exudation,  and  are  dark  and  heavy.  In  other  cases  the  kidney  is 
yellow-white,  and  perhaps  mottled  from  small  hemorrhages.  The 
oedematous  capsule  strips  readily  and  the  cut  section  drips  blood. 
On  section  the  cortex  is  swollen  and  granular,  and  its  striations  are 
blurred  and  pale  in  contrast  with  the  dusky  medulla;  the  glomeruli 
are  frequently  -sdsible  as  red  or  later  as  yellow  dots.  Without  the 
microscope,  lesser  degrees  of  acute  nephritis  may  be  confused  with 
fatty  or  parenchymatous  degeneration.  Microsco'pic  changes  are 
usually  diffuse,  (a)  Glomerular  changes.  Glomerulonephritis,  espe- 
cially described  by  Klebs,  is  caused  by  toxins  reaching  the  tufts  through 
the  blood  current.  It  is  best  exemplified  by  the  scarlatinal  form  {q.v.). 
The  glomerular  capillaries  show  infiltration  with  leukocytes,  an  albu- 
minous or  cellular  exudate  escapes  into  the  capsule,  and  the  epithelium 
of  Bowman's  capsule  degenerates,  desquamates,  and  later  proliferates; 
in  some  cases  numbers  of  red  disks  escape  with  the  serum  and  leuko- 
cytes. (&)  Tubular  changes.  Cloudy  swelling,  hyaline  and  fatty 
degeneration  occurring  especially  in  the  cortex,  may  be  difficult  to 
differentiate  from  febrile  and  other  degenerations,  though  interstitial 
exudation  occurs  in  every  case  of  nephritis.  In  severe  cases  some  cells 
necrose  entirely  and  desquamate;  of  this  the  diphtheritic  form  is  the 
best  type.  The  swelling  in  and  around  the  convoluted  tubules  is  one 
cause  of  the  kidney  enlargement,  (c)  Vascular  and  interstitial  changes 
are  essential  to  the  pathological  diagnosis  and  are  more  focal  than 
diffuse.  Serum  exudes  into  the  connective  tissue,  tufts,  and  tubules, 
and  coagulates  in  them;  it  is  probably  the  cause  of  the  casts;  leuko- 
cytes escape  into  the  parenchyma  and  interstitium,  and  in  some  cases 
red  cells  also  (hemorrhagic  nephritis).  Councilman  describes  Unna's 
plasma  cells,  which  he  thinks  are  conveyed  to  the  kidney  from  the 
spleen  and  marrow. 

Symptoms. — The  onset  may  be  sudden,  especially  in  cases  following 
exposure.  In  other  cases  it  develops  gradually  in  the  course  or  con- 
valescence of  the  causal  infection  as  scarlatina,  diphtheria,  etc.  In 
many  cases  it  may  be  unrecognized  unless  frequent  analyses  of  the 
urine  are  made,  or  until  ursemic  symptoms  develop. 

1.  Urinary  Findings. — (a)  The  urine  is  decreased  to  ten  or  twelve 
ounces  (a  few  hundred  c.c.)  or  in  severe  cases  is  supp-essed;  this  is 
due  to  glomerulitis  or  stoppage  of  the  tubules  by  coagulated  albumin 
and  desquamated  epithelium;  the  decrease  usually  runs  parallel  with 
the  intensity  of  inflammation  and  hydrops.  During  convalescence  the 
urine  becomes  abundant  and  clear.  (&)  Its  color  may  range  from  that 
of  febrile  urine  to  a  dark  smoky  tinge;  it  is  seldom  red  or  actually 
bloody;  in  the  haemoglobin  uric  form  it  is  chocolate-colored,  (c)  The 
specific  gravity  averages  1,025  to  1,030  and  (d)  the  reaction  is  acid. 


ACUTE  NEPHRITIS 


769 


(e)  Albuminuria  is  almost  invariable;  the  albumin  amounts  to  ^  to 
1  per  cent,  and  one  to  two  drams  (5  to  8  gm.)  daily.  There  is  serum 
albumin,  considerable  quantities  of  globulin,  and  if  there  are  many 
cells  as  in  tubular  nephritis,  nucleo-albumin.  The  author  has  seen  six 
fatal  cases  of  acute  diffuse  nephritis,  confirmed  by  autopsy,  in  which 


Fig.  45. 


•"-^^-..aid^  ^^^      ^.^■ 


m 


Casts.  1-4,  amyloid;    5,  cast,  epithelial  in  its  upper,  and  granular  in  its  lower,  part. 

there  was  no  albuminuria.  Similar  cases  are  reported  by  Quirolo, 
Henoch,  Senator,  Fermi,  Sanne,  and  others,  (/)  Urea  is  decreased 
even  to  ^  its  normal  quantity,  as  are  also  the  chlorides  and  phosphates; 
the  uric  acid  remains  normal,  and  the  xanthin  (alloxur)  bases  may  be 
increased;  for  the  molecular  constitution  of  the  blood  and  cryoscopy, 
see  Chronic  Nephritis,    (g)  The  sediment  in  mild  acute  tubular  neph- 

FiG.  46, 


1.^1 


/Tf 


.0  <,^ 


,  o  u,  Of, 


Urinary  casta;    1,  hyaline,  with  fat  droplets  and  cells  ;    2,  hyaline,  with  leukocytes  ;  3,  [cast  with 
"  fat  droplets. 

ritis  consists  of  many  epithelial  cells,  some  red  and  white  corpuscles, 
and  hyaline  casts,  with  crystals  of  oxalate  of  lime  and  uric  acid,  and 
sometimes  haemoglobin  granules,  which  may  be  also  found  as  free 
granules.  In  diffuse  glomerular  nephritis  there  are  almost  always 
red  cells,  mono-  and  polynuclear  leukocytes,  epithelium,  fatty,  hyaline 
and  granular  casts,  granules  of  fat  and  often  of  haemoglobin,  uric  and 

49 


770  DISEASES  OF  THE  KIDNEY 

calcium  oxalate  crystals,  and  sometimes  various  micrococci.  Senator 
maintains  that  the  leukocytes  from  the  kidney  are  mononuclear. 
Waxy  and  epithelial  casts  are  found  only  in  the  severest  types.  Blood 
and  casts  may  appear  before  and  may  also  outlast  the  albuminuria. 
The  significance  of  casts  (cylindruria)  will  be  considered  under  chronic 
parenchymatous  nephritis. 

2.  Hydrops  (Anasarca). — This  is  often  the  first  symptom  to  attract 
attention,  (a)  It  occurs  about  the  eyes  early  in  the  morning  and  later 
in  the  day  in  other  parts,  as  the  limbs  and  external  genitalia.  As  the 
process  advances  it  may  become  general,  (b)  It  changes  its  location 
readily,  and  with  ancemia  gives  a  rather  characteristic  fades,  (c) 
Anasarca  occurs  most  commonly  in  cases  due  to  scarlatina  and  ex- 
posure, rather  less  commonly  in  those  following  pregnancy,  malaria, 
alcoholism,  and  skin  diseases,  and  seldom  in  those  developing  in  sepsis, 
pneumonia,  typhoid,  or  diphtheria,  (d)  It  is  caused  by  inflammation 
of  the  skin  vessels,  is  identical  with  the  inflammation  in  the  glomerular 
vessels,  and  is  nearly  always  associated  with  glomerulitis.  (e)  Iden- 
tical changes  may  occur  in  the  serous  sacs  (pleura,  pericardium,  or, 
far  less  often,  peritoneum,  meninges,  and  joints),  mvxious  membranes 
(glottis  or  intestinal  tract),  or  viscera  (pulmonary  or  cerebral  oedema). 
(/)  It  parallels  the  intensity  of  the  nephritis  and  the  decrease  of  urine. 

3.  Ansemia. — Anaemia  is  often  an  early  symptom  and  with  the  dropsy 
is  almost  suggestive  of  acute  nephritis.  The  red  cells  and  haemoglobin 
are  reduced,  the  specific  gravity  of  the  serum  is  lowered,  and  the 
freezing  point  is  raised  {v.  Chronic  Nephritis). 

4.  Cardio-Vascular  Symptoms. — The  right  heart  may  become  di- 
lated. Hypertrophy  of  the  left  ventricle  is  very  uncommon,  though  it 
was  observed  by  Riegel  and  Leube  within  ten  days  of  the  beginning 
of  the  disease.  The  pulse  is  usually  slow  and  tense;  the  sphygmogram 
shows  increase  of  the  tidal  and  decrease  of  the  dicrotic  wave,  and  the 
sphygmomanometer  shows  the  blood  tension  increased  even  to  180  or 
200  mm.;  these  phenomena  are  due  probably  to  vascular  contraction 
induced  by  metabolic  products  retained  in  the  blood.  The  second 
aortic  tone  may  become  accentuated,  and,  if  heart  fatigue  develops, 
the  gallop-rhythm  is  heard. 

5.  Temperature. — Fever  and  rigors  are  exceptional. 

6.  Pain. — Occasionally  there  may  be  pain  and  tenderness  in  the 
back,  frequent  and  painful  urination,  emaciation,  and  epistaxis.  Con- 
stipation is  the  rule.    The  skin  is  generally  dry. 

Diagnosis. — The  urinary  findings  are  characteristic;  albuminuria 
(q.v.)  may  result  from  other  causes,  as  fever,  amyloidosis,  or  stasis; 
casts,  leukocytes,  epithelia,  and  even  red  cells,  may  also  occur  in  chronic 
nephritis,  but  the  history  and  evolution  determine  the  diagnosis  (v.i. 
Differential  Table  of  Diffuse  Diseases  of  the  Kidney);  cases 
without  urinary  findings  are  extremely  rare.  The  greatest  danger  lies 
in  the  diagnosis  of  an  acute  nephritis,  when  the  condition  is  only  an 
acute  exacerbation  of  a  chronic  process;  fully  half  of  the  so-called  idio- 
pathic acute  cases  which  the  author  has  seen  belong  to  this  category. 


ACUTE  NEPHRITIS  771 

In  renal  hoBmaturia  the  urine  contains  no  casts  (save  perhaps  red  cell 
casts),  few  leukocytes,  and  practically  no  epithelia;  there  is  no  ana- 
sarca; the  urine  is  clear  at  one  time  and  is  laden  with  blood  at  another. 
Anasarca  (v.s.)  occurs  in  certain  types  only  and  in  various  cachectic 
states. 

Diagnosis  of  Types. — (a)  The  kidney  of  pregnancy  usually  develops 
in  the  last  half  of  gestation,  and  infrequently  before  the  third  month. 
Its  pathogenesis  is  yet  vigorously  disputed,  though  toxaemia  due  to  the 
double  task  imposed  upon  the  maternal  kidneys  seems  to  be  the  most 
probable  cause.  It  has  been  suggested  that  decreased  antitoxic  activity 
of  the  thyroid  gland  is  a  causal  factor.  The  placenta  is  thought  by 
some  to  elaborate  toxins  (syncytiolysins).  The  urine  is  decreased,  pale, 
and  of  low  specific  gravity;  it  contains  much  albumin  and  not  much 
sediment,  though  red  and  white  cells,  lymphocytes,  fatty  epithelia, 
and  sometimes  casts,  are  found.  The  attendant  anasarca,  like  that  of 
stasis,  develops  from  below  upward.  When  retinitis  develops  its 
prognosis  is  more  favorable  than  it  is  in  other  nephritides.  The  con- 
vulsive seizures  (eclampsia)  are  generally  ursemic,  though  Ingerslev 
collected  106  cases  in  which  there  was  neither  clinical  albuminuria  nor 
renal  alteration'^at  necropsy.  Fehling  remarks  on  the  slight  anatomical 
changes  in  the  kidney  and  on  the  fact  that  but  5  per  cent,  of  pregnant 
patients  having  nephritis  develop  eclampsia.  The  exact  explanation 
of  the  convulsions  remains  obscure,  though  it  seems  that  the  brain 
centres  during  gestation  are  unduly  susceptible  to  irritation.  The 
embolism  of  placental  cells  in  the  brain  or  lungs  (Schmorl)  is  con- 
sidered by  some  rather  as  a  result  than  a  cause  of  eclampsia.  Zweifel 
maintains  that  the  oxydation  of  the  albumins  is  decreased,  the  nitrogen 
output  is  decreased,  the  ammonia  (as  in  diabetic  coma)  is  increased, 
and  that  sarcolactic  acid  is  found  in  the  blood  and  urine.  The  maternal 
mortality  is  25  to  30  per  cent.,  and  that  of  the  child  over  50  per  cent. 
Very  few  cases  develop  chronic  nephritis,  (b)  The  cholera  nephritis 
is  parenchymatous  and  chiefly  tubular.  Various  factors  are  operative, 
as  toxaemia,  arterial  anaemia,  venous  hyperaemia,  and  heart  weakness. 
By  some  it  is  considered  renal  ischaemia  rather  than  nephritis.  The 
urea,  chlorides,  calcium  and  magnesium  salts  are  decreased,  and 
much  indican,  aromatic  sulphates,  acetone,  and  ammonia,  are  found. 
The  anuria  may  last  three  or  even  fifteen  days,  (c)  Hcemoglobinuric 
nephritis  is  probably  due  to  haemolysins,  which  disorganize  the  blood 
and  irritate  the  kidneys  by  the  haemoglobin  thus  set  free.  It  is  found 
in  burns,  acute  infections  (typhoid,  pernicious  malaria,  scarlatina, 
yellow  fever,  Winckel's  disease  of  the  new-born),  exposure,  haemo- 
globin aemia,  and  various  drug  poisonings,  notably  that  of  chlorate  of 
potash.  Haemoglobin uria,  red  disks  in  the  urine,  casts,  leukocytes, 
epithelial  cells,  and  abundant  albuminuria,  are  indicative  of  hcemo- 
globinuric nephritis,  (d)  Acute  recurrent  (chiefly  hemorrhagic)  nephritis 
is  uncommon. 

Prognosis. — The  prognosis  of  acute  nephritis  is  always  dubious. 
The  following  factors  are  important:    (a)  Recovery  is  usual  in  light 


772  DISEASES  OF  THE  KIDNEY 

forms  not  involving  the  glomeruli.  Atypical  forms  are  generally 
favorable.  (6)  The  prognosis  varies  according  to  the  causal  affection; 
the  scarlatinal  type  has  a  mortality  of  33  per  cent.;  the  virulence  of 
the  epidemic  is  an  important  factor,  as  are  also  heart  complications, 
(c)  Complications  may  affect  the  prognosis,  as  (i)  intercurrent  inflam- 
mations, such  as  pneumonia,  pleuritis,  pericarditis,  or  erysipelas;  (ii) 
cedema  of  the  pharynx,  larynx,  lungs,  or  serous  sacs;  and  (iii)  uroemia, 
which  will  be  fully  covered  under  chronic  interstitial  nephritis;  uraemia 
is  more  often  an  adult  than  an  infantile,  and  a  later  rather  than  an  early, 
complication,  though  convulsions  may  be  its  first  symptom;  headache, 
delirium,  dyspnoea,  convulsions,  coma,  and  vomiting,  are  among  the 
salient  signs  of  uraemia. 

Course. — ^The  course  is  seldom  fatal  within  a  few  days.  In  general 
there  are  more  recoveries  than  deaths.  The  average  duration  is  less 
than  two  weeks,  though  one  or  two  years  may  elapse  before  recovery. 
Convalescence  is  usually  complete,  though  gradual  transition  into 
chronic  nephritis  sometimes  results. 

Treatment. — Most  of  the  points  mentioned  will  be  considered  more 
fully  in  the  treatment  of  chronic  nephritis,  (a)  Prophylaxis  is  of 
limited  value.  Drugs  which  irritate  the  kidneys  should  be  carefully 
avoided  in  acute  infections  or  in  pregnancy.  In  fevers,  with  or  without 
albuminuria,  water  should  be  given  freely  by  mouth  or  by  enema; 
hydrotherapy  is  prophylactic,  save  in  scarlatina,  when  all  prevention  is 
seemingly  futile  and  cold  baths  are  contra-indicated.  Induction  of 
labor  is  indicated  in  severe  cases  in  pregnancy.  (6)  The  diet  should 
be  regulated.  Milk  is  a  moderate  diuretic,  is  non-irritant,  and  contains 
little  or  no  extractives  or  salt.  It  should  be  given  as  in  typhoid  (q.v.). 
Thoroughly  cooked  carbohydrates,  as  gruels,  make  a  good  combina- 
tion with  it.  Broths  and  beef-tea  are  to  be  avoided,  and  meats  should 
be  administered  only  late  in  convalescence.  Alcohol  is  contra-indicated, 
save  as  exceptionally  necessitated  by  the  causal  disease,  (c)  Abso- 
lute rest  in  bed  is  imperative;  rest  with  the  body  covered,  protects  the 
skin  and  spares  the  products  of  the  tissue  waste,  which  are  eliminated 
by  the  kidneys;  the  patient  should  lie  between  flannel  blankets  and 
should  be  dressed  in  flannel  nightgowns,  {d)  There  is  no  drug  which 
affects  the  nephritis;  tannin  and  ergotin  (of  each  five  grains  three 
times  daily)  seem  to  restrict  renal  hemorrhage.  Salt  should  be  largely 
withheld,  because  it  increases  albuminuria  and  oedema  (see  Treat- 
ment OF  Chronic  Nephritis),  (e)  The  best  diuretics  are  water  and 
milk,  which  flush  out  detritus  from  the  kidneys.  The  alkaline  charged 
waters  seem  to  search  out  waste  substances  in  the  tissues  and  facilitate 
their  removal  by  the  kidney  (but  excessive  quantities  are  often  given) ; 
potassium  citrate  and  sodium  benzoate  are  said  to  have  the  same 
effect ;  the  citrate  may  be  given  in  doses  of  half  a  dram  with  sweetened 
weak  lemonade.  Sweet  spirits  of  nitre  5ss  to  5j>  q-i-d.,  is  diuretic 
and  also  dilates  the  bloodvessels.  All  stronger  diuretics  are  to  be 
avoided.  (/)  The  skin  should  receive  consideration.  Warm  baths  are 
diuretic  and  stimulate  some  vicarious  elimination  through  the  skin. 


ACUTE  NEPHRITIS  773 

Careful  covering  and  rest  in  bed  keep  the  skin  relaxed  and  not  only 
materially  aid  its  functions  but  also  relieve  renal  hypersemia.  (g) 
Management  of  the  bowels  is  as  important  as  that  of  the  skin.  Saline 
catharsis  lowers  arterial  tension  and  aids  compensatory  elimination. 
As  salts  often  derange  the  stomach,  an  ounce  should  be  given  by 
rectum  with  two  ounces  of  glycerine  and  one  of  water.  One-half  to 
one  dram  of  compound  jalap  powder  or  A  grain  of  elaterin  is  indicated 
when  uraemia  is  imminent,  (h)  Treatment  of  uraemia  (see  Treatment 
OF  Chronic  Nephritis).  For  suppression  of  urine  a  full  warm  bath 
lasting  fifteen  to  twenty  minutes  should  be  given;  a  hot  pack  should 
be  applied  followed  by  wrapping  in  blankets  and  covering  heavily 
with  a  rubber  sheet;  or  the  alcohol  sweat  or  hot-air  sweat  may  be 
given  as  described  under  Treatment  of  Chronic  Nephritis.  Cups 
applied  to  the  back  may  divert  blood  away  from  the  kidneys,  because 
the  vessels  of  the  loin  anastomose  with  those  of  the  kidney.  Pilocarpin 
hydrochlorate,  gr.  ^  to  |-  in  adults,  and  one-half  as  much  in  children, 
causes  profuse  sweating  and  salivation  but  long  ago  the  author  aban- 
doned its  use  after  witnessing  two  deaths  from  sudden  pulmonary 
oedema  in  patients  with  apparently  strong  hearts;  of  course  it  should 
never  be  employed  when  the  heart  is  weak.  Active,  rapid  catharsis 
is  effected  by  giving  two  drops  of  croton  oil  on  the  tongue;  this  may 
be  repeated  in  two  hours  if  necessary.  If  ursemic  symptoms  (in  an 
oedematous  patient)  appear  slowly,  an  incision  two  inches  long  should 
be  made  over  the  lower  tibiae  down  to  the  bone,  thereby  directly  drain- 
ing away  the  serum  with  its  retained  toxins;  this  is  better  than  the 
use  of  small  punctures,  or  Southey's  capillary  tubes,  which  are  attended 
by  all  the  dangers  of  puncture-wounds.  If  uraemia  develops  suddenly, 
the  legs  should  be  incised  and  a  pint  or  more  of  blood  should  be 
withdrawn  from  the  veins  of  the  arm;  whether  venesection  relieves 
the  circulation  mechanically  or  removes  toxins  is  still  a  matter  of  theory, 
but  practically,  relief  is  often  obtained.  It  should  be  followed  by  sub- 
cutaneous normal  salt  infusions — or  plain  water  without  the  salt — 
which  stimulate  the  heart  and  kidneys  and  lower  the  molecular  con- 
centration of  the  blood.  Pleural  or  ascitic  hydrops  should  be  aspirated. 
The  heart  must  be  stimulated  by  strychnine  and  digitalis  as  in  cardiac 
insufficiency,  though  hypodermics  are  better  than  oral  administration. 
A  hypodermic  of  morphine  is  beneficial  and  harmless  when  there  is 
much  dyspnoea  and  restlessness.  Chloral  and  bromides  modify  sudden 
convulsions  (v.  Chronic  Nephritis).  OEdema  of  the  lungs  (q.v.), 
vomiting,  and  diarrhoea,  are  caused  by  several  factors,  viz.,  cardiac 
stasis,  uraemia,  oedema  of  the  alimentary  mucosa,  and  the  vicarious 
elimination  of  urea,  which  breaks  up  in  the  digestive  tract  into  irritat- 
ing ammonium;  vicarious  vomiting  and  diarrhoea  should  not  be 
checked  at  once;  if  persistent,  the  vomiting  is  treated  as  outlined 
in  chronic  gastritis  (q.v.)  or  typhoid;  gastric  lavage  is  beneficial,  and 
dilute  hydrochloric  acid,  ngx  to  xv,  neutralizes  the  ammonium,  (i) 
In  convalescence,  iron  and  other  mild  tonics  should  be  given,  irritating 
foods  and  beverages  interdicted,  exercise  carefully  restricted,  and  cold 


774  DISEASES  OF  THE  KIDNEY 

and  exposure  should  be  avoided  by  sending  the  patient,  if  possible, 
to  a  warm  climate. 

(B).  CHRONIC  NEPHRITIS. 

Our  knowledge  of  chronic  Bright's  disease  dates  from  Richard 
Bright's  communications  in  1827.  Aetius,  Avicenna,  Cotugno  (1770), 
and  other  writers,  mentioned  the  association  of  hydrops  and  albumin- 
uria, but  to  Bright  is  due  the  credit  of  correlating  renal  disease,  albu- 
minuria, and  dropsy ;  he  also  noted  the  etiological  importance  of  alcohol 
and  cold,  as  well  as  the  cardiac  hypertrophy,  uraemia,  brain  hemorrhage, 
coma,  convulsions,  blindness,  and  the  tendency  to  serositis. 

The  following  classification  of  nephritis  is  given  as  covering  typical 
cases,  though  it  must  be  borne  in  mind  that  combined  or  mixed  types 
are  equally  frequent.  As  a  cause  of  death,  chronic  nephritis  ranks 
sixth,  after  pneumonia,  tuberculosis,  heart  disease,  endocarditis,  and 
unknown  causes. 


I.  Chronic  Parenchymatous  Nephritis. 

Definition. — Chronic  Bright's  disease,  with  special  involvement  of 
the  parenchyma  (though  the  interstitial  tissue  is  always  affected),  with 
much  albuminuria,  and  with  abundant  formed  elements  in  the  urinary 
sediment.    The  affection  constitutes  3  per  cent,  of  all  cases  of  disease. 

Etiology. — It  may  result  from  (a)  infections,  as  tuberculosis  (which 
causes  25  per  cent.),  malaria,  and  syphilis;  (b)  from  exposure  to  cold 
and  dampness;  (c)  from  toxic  factors,  as  alcohol  and  lead,  and  less 
frequently  others,  as  mercury  or  arsenic;  (d)  from  cardiac  disease; 
14  per  cent,  of  these  cases  develop  nephritis,  (e)  Exhausting  dis- 
charges, suppuration,  and  ulceration  may  cause  it.  (/)  Acute  nephritis 
seldom  becomes  chronic,  though  it  is  a  somewhat  predisposing  factor. 
(g)  Age  and  sex  are  of  etiological  importance.  Most  cases  occur 
between  twenty  and  fifty  years  of  age;  it  is  rare  in  children.  Males 
are  affected  more  often  than  females. 

Pathology. —  Three  types  of  the  disease  exist,  besides  the  mixed 
forms. 

1.  The  "Large  White  Kidney"  or  "Inflamed  Fatty  Kidney."— This  is 
never  decreased  in  size  and  may  weigh  10  to  12  ounces  (300  to  360  gm.) 
and  measure  two  or  three  times  the  normal  size. 

Gross  Characters. — The  capsule  is  loose  and  non-adherent;  the 
surface  is  smooth,  yellow-gray,  with  prominent  stellate  veins,  and 
sometimes  has  dots  of  hemorrhage  upon  it.  On  section  the  cortex  is 
broader  than  normal,  the  striations  are  poorly  marked,  and  when  cut, 
streaks  of  fat  may  show;  the  glomeruli  and  convoluted  tubules  are 
yellow,  and  contrast  with  the  gray  bands  of  newly  formed  connective 
tissue.  The  medulla  shows  fewer  changes,  and  is  red,  in  sharp  contrast 
with  the  light  cortex. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS  775 

Microscopic  Characters. — The  most  essential  change  is  hyaline 
and  fatty  degeneration  and  atrophy,  chiefly  in  the  convoluted  tubules, 
in  which  lie  desquamated  epithelia  and  coagulated  albumin.  The 
glomeruli  are  always  diseased,  but  to  a  varying  degree;  they  are 
enlarged,  their  vessels  show  hyaline  and  fatty  degeneration  and  nuclear 
multiplication;  albumin  is  found  in  their  capsules,  and  the  epithelium 
is  swollen,  fatty,  or  even  necrotic.  The  connective  tissue  is  always 
increased,  which  histologically  separates  chronic  nephritis  from  acute 
nephritis  and  mere  degeneration.  These  changes  are  never  equally 
diffuse. 

2.  The  "Large  Red"  or  "Variegated  Kidney." — Gross  Characters. — 
It  is  also  large,  but  is  firmer  than  the  kidney  just  described 
or  that  of  acute  inflammation,  for  it  has  more  connective  tissue, 
which  may  cause  some  tearing  and  loss  of  the  cortex  when  the  capsule 
is  stripped  off.  The  surface  may  be  perfectly  smooth.  The  cortex 
is  swollen,  indistinctly  striated,  dotted  yellow  from  fatty  glomerular 
change,  or  red  from  minute  ecchymoses,  and  sometimes  streaked  yellow 
and  red  from  similar  tubular  changes. 

Minute  Characters. — These  are  essentially  those  of  the  large 
white  kidney,  with  the  exception  that  fatty  degeneration  is  less  marked, 
and  connective  tissue  alteration  and  hemorrhages  are  more  conspicuous. 

3.  The  Secondary  Contracted  Kidney. — This  form  may  develop 
after  a  year  or  two  from  the  above  forms.  Some  consider  it  a  primary, 
independent  form. 

Gross  Characters. — It  is  seldom  decreased  in  size  and  may  be  as 
large  as  the  "large  white"  or  "large  red  kidney";  the  name  refers 
rather  to  its  connective  tissue  than  to  any  visible  renal  shrinkage. 
The  capsule  is  adherent  in  places,  and,  when  stripped,  tears  off  small 
areas  of  the  renal  substance.  The  surface  is  rough  and  shows  in  some 
places  reddish  depressed  areas  (fibrous  contraction  or  granulations, 
and  parenchymatous  atrophy)  and  in  others  yellow  areas  (which  are 
more  normal,  though  fatty).  Section  shows  decrease  in  the  cortex, 
corresponding  to  the  reddish  foci.  It  differs  from  the  genuine  con- 
tracted kidney  (primary  interstitial  nephritis)  in  the  following  respects: 
it  is  secondary,  much  more  rapid  in  development,  contains  fewer 
cysts,  is  more  yellow,  and  its  red  granulations  and  yellow  prominences 
are  larger. 

Minute  Characters. — Epithelial  changes  resemble  those  of  the 
two  forms  described.  The  membrana  propria  of  the  tubules  thickens, 
adheres,  and  obliterates  many  tubules.  The  glomeruli  collapse,  thicken, 
and  shrink  to  small  dark-gray  granular  bodies,  which  sometimes 
calcify.  The  retracted  areas,  capsular  adhesions,  and  cortex  shrink- 
age, correspond  to  connective  tissue  contraction. 

Symptoms. — The  onset  is  in  most  cases  gradual  and  insidious,  the 
earliest  symptoms  being  loss  of  strength,  pallor,  emaciation,  simple 
decline  of  health,  indigestion,  anorexia,  headache,  shortness  of  breath 
on  exertion,  or  chronic  bronchitis.  Sometimes  there  is  tenderness  over 
the  kidneys. 


776  DISEASES  OF  THE  KIDNEY 

1.  Urinary  Findings. — Except  in  the  secondary  contracted  kidney 

(a)  the  urine  is  decreased  to  seven  ounces  or  a  quart  (200  to  1,000  c.c); 

(b)  the  color  is  dark  yellow-red,  opaque,  or  rarely  smoky;  the  urates 
are  held  in  suspension  by  the  albumin;  sometimes  its  surface  is  shim- 
mering from  fatty  cells  and  casts;  (c)  the  specific  gravity  is  1,020  to 
1,040  and  (d)  the  reaction  is  acid;  (e)  albumin  is  almost  never  absent, 
is  more  abundant  in  the  day  time  than  at  night,  and  amounts  to  1  to  3 
per  cent,  and  one-half  to  one  ounce  (15  to  30  gm.)  daily;  it  coats  the 
bubbles  formed  by  agitation  of  the  specimen  and  preserves  them  for 
a  long  time.  (/)  The  absolute  amount  of  solids  is  generally  decreased; 
for  example,  the  urea  (which  normally  constitutes  90  per  cent,  of  the 
nitrogen  output  and  amounts  to  about  an  ounce  [35  gms.]  daily), 
kreatin,  and  sodium  chloride,  are  decreased,  and  the  freezing  point  of 
the  urine  is  lowered  {v.  ^.).  {g)  The  sediment  is  abundant,  and  hyaline, 
granular,  fatty,  and  epithelial  casU  abound  (first  noted  by  Simon  and 
Nasse);  coarsely  granular  and  waxy  casts  appear  late  in  the  disease; 
the  granular  type  is  due  chiefiy  to  fat  particles,  which  may  darken  the 
casts.  They  have  been  long  regarded  as  significant  of  nephritis. 
Key,  Nothnagel,  Rosenstein,  and  others  afterward,  observed  their 
occurrence  in  the  urine  of  othermse  normal  indi^-iduals,  and  of  late 
there  has  been  a  tendency  to  underestimate  their  importance.  Accord- 
ing to  Senator,  casts  originate  in  the  kidney  chiefly  from  epithelial 
cells,  and  always  indicate  some  renal  disease.  They  may  be  dissolved 
in  the  bladder  by  the  pepsin  contained  in  the  urine  (Sehrwald).  Leuko- 
cytes and  fatty  epithelia,  and,  in  some  forms  of  nephritis,  red  cells, 
occur  in  considerable  amounts.  In  Ackermann's  case  no  casts  were 
found  in  the  urine,  but  were  found  in  masses  in  the  renal  pelvis  at 
necropsy. 

In  the  secondary  contracted  kidney  the  urinary  findings  are  the 
same  except  that  the  urine  amounts  to  three  pints  or  two  quarts  (1,500 
to  2,000  c.c),  is  clearer,  is  somewhat  lower  in  specific  gravity,  and 
contains  somewhat  less  albumin  and  casts. 

2.  (Edema. — (Edema  is  very  frequent.  Its  absence  argues  for  little 
glomerular  involvement.  It  commences  aboid  the  eyes,  changes  its 
location  readily,  and  is  at  first  evanescent,  but  soon  becomes  general, 
obstinate,  and  ominous.  It  is  more  pronounced  in  the  "large  white 
kidney"  than  in  other  t}"pes  and  increases  as  the  urine  decreases.  The 
puffy  eyes,  pale  swollen  cheeks,  dull  expression,  distended  abdomen, 
and  shapeless  •v\Tists  and  ankles,  often  tempt  one  to  a  snap  diagnosis. 
The  serous  and  mucous  membranes  are  similarly  involved,  though  to  a 
lesser  degree,  and,  also,  as  possible  terminal  events,  pulmonary  or  cere- 
bral oedema  may  develop.  (Edema  is  caused  (a)  by  hypalbuminosis 
and  hydrsemia  of  the  blood  (Bright's  theory),  or  (b)  by  alterations  in 
the  vessel  walls,  i.e.,  abnormal  permeability,  a  theory  advanced  by 
Cohnheim  and  Lichtheim. 

3.  Anaemia. — Anaemia  distinguishes  chronic  parenchymatous  ne- 
phritis from  the  genuine  interstitial  type.  There  is  usually  retention 
of  urea,  uric  acid,  and  chlorides;  sometimes  the  blood  is  cloudy. 


CHRONIC  INTERSTITIAL  NEPHRITIS  777 

4.  Cardiovascular  Findings. — The  pulse  is  more  often  small,  soft, 
rapid,  and  associated  with  a  weak  apex,  indicating  dilatation,  than 
tense  and  associated  with  a  loud  second  aortic  tone  and  strong  apex, 
indicating  hypertrophy.  Secondary' contraction  and  mixed  nephritis 
are  likely  to  develop  findings  similar  to  those  of  the  genuine  inter- 
stitial nephritis;  Senator  finds  hypertrophy  with  dilatation  (eccentric 
hypertrophy)  in  parenchymatous,  and  simple  or  concentric  hypertrophy 
in  interstitial  nephritis.    Myocardial  degeneration  is  common. 

Complications,  and  Causes  of  Death. — (a)  Marasmus  results  from 
the  anaemia,  indigestion,  diarrhoea,  oedema  of  the  alimentary  mucosa 
or  its  irritation  by  decomposed  urea,  (b)  Intercurrent  infections  may 
result,  as  inflammation  of  the  pleurae  or  pericardium,  cellulitis,  and 
especially  pneumonia;  in  one  instance  the  writer  saw  acute  necrosis 
and  sloughing  of  the  scrotum,  after  which  the  patient  improved  re- 
markably; many  pneumonia  deaths  really  result  from  nephritis. 
Other  complications  are  (c)  oedema  of  the  lungs,  larynx,  serous  sacs, 
and  extremities,  impeding  respiration  and  obstructing  the  arterial  flow 
in  the  peripheral  vessels;  {d)  hemorrhages  (in  8  per  cent.)  in  the  brain 
or  other  organs;  (e)  retinitis  (in  18  per  cent.);  (/)  uraemia,  with  its 
numerous  nervous,  circulatory,  and  digestive  symptoms  {v.  Inter- 
stitial Nephritis)  ;  {g)  acute  exacerbations ,  particularly  in  the  chronic 
hemorrhagic  type;   and  ih)  cardiac  insufficiency. 

Diagnosis. — The  diagnosis  rests  upon  three  cardinal  symptoms: 
(a)  the  urinary,  which  are  characteristic  when  twenty-four-hour  speci- 
mens are  carefully  and  repeatedly  examined  in  every  case  coming 
under  our  care;  (6)  the  anasarca,  which  is  usually  present,  though 
sometimes  absent  in  secondary  contracted  kidney  and  in  Wagner's 
hemorrhagic  type;  and  (c)  the  anaemia.  (For  differentiation,  see 
Differential  Table  of  Diffuse  Renal  Diseases,  pages  796-797.) 

Prognosis. — Though  some  cases  which  suggest  an  arrest  of  the 
process  are  found  at  autopsy,  and  some  cases  may  recover  after  a 
year  or  two,  the  chnical  course  is  usually  progressive  and  fatal.  Dropsy 
usually  causes  death  in  a  few  months  to  a  year,  though  the  author  has 
seen  three  typical  cases  apparently  recover  after  two  and  a  half  years ; 
these  cases  did  not  result  from  acute  infections  like  the  cases  of  recovery 
after  one  to  two  years  reported  by  Senator  and  Rosenstein.  The 
outlook  is  shghtly  better  in  children  than  in  adults.  The  "large, 
white  kidney"  causes  death  in  one-half  to  one  year,  the  "large,  varie- 
gated kidney"  in  one  and  a  half  to  three  years,  and  the  secondary 
contracted  kidney  in  one  and  a  half  to  three  years.  The  treatment 
is  considered  under  chronic  interstitial  nephritis  {q.v.). 

II.  Chronic  Interstitial  Nephritis. 

Definition. — A  primary,  interstitial,  contracting  sclerosis  of  the 
kidney,  characterized  clinically  by  abundant  urine  of  low  specific 
gravity,  with  small  amounts  of  albumin  and  few  cellular  elements;  and 
by  marked  cardiac  hypertrophy,  arteriosclerosis,  retinitis,  and  uraemia. 


778  DISEASES  OF  THE  KIDNEY 

This  genuine  contracted  kidney  (primary  contraction)  must  not  be 
confused  with  secondary  contracted  kidney,  arteriosclerotic  contrac- 
tion, embolic  contracion  or  the  contraction  resulting  from  ascending 
infection — e.  g.,  cystopyelonephritis. 

Frequency. — In  ten  years  Eichhorst  treated  31,562  cases,  of  which 
409  (1.4  per  cent.)  had  contracted  kidneys;  he  finds  this  form  six  and 
a  half  times  as  frequently  as  the  parenchymatous  form,  though  with 
us  the  latter  is  at  least  equally  frequent. 

Etiology. — The  etiology  is  essentially  that  of  arteriosclerosis,  with 
which  contracted  kidney  has  a  three-fold  relation :  (a)  arteriosclerosis 
may  cause  the  arteriosclerotic  kidney;  (6)  contracted  kidney  may 
cause  arteriosclerosis;  or  (c)  both  may  result  from  a  common  cause. 
The  noxa  or  toxin  reaches  the  kidney  through  the  blood  stream. 

The  disease  may  result  from  (a)  chronic  alcoholism,  especially  when 
combined  with  exposure  or  over-eating;  (6)  chronic  lead-poisoning, 
proven  to  be  a  cause  by  clinical  and  experimental  evidence  (Lancereaux 
and  Ollivier);  (c)  gout  (Todd),  caused  by  uric  or  oxalic  acid  and 
the  alloxur  bodies;  (d)  syphilis;  (e)  diabetes  (Senator),  caused  by 
sugar,  acetone,  oxybutyric  acid,  or  kreatin;  the  diabetes  lessens  or 
ceases  when  induration  develops;  (/)  age;  it  begins  between  the  ages 
of  thirty  and  fifty,  and  is  clinically  manifest  after  fifty  years  of  age. 
Sawyer  collected  24  cases  in  children,  13  of  whom  were  under  ten 
years,  (g)  Sex  is  an  etiological  factor.  The  disease  is  two  to  three 
times  as  frequent  in  men  as  in  women.  In  the  infantile  form  most 
cases  occur  in  girls,  (h)  Other  infrequent  causes  are  acute  nephritis, 
the  kidney  of  pregnancy,  hereditary  tendency  as  in  Dickinson's  series 
through  four  generations,  and  endocarditis. 

Pathology. — It  is  undecided  whether  the  process  is  inflammatory 
or  atrophic;  Weigert  believes  that  cellular  degeneration  occurs  first 
and  induration  follows. 

Gross  Pathology. — (a)  The  kidneys  are  contracted  even  to  one-third 
their  original  size  and  may  weigh  but  1.6  ounces  (50  gm.),  or  0.6  ounces 
(21  gm.);  contraction  is  rarely  symmetrical  in  both,  (b)  Their  con- 
sistence is  increased,  (c)  The  capsule  is  thick,  tendinous,  wrinkled, 
vascular,  and  adherent,  and  strips  off  particles  of  cortex  when  removed. 
(d)  The  surface  is  uneven;  there  are  small  reddish  or  sometimes  paler 
prominences,  measuring  0.5  to  5  mm.  and  representing  the  more 
normal  tissue;  the  paler  retracted  areas  are  fibrous  retraction,  (e) 
Small  cysts  are  frequently  found,  usually  with  clear  contents;  they 
vary  in  number  and  their  size  ranges  from  that  of  a  pin-point  to  that 
of  a  cherry;  they  apparently  result  from  glomerular  and  tubular 
constriction  by  connective  tissue  (retention  cysts).  (/)  On  section  the 
cortex  is  shrunken,  even  to  1  mm.,  is. irregular  and  gray  from  fibrillar 
connective  tissue.  The  medulla  is  less  changed,  though  also  shrunken; 
pale  fibrous  lines  alternate  with  red  dilated  vessels;  uric  acid  or 
calcium  salts  are  deposited,  (g)  The  pelvis  is  large  and  much  fat 
surrounds  the  kidney. 


CHRONIC  INTERSTITIAL  NEPHRITIS  779 

Minute  Pathology. — The  changes  are  largely  cortical,  focal,  asym- 
metrical, and  interstitial,  (a)  The  glomeruli  early  contain  round  cells, 
nuclear  increase,  desquamated  cells,  and  albumin;  later  they  atrophy 
from  degeneration  of  the  afferent  artery;  multiplication  of  cells  is  noted 
between  the  loops,  and  hyaline  change  occurs  in  the  glomerular  vessels; 
in  the  extreme  stage  the  glomeruli  become  hyaline  and  fibrous;  some 
tufts  remain  normal  and  others  may  visibly  hypertrophy,  Sabourin's 
compensatory  adenomata.  (6)  The  epithelium  is  always  changed, 
though  much  less  than  in  parenchymatous  forms ;  in  the  sunken  areas 
many  tubules  disappear,  and  degenerated  cells  are  seen  in  the  promi- 
nent surface  granulations;  in  the  medulla  the  collecting  tubules  are 
larger,  even  cystic,  and  are  filled  with  colloid  material,  (c)  The  con- 
nective tissue  is  increased  everywhere,  but  more  in  the  cortex  than  in 
the  medulla;  round  cell  infiltration  occurs  early  and  induration  late; 
the  vessels  are  sclerotic  in  all  their  coats,  but  especially  in  the  intima, 
and  many  writers  consider  that  the  vascular  changes  are  the  earliest 
and  causative  alteration. 

Symptoms. — Long  latency  for  years,  insidious  onset,  and  protracted 
compensation  by  heart  hypertrophy ,  are  characteristic  of  this  type'. 
Many  cases  are  first  discovered  during  an  acute  infection,  as  pneu- 
monia; they  may  be  found  on  examination  for  life  insurance,  or  at 
the  coroner's  autopsy  after  accidents.  It  may  appear  to  be  a  phys- 
iological, intermittent,  or  cyclic  albuminuria.  Polyuria,  cardiac  symp- 
toms, retinitis,  indigestion,  or  depreciation  of  health,  may  be  the  first 
symptoms.  The  cedema,  pronounced  urinary  findings  (in  a  single 
specimen)  and  anaemia  of  chronic  parenchymatous  nephritis,  are 
seldom  conspicuous  and  almost  never  early  symptoms  in  this  type. 
The  condition  may  be  first  declared  by  heart  incompetence,  ursemic 
coma,  or  convulsions. 

1.  Urinary  findings  are  generally  the  earliest  signs.  Twenty-four- 
hour  specimens  should  be  examined  (with  a  fresh  specimen  for  micro- 
scopic examination)  repeatedly  in  doubtful  cases,  (a)  The  amount, 
which  is  at  first  normal,  is  gradually  increased  (polyuria);  this  is  a 
frequent  cause  for  consulting  the  physician.  The  urine  is  also  passed 
too  frequently  (pollakiuria) ,  especially  at  night;  this  is  always  sus- 
picious when  the  prostate  is  normal.  In  well-developed  cases  it  totals 
two  to  three  quarts  (2  to  3,000  c.c),  rarely  more,  though  8  to  10  quarts 
(8  to  10,000  c.c.)  were  passed  in  a  case  of  Lecorch^  and  Talamon  and 
12  quarts  in  Bartel's  case.  (6)  It  is  pale  and  (c)  weakly  acid,  (d) 
The  specific  gravity  averages  1,010  (1,005  to  1,012).  (e)  A  permanent 
foam  due  to  the  albumin  is  frequent.  (/)  Albumin  is  present  in 
most  cases,  but  is  not  abundant;  the  merest  traces  are  found  up  to 
8  grains  (0.5  gm.)  pro  mille,  and  a  daily  total  of  one-half  to  one  dram 
(2  to  5,  rarely  10  gm.).  It  is  often  absent  in  single  specimens,  espe- 
cially in  the  morning,  whence  a  twenty-four-hour  specimen  should 
always  be  examined.  Delicate  tests  (v.  Albuminuria)  are  often  neces- 
sary. It  may  appear  only  after  eating,  exercise,  excitement,  or  fatigue, 
whence  its  greater  frequency  toward  night;    it   may  increase  after 


780  DISEASES  OF   THE  KIDXEY 

dyspepsia  or  bronchitis.  Senator's  statement  that  its  alleged  absence 
is  due  to  an  arteriosclerotic  kidney  and  not  to  interstitial  nephritis 
is  not  invariably  correct,  according  to  personal  experience.  Albumin- 
uria may  be  absent  for  weeks  or  months,  (g)  Solids  are  decreased, 
i.  e.,  the  urea,  uric  acid,  ammonium,  chlorides,  and  phosphates.  The 
determination  of  the  freezing  point,  cryoscopy,  was  first  employed  by 
Koranyi  to  estimate  the  amount  of  soluble  molecules  in  the  blood 
and  urine.  The  blood,  when  there  is  deficient  renal  excretion,  freezes 
at  a  lower  point,  because  its  molecular  concentration  is  greater;  this 
point  is  0.56°  C.  (with  0.02°  physiological  variation  in  either  direction), 
lower  than  that  of  distilled  water.  The  urine  freezes  at  a  higher  point 
than  normal,  as  its  molecular  concentration  is  less.  Normal  urine 
freezes  at  0.9°  C,  lower  than  distilled  water;  in  chronic  nephritis  the 
urine  freezes  at  0.5  or  even  0.2°  below  that  of  water.  The  smaller 
the  molecules,  the  greater  their  influence  in  lowering  the  freezing 
point;  the  chloride  molecules  are  more  potent,  therefore,  than  those 
of  the  urea  group.  Increased  molecular  concentration  of  the  blood 
usually  (not  always)  indicates  disease  of  both  kidneys.  Cabot  recently 
concluded  that  cryoscopy  is  of  no  great  value  in  medical  cases,  {h) 
The  Wapidity  of  elimination  is  decreased.  ^Methylene  blue  was  em- 
ployed by  Achard  and  Castaigne  (1897)  to  test  this  point.  One  cubic 
centimeter  of  a  5  per  cent,  aqueous  solution  is  injected  subcutaneously; 
normally  it  should  stain  the  urine  in  one-half  to  one  hour,  reach  a 
maximum  in  three  to  four  hours,  and  cease  in  thirty-six  to  seventy- 
two  hours;  elimination  may  be  nearly  or  even  more  rapid,  in  chronic 
parenchymatous,  but  it  is  much  slower  than  normal  in  interstitial 
nephritis  (Bard).  The  permeability  of  the  kidneys  may  also  be  tested 
by  a  hypodermic  injection  of  one  cubic  centimeter  of  a  one-half 
per  cent,  solution  of  phloridzin  (x4chard),  which  produces  glycosuria 
in  normal  kidneys;  phloridzin  glycosuria  is  reduced  or  absent  in 
interstitial  nephritis.  A  dilution  test  may  be  made.  Drinking  of  large 
amounts  of  water  raises  the  freezing  point  of  the  urine  to  0.3,  0.2,  or 
0.1°,  in  interstitial  nephritis  and  in  health,  but  does  not  raise  it  in  par- 
en  chjTnatous  nephritis,  (i)  The  sediment  is  scant,  absent,  or  can  be 
obtained  only  by  the  centrifuge.  Hyaline,  granular,  and  epithelial 
casts,  are  found  in  small  numbers  when  the  light  is  moderated  by  the 
diaphragm;  the  granular  form  is  found  in  some  cases  only  after 
repeated  search;  the  granular  casts  are  often  wide,  originating  in  the 
dilated  tubules  of  the  medulla.  A  few  epithelia,  leukocytes,  and  crystals 
of  uric  acid  and  oxalate  of  lime,  are  found.    Red  cells  are  infrequent. 

The  urinary  findings  are  somewhat  modified  by  intercurrent  uraemia, 
fever,  and  heart  failure,  all  of  which  concentrate  the  urine,  raise  its 
specific  gravity,  and  deepen  its  color. 

2.  Cardiovascular  symptoms  were  noted  by  Bright,  but  their  signi- 
ficance was  first  established  by  Traube.  They  appear  in  50  to  90 
per  cent,  of  cases,  and  later  than  the  urinary  findings.  Cardiac  hyper- 
trophy is  more  quickly  detected  clinically  than  pathologically,  especially 
in  the  young,  because  the  urine  is  increased  early  before  the  physical 


CHRONIC  INTERSTITIAL  NEPHRITIS  781 

signs  of  hypertrophy  prevail,  and  again  because  concentric  hyper- 
trophy is  present  long  before  dilatation  appears.  Emphysema  may 
obscure  the  precordial  evidences  of  hypertrophy,  such  as  the  heaving 
apex  beat,  and  one  must  therefore  depend  on  the  evidences  presented 
by  the  te7ise  pulse,  the  hardness  of  the  arteries,  the  sphygmographic 
tracings  with  a  square  apex,  the  loud  ringing  second  aortic  tone,  or 
other  manifestations  of  increased  arterial  tension,  as  epistaxis,  vertigo, 
headache,  tinnitus,  palpitation,  or  cardiac  asthma.  Strassburger,  Sahli, 
and  Fellner,  estimate  the  normal  systolic  blood  pressure  at  125  mm. 
and  the  diastolic  at  29  mm. ;  in  interstitial  nephritis  the  systolic  pres- 
sure may  mount  to  200  mm.  or  more.  High  tension  is  one  of  the  most 
constant  and  early  symptoms;  its  early  occurrence  leads  some  writers 
to  incorrectly  regard  contracted  kidney  rather  as  a  disease  of  the 
arteries  than  of  the  kidneys.  The  cause  of  the  hypertrophy  is  not 
definitely  known ;  theories  of  mechanical  obstruction  to  the  blood-flow 
by  the  renal  contraction,  and  of  vasomotor  constriction  excited  by 
retained  waste  substances,  have  been  advanced.  Though  hypertrophy 
should  be  looked  for  in  interstitial  rather  than  in  parenchymatous 
nephritis,  it  must  never  be  forgotten  that  the  two  types  often  mingle 
with  the  urinary  findings  of  the  "large  white  kidney"  and  the  cardio- 
vascular findings  of  a  renal  contraction.  In  the  last  stage  of  contracted 
kidney  the  hypertrophied  heart  weakens,  the  pulse  tension  falls,  the 
apex  becomes  weaker,  a  systolic  murmur  appears  from  myocardial 
insufficiency,  and  Potain's  gallop-rhythm,  a  sign  of  heart  fatigue,  is 
heard. 

3.  Retinitis  may  be  the  first  declaration  of  the  disease,  and  may 
come  under  the  observation  of  the  ophthalmologist.  It  occurs  more 
frequently  than  in  any  other  renal  lesion,  22.4  per  cent.  (Groenauw) 
to  28  per  cent.  (Eates).  Its  various  forms  are  stellate  white  areas  of 
fatty  and  fibrous  tissue,  a  white  zone  surrounding  the  disk,  degenera- 
tion of  the  disk,  retina,  or  of  both  together,  "flame-like"  hemorrhages, 
and  the  choked  disk  whose  large  veins  are  compressed  where  the 
arteries  cross  them.  (See  Plate  VI,  Fig.  8.)  The  retinitis  albuminurica 
is  not  specific,  identical  findings  occurring  in  other  conditions. 

4.  Uraemia  is  the  most  dreaded  and  frequent  complication;  its 
nature  and  immediate  cause  are  unknown;  it  can  only  be  stated 
that  it  is  an  auto-intoxication,  due  to  disturbance  of  renal  function, 
probably  with  retention  within  the  blood  of  nitrogenous  substances. 
Further  explanations  are  wholly  theoretical,  such  as  decreased  alkalin- 
ity of  the  blood  (acidosis);  failure  of  the  normal  "internal  secretion" 
of  the  kidney;  the  toxic  action  of  abnormal  products  of  metabolism 
or  breaking  up  of  the  proteids,  resulting  from  destruction  of  the  renal 
tissue  (nephrolysins,  Ascoli);  it  is  not  due  to  retention  of  urea  alone, 
nor  to  mechanical  conditions  alone,  as  oedema  or  anaemia  of  the  brain. 
It  occurs  most  often  in  chronic  interstitial,  next  in  acute,  then  in  chronic 
parenchymatous  nephritis,  and  is  much  less  common  in  other  diseases 
of  the  urinary  tract,  as  pyelonephritis,  etc. 


782  DISEASES  OF  THE  KIDNEY 

Uraemic  symptoms  may  be  acute  or  chronic,  but  will  be  considered 
as  nervous,  respiratory,  cardiac,  and  digestive. 

NERYors  Symptoms. — (i)  Acute  convulsions  (eclampsia)  are  due 
to  irritation  of  the  cortex  by  toxins;  they  closely  resemble  the  epi- 
leptic attack.  There  are  usually  prodromes,  as  pain  or  pressure  in 
the  head,  migraine,  neuralgia,  insomnia,  vertigo,  visual  disturbance, 
tinnitus,  nausea,  vomiting,  or  dyspnoea;  there  is  usually  no  "epileptic 
cry."  In  less  than  a  day  clonic  or  tonic  convulsions  appear,  usually 
generalized  (sometimes  Jacksonian)  and  involving  especially  the  flexor 
or  extensor  muscles  of  the  arms  and  legs;  the  abdomen  is  retracted; 
there  are  dyspnoea,  cyanosis,  and  involuntary  evacuations;  the  reflexes, 
especially  the  patellars,  are  increased;  the  pupils  are  vdde  and  'v\'ithout 
reaction;  the  pulse  is  full  and  slow  before  the  attack  but  becomes 
rapid  during  the  convulsions.  The  skin  becomes  covered  with  sweat 
and  the  temperature  is  usually  elevated.  The  convulsions  cease  after 
fifteen  to  thirty  minutes  and  coma  intervenes,  during  which  the  con- 
vulsions may  recur.  Death  is  the  usual  outcome,  but  recovery  is 
possible,  as  in  one  of  the  author's  cases  in  which  the  anterior  third 
of  the  tongue  was  bitten  off.  (ii)  Other  motor  manifestations.  The 
most  concise  general  statement  regarding  ursemic  nervous  phenomena 
is  as  follows:  paralysis  affects  especially  the  sensorium,  to  a  lesser 
degree  the  special  senses,  and  rarely  motility;  irritation  seldom  affects 
the  sensorium  {e.g.,  produces  delirium),  it  principally  acts  upon  the 
motor  paths  (convulsions)  and  very  seldom  upon  the  special  senses, 
Ursemic  convulsions  are  usually  general  but  may  resemble  focal 
symptoms,  such  as  convulsions  of  only  half  the  body,  for  instance,  of 
one-half  the  tongue,  of  the  left  arm  and  leg,  or  deviation  of  the  head 
to  the  left.  They  may  rarely  occur  with  convergent  strabismus,  facial 
spasm,  Jacksonian  epilepsy,  nystagmus,  tremor,  localized  trembling 
and  t^sdtchings,  muscular  cramps,  grinding  of  the  teeth,  tetanic  con- 
vulsions, trismus,  con\ailsions  on  one  side  and  contractions  on  the 
other,  rigidity  of  the  neck  or  opisthotonos.  In  seven  cases,  seen  by  the 
author,  the  symptoms  were  those  of  an  acute  focal  brain  lesion;  in 
two,  which  were  treated  by  lumbar  puncture,  relief  was  immediate. 

Paralyses  in  ureemia  are  infrequent,  are  chiefly  transitory  hemi- 
plegias and  are  due  to  cerebral  cedema,  capillar)^  hemorrhage,  softening, 
apoplexy,  inflammatory  foci  or  cortical  overstimulation  by  toxins. 
Hemiplegia  may  occur  ^dXh.  aphasia,  amnesia,  deafness,  crossed  oculo- 
motor paralysis,  glossoplegia,  or  conjugate  de^-iation  of  the  eyes.  The 
author  has  reported  five  cases  in  which  uraemia  resembled  meningitis 
very  closely.  Other  cases  have  been  suggestive  of  brain  tumor,  (iii) 
Acute  coma  often  occurs  "without  antecedent  eclampsia,  being  preceded 
by  headache,  stupor  or  apathy;  coma  may  last  for  days  or  even  months, 
(iv)  Psychical  symptoms.  One  of  the  most  common  chronic  symptoms 
is  a  characteristic  restlessness  and  anxiety.  Obstinate  headache  of  a 
dull,  throbbing  nature  is  common;  it  often  begins  in  the  early  morn- 
ing; it  may  be  occipitial,  or  hemicranic.  Insomnia  is  common,  though 
during  the  day  the  patient  is  often  sleepy.     Delirium  and  mania  are 


CHRONIC  INTERSTITIAL  NEPHRITIS  783 

more  frequent  in  chronic  nephritis  in  adults  than  in  juvenile  cases; 
melancholia  and  delusional  insanity  occur;  these  mental  states  may 
assume  medico-legal  importance  as  to  the  testamentary  capacity  of  the 
patient,  (v)  Special  senses.  Sudden,  complete  and  bilateral  blindness 
is  cortical  in  origin;  this  amaurosis  may  be  an  initial  symptom;  there 
are  usually  no  retinal  findings  and  the  condition  lasts  but  a  few  hours, 
though  in  exceptional  cases  oedema  of  the  disk  (Schmidt),  or  even 
choked  disk  is  found.  The  pupils  are  wide  and  without  reaction  in 
acute  eclampsia,  but  are  small  and  mobile  in  chronic  ursemia.  There 
may  be  sudden  or  gradual  ursemic  deafness  and  tinnitus  aurium. 

Respiratory  or  Cardiac  Symptoms. — Dyspnoea  is  very  com- 
mon. It  is  sometimes  toxic  and  central,  occurring  in  close  parallelism 
with  cerebral  manifestations.  In  other  cases  asthma  ursemicum 
develops  when  the  mind  is  absolutely  clear,  and  it  is  then  correctly 
referred  to  the  heart.  Prodromal  slowing  of  the  heart  to  40  to  60 
beats  is  frequent  in  incipient  uraemia.  The  dyspnoea  may  be  continu- 
ous or  paroxysmal  and  is  often  nocturnal.  Cheyne-Stokes  breathing 
may  develop  in  the  day  time  or  during  sleep  and  is  always  an  un- 
favorable sign,  though  recovery  is  possible.  Obstinate  hoarseness  and 
a  rare  form  of  laryngeal  spasm  are  recorded. 

Digestive  Symptoms. — These  rank  second  to  the  nervous  symptoms 
in  frequency.  The  breath  is  often  offensive  and  sometimes  has  an 
odor  of  urine,  which  condition  Senator  refers  to  trimethylamine;  he 
considers  it  of  poor  prognostic  value,  for  it  often  precedes  eclampsia. 
The  tongue  is  foul,  the  mouth  is  inflamed  and  the  saliva  is  frequently 
increased.  Nausea  and  vomiting  are  partly  central  and  partly  local 
from  decomposed  urea,  eliminated  vicariously  into  the  stomach;  the 
same  may  be  said  of  hiccough  and  diarrhoea.  All  these  symptoms  may 
be  very  acute.  Diarrhoea  may  be  serous  or  dysenteric  from  the  Bac. 
dysenteriae  (Flexner).  Mathieu  and  Roux  in  a  recent  study  of  23 
cases  of  "ursemic  ulcers"  found  them  chiefly  in  cases  of  advanced 
nephritis  in  subjects  under  twenty  years  old;  they  rarely  occur  in  the 
stomach;  diarrhoea  is  common,  but  bowel  hemorrhage  and  constipa- 
tion are  rare.  They  are  seemingly  produced  by  necrosis  due  to  tox- 
aemia, though  sometimes  secondary  to  submucous  haematomata.  Heal- 
ing is  very  rare  and  the  prognosis  is  almost  always  unfavorable. 

5.  Other  Complications  and  Symptoms. — (a)  Various  hemorrhages 
occur;  of  the  brain  in  7  to  17  per  cent,  of  cases;  also  in  the  dura, 
skin,  nose,  bronchi,  stomach,  bowels,  uterus,  conjunctiva  or  retina. 
The  author  has  observed  9  cases  of  profuse  gastro-intestinal  hemor- 
rhages in  uraemic  subjects,  (b)  Inflammations  may  develop.  Chronic 
bronchitis  always  suggests  kidney  disease.  Pericarditis,  pleuritis,  and 
pneumonia  especially,  may  develop  as  terminal  infections.  A  large 
number  of  deaths  from  pneumonia  is  due  to  nephritis  which  was 
previously  unnoticed.  Laryngitis  and  acute  (inflammatory)  oedema 
glottidis  may  occur,  (c)  (Edema  is  a  late  symptom  and  results  not 
from  the  nephritis  unless  it  is  of  the  mixed  type,  but  from  failing  of 
the  heart.     Ascites  also  is  nearly  always  cirrhotic  or  cardiac,     (d)  The 


784  DISEASES  OF  THE  KIDNEY 

skin  is  usually  dry  and  harsh  and  is  sometimes  covered  with  urea 
crystals — ^the  "urea  frost"  or  uridrosis.  Itching,  erythema,  urticaria, 
eczema  and  numbness  or  "dead  fingers,"  unusual  susceptibility  to  cold 
(crysesthesia),  neuritis,  rheumatoid  pains  or  clubbing  of  the  fingers 
are  probably  toxeemic. 

Diagnosis  of  Chronic  Interstitial  Nephritis. — ^There  are  three  car- 
dinal findings,  cardiovascular,  urinary  and  retinal;  and  as  Senator 
says,  he  who  invariably  examines  the  urine  and  heart  in  every  instance 
rarely  fails  to  diagnosticate  nephritis  correctly. 

Cardiac  Symptoms. — The  very  interdependence  of  cardiac  and  renal 
changes  may  prove  to  be  a  source  of  clinical  confusion;  thus  primary 
cardiac  disease  may  cause  renal  congestion,  embolism  or  even  acute 
or  chronic  nephritis;  again  alcohol  or  syphilis  may  be  a  common 
cause  of  arteriosclerosis,  myocarditis  and  nephritis;  and  finally,  the 
heart  lesion  may  be  wholly  secondary  to  renal  disease.  Simple  renal 
stasis  is  considered  in  the  differential  table  given  below.  In  terminal 
cardiac  weakness  caused  by  contracted  kidney,  the  hydrops,  dyspnoea, 
rales  or  systolic  murmur  may  suggest  myocarditis  with  renal  stasis; 
gallop-rhythm  is  more  common  in  the  heart  of  renal  disease  than  in 
primary  cardiac  affections. 

The  Urinary  Findings. — In  diabetes  mellitus  there  is  an  increased 
flow  of  urine,  in  which  the  high  specific  gravity,  glycosuria  and  less 
prominent  heart  findings  are  distinctive;  in  diabetes  insipidus,  the 
absence  of  albumin,  casts  and  cardiac  changes  are  characteristic; 
and  pyelitis  is  characterized  by  albumin  and  pyuria  but  not  by  casts 
or  cardiac  changes.  In  the  arteriosclerotic  kidney,  arterial  and  cardiac 
antedate  the  urinary  changes  (the  converse  is  true  in  interstitial  neph- 
ritis), the  specific  gravity  is  higher,  albumin  less  in  amount  and  in 
frequency  of  occurrence,  and  the  course  is  much  more  rapid.  For 
differentiation  from  other  Diffuse  Renal  Diseases  See  Table, 
pages  796-797. 

Diagnosis  of  Uraemia. — Skull-fracture,  miliary  tuberculosis,  lepto- 
meningitis, cerebral  abscess,  sepsis  and  other  diseases  may  be  falsely 
diagnosticated  uraemia,  simply  because  nephritis  is  also  present. 
Senator  has  said  that  without  a  previous  history  we  can  often  only 
diagnosticate  a  renal  disease  and  suspect  the  presence  of  other  (latent) 
affections.  The  danger  of  mistaking  ureemic  symptoms,  as  hemicrania, 
nervous  symptoms,  dysentery  etc.,  for  independent  disease  is  greater 
in  direct  ratio  to  the  difficulty  of  diagnosis  of  the  nephritis  itself  and 
many  authors  have  remarked  on  the  lack  of  correspondence  between 
the  clinical  and  pathological  findings  in  nephritis.  According  to 
Leube,  ursemic  intoxication  is  assumed  to  be  the  cause  of  nervous 
symptoms  only  when  other  causes  may  be  excluded,  because  in  the 
course  of  renal  disease,  organic  nervous  lesions,  as  hemorrhage  and 
meningitis,  may  simulate  uraemia.  Though  the  urine  is  usually  de- 
creased before  an  attack  of  uraemia,  Liebermeister  instances  a  case 
in  which,  immediately  before  a  ursemic  seizure,  both  urine  and  urea 
were  increased  two-fold,  hours  before  uraemia  developed.     Biermer 


TREATMENT  OF  CHRONIC  NEPHRITIS  785 

reports  an  anuria  which  lasted  two  hundred  and  twenty-two  hours 
before  uraemia  developed. 

Apo'plexy  is  probably  present  when  pressure  symptoms,  as  vomiting, 
or  slow,  tense  pulse,  complete  hemiplegia,  or  conjugate  deviation,  exist; 
it  is  rarely  completely  simulated  by  uraemia.  Meningitis,  insolation, 
or  the  coma  resulting  from  alcohol  or  opium  are  rarely  simulated; 
in  very  exceptional  instances  focal  symptoms  and  fever  may  cause 
diagnostic  error.  The  author  has  seen  a  few  cases  in  which  uraemia 
simulated  typhoid  or  sepsis  by  the  constant  high  temperature,  though 
the  autopsy  disclosed  nephritis,  and  two  cases  in  which  there  was 
no  bacteriological  evidence  of  secondary  or  terminal  infection. 

Prognosis  of  Interstitial  Nephritis. — Because  the  disease  is  insid- 
ious in  onset,  it  is  too  often  detected  only  when  the  patient  suffers 
from  cardiac  insufficiency,  beginning  uraemia,  apoplexy  or  intercurrent 
inflammations;  for  this  reason  this  incurable  malady  is  rather  seldom 
treated  in  its  early  stages.  The  clinical  course  usually  runs  five  to 
ten  years  after  albuminuria  is  found;  a  longer  duration  is  not  uncom- 
mon; a  course  of  twenty  years  is  reported  by  Senator  and  Aufrecht, 
of  twenty-three  years  by  Oppolzer  and  of  thirty  by  Rosenstein.  Much 
depends  on  the  docility  and  financial  ability  of  the  patient.  Marked 
arteriosclerosis  naturally  hastens  the  fatal  issue.  Retinitis  is  usually 
an  ominous  symptom;  in  Belt's  419  cases,  72  per  cent,  died  in  one, 
and  90  per  cent,  in  two  years.  Retinitis  increases  the  gravity  of  the 
outlook  four-fold.  Staub's  and  Gruening's  figures  are  almost  iden- 
tical. Webster,  Wert,  Hare,  Mix,  and  the  author  have  seen  cases 
which  lived  from  four  to  ten  years  after  retinitis  was  found.  Uraemia, 
pneumonia,  apoplexy,  and  other  complications  are  decidedly  unfavor- 
able. 

Treatment  of  Chronic  Nephritis,  Parenchymatous  and  Interstitial. 

— Both  forms  are  considered  together,  because  they  often  blend  (mixed 
nephritis). 

1.  Prophylaxis. — Prevention  and  treatment  of  the  cause  have  a  very 
limited  practical  application.  Irritating  foods,  excessive  eating,  all 
forms  of  intemperance,  over-work,  neglect  of  infections,  and  dyspepsia 
come  under  this  head,  but  are  usually  treated  too  late. 

2.  Rest,  Exercise. — The  kidneys  should  be  relieved  by  rest  in  the 
horizontal  posture,  because  exertion  and  even  the  erect  position,  which 
per  se  may  cause  albuminuria,  only  increase  preexisting  albuminuria. 
If  in  severe  cases  exercise  seems  advisable,  it  should  be  given  passively 
with  the  patient  in  the  recumbent  posture.  The  rest  should  be  abso- 
lute as  long  as  the  heart  is  weak,  the  urine  scanty,  or  hydrops  con- 
spicuous. The  importance  of  rest  in  bed  was  recognized  by  Bright 
and  Bartels.  When  there  is  moderate  renal  involvement,  or  in  the  inter- 
vals of  improvement,  relative  restriction  of  exercise  should  be  enforced. 
Rest  in  bed  lessens  the  amount  of  waste  products  to  be  eliminated  by 
the  kidneys  and  so  protects  the  skin  and  dilates  its  vessels  that  the 
cutaneous  functions   become  more  active   and   relieve  the   vascular 

50 


786  DISEASES  OF  THE  KIDNEY 

hypertension,  just  as  a  patient  with  a  cold  should  remain  in  bed,  in 
order  to  increase  the  activity  of  the  skin  and  promote  that  of  the 
kidneys.  The  author  has  treated  two  severe  cases  of  parenchymatous 
nephritis  by  rest  in  bed  for  a  year,  and  absolute  recovery  resulted. 
It  is  a  question  if  lying  covered  in  bed  is  not  one  of  the  reasons  why 
nephritics  pass  more  urine  at  night  than  in  the  day  time.  Fatigue, 
dampness,  and  cold  must  be  avoided;  these  indications  are  best 
carried  out  by  rest  in  bed  during  the  time  of  severe  symptoms  or  of 
acute  exacerbations,  and  by  relative  rest  and  warm  clothing  in  cases 
of  moderate  severity.  Practitioners  do  not  sufficiently  insist  on  psy- 
chical rest;  in  men  leading  a  strenuous  life,  moderate  nephritis  has 
often  decreased  and  sometimes  disappeared  when  nervous  tension 
was  relieved;  too  often  these  subjects  take  physical  exercise  or  courses 
of  training  after  they  are  already  exhausted  by  head-work;  in  any 
event  exercise  should  supplant  work  and  not  be  taken  after  hard 
nervous  strain. 

3.  Springs,  Climate.^" Cures"  at  water  resorts  have  the  general 
advantage  that  the  importance  of  diet  and  hygiene  is  often  much  im- 
pressed on  the  patient;  the  psychical  or  suggestive  element  is  also 
an  important  therapeutic  agent.  Diffuse  nephritis  (with  considerable 
parenchymatous  and  interstitial  change)  is  most  benefited.  Only 
patients  without  oedema  or  serious  heart  involvement  should  be  sent 
to  such  places  as  Poland  Springs,  Bedford  Springs,  Saratoga,  Vichy, 
or  Neuheim.  A  stay  in  the  California,  Mississippi,  or  North  Carolina 
climate  during  the  winter  at  least  will  materially  benefit. 

4.  Diet. — The  diet  must  be  non-irritative,  must  not  especially  tax 
the  kidneys  in  its  elimination,  must  not  burden  the  circulation,  and 
must  maintain  nutrition.  Disease  of  the  glomeruli  alone  may  be  com- 
pensated by  vicarious  excretion  of  water  through  the  lungs,  skin,  and 
intestines,  but  disease  of  the  tubules  whose  function  is  ehmination  of 
the  end-products  of  albuminoid  metabolism,  cannot  well  be  compen- 
sated by  other  structures,  whence  the  indication  is  for  limitation  of 
albuminous  foods  and  their  replacement  by  fats  and  carbohydrates. 
The  amount  of  albumin  lost  through  the  kidneys  is  small  and  can 
easily  be  offset  by  a  glass  or  two  of  milk  daily;  in  this  respect 
nephritis  differs  from  diabetes  in  which  the  system  is  irritated  by 
unappropriated  sugar  and  loses  a  vast  number  of  units  of  heat  and 
energy  each  day.  Albuminous  food  is  restricted  only  to  spare  irrita- 
tion of  the  excreting  renal  cells,  and  no  absolute  rule  can  be  laid  down 
for  all  cases.  Chittenden  has  recently  shown  that  we  eat  twice  as 
much  meat  as  we  need.  It  is  an  obvious  mistake  to  guage  the  severity 
of  a  nephritis  by  the  degree  of  albuminuria,  or  to  estimate  improvement 
by  the  influence  of  diet  upon  the  albuminuria  alone.  Fats  as  butter, 
olive  and  cod-liver  oils,  and  cream,  are  very  important,  because  they 
supply  energy  and  heat  units  in  place  of  the  restricted  albumin.  As 
in  diabetes,  the  restriction  of  diet  must  not  merely  concern  renal 
irritation,  but  also,  and  most  of  all,  the  maintenance  of  nutrition, 
especially  when  the  patient  suffers  from  parenchymatous  nephritis, 


TREATMENT  OF  CHRONIC  NEPHRITIS  787 

the  very  form  in  which  restriction  of  diet  is  theoretically  most  needed; 
anaemia  and  malnutrition  are  the  most  distinguishing  features  of  the 
parenchymatous  as  contrasted  with  the  interstitial  type  of  nephritis. 
The  individual  patient  must  be  considered  more  than  the  disease  per  se 
or  the  type  of  the  disease. 

The  milk  diet  is  free  of  extractives,  is  easy  of  digestion,  and  is  a  diu- 
retic. It  has  its  restrictions;  it  is  bulky,  over  four  quarts  being  neces- 
sary to  maintain  nutrition,  and  it  therefore  may  cause  dyspepsia; 
it  lacks  iron,  but  this  can  be  easily  compensated;  four  quarts  contain 
an  excess  of  about  60  per  cent,  of  proteid;  it  contains  too  much  water, 
thereby  possibly  overloading  the  blood  and  straining  the  heart;  and 
its  phosphates  and  chlorides  tax  the  kidneys.  One  to  one  and  a  half 
quarts  of  milk  with  a  pint  of  cream,  fats  and  carbohydrates  (baby  foods, 
sago,  rice,  or  potatoes),  will  meet  the  needs  of  metabolism;  and,  some- 
times over  half  of  the  phosphates  of  the  milk  can  be  precipitated  and 
kept  in  the  intestine  (and  away  from  the  blood  and  kidneys)  by  giving 
calcium  carbonate  gr.  v  to  x  with  the  milk  (von  Noorden).  It  should 
be  taken  slowly,  in  sips,  and  it  should  be  remembered  that  it  is  a  food 
and  not  a  beverage.  Milk  was  one  of  the  chief  articles  of  diet  of  the 
older  masters  in  medicine;  a  very  short  time  ago  we  heard  that  it 
contained  an  excess  of  water;  now  we  are  told  it  is  excellent  because 
it  contains  so  little  salt.     Part-truths  are  misleading. 

In  regard  to  a  meat  diet,  there  is  much  liberality  at  present,  though 
probably  the  reaction  in  favor  of  the  meat  diet  is  extreme,  as  Strubell's 
recent  experiments  demonstrate  that  a  meat  diet  promotes  uraemia. 
The  average  daily  amount  allowed  by  von  Noorden  is  three  ounces 
(100  gm.).  There  is  absolutely  no  difference  between  red  and  white 
meats,  as  to  extractives,  or  purin  bodies  (Walker  Hall,  Kaufmann, 
Mohr  and  others).  The  eating  of  some  meat  is  preferable  to  over- 
loading the  stomach  and  bowels  with  a  bulky  vegetable  diet,  save 
when  toxaemia  (uraemia)  is  imminent. 

Raw  eggs  increase  (perhaps  induce)  albuminuria;  not  more  than 
two  daily  should  be  given.  Substances  excreted  with  difficulty  include 
the  following,  according  to  von  Noorden;  urea  (in  meat),  creatinin 
(in  meat  broths,  extractives  and  to  a  less  extent  in  eggs),  urinary 
pigments  (in  haemoglobin),  hippuric  acid  (in  cranberries,  fruits  with 
pits,  prunes,  plums  and  gages),  phosphates  (in  milk)  and  inorganic 
sulphates  (in  meat) ;  uric  acid  and  alloxur  bodies,  contrary  to  general 
opinion,  are,  according  to  von  Noorden,  eliminated  readily;  (they  are 
found  in  glandular  organs, — such  as  the  thymus,  sweetbreads,  liver 
and  kidney, — in  broths,  and  according  to  Taylor,  in  coffee).  The, 
chlorides  are  especially  to  be  avoided  in  parenchymatous  nephritis 
with  oedema.  As  pointed  out  by  Widal,  Lemerre,  Javal,  Mercklen 
and  Courmont  in  1903,  administration  of  salt  (which  is  retained  in 
the  blood)  increases  the  body-weight,  induces  oedema  and  aggravates 
albuminuria, while  "dechlorination"  of  the  food  reduces  weight,  oedema, 
and  albuminuria.  Probably  the  entire  truth  is  not  yet  known ;  Rumpf 
(1905)  found  cases  with  oedema,  uraemia  and  retinitis  in  which  the 


788  DISEASES  OF  THE  KIDNEY 

chlorides  of  the  blood  were  decreased.  Irritants,  as  cheese,  relishes, 
horseradish,  onions,  rhubarb,  asparagus,  spices,  sauces,  broths,  beef- 
tea  and  alcoholics  should  be  absolutely  avoided;  tea  and  coffee  must 
be  taken  ynth  great  moderation  because  they  may  aggravate  or  pro- 
duce nephritis  (Penzoldt,  Hubach). 

5.  Water. — In  regard  to  giving  water,  the  same  extremes  of  opinion 
are  noted;  fluids  were  once  excessively  restricted,  but  more  lately 
undue  quantities  were  recommended;  von  Noorden  states  that  flooding 
the  vascular  system  with  water  overtaxes  and  damages  the  heart; 
"water  can  only  be  excreted- by  the  kidney  if  the  blood  pressure  is 
increased;  it  is  difficult  to  demonstrate  that  the  heart  is  damaged 
by  excessive  water  drinking,  but  indirectly  this  can  be  showTi,  for 
many  patients  having  weak  hearts  give  a  history  of  excessive  water 
drinking  for  long  periods  of  time;  in  such  cases  improvement  is 
frequent  if  the  ingestion  of  water  is  limited;  about  three  pints  (1,500 
c.c.)  should  be  the  average  amount."  Nevertheless  relief  of  high 
arterial  pressure  and  minor  ursemic  symptoms  may  follow  copious 
drinking  of  water. 

The  following  therapeutic  measures  are  but  symptomatic. 

6.  Diuretics. — These  are  generally  useless  and  should  be,  for  the 
most  part,  avoided.  Diuretin  is  said  to  produce  no  renal  hypersemia 
but  to  act  directly  on  the  epithelium  and,  according  to  Gruenwald,  to 
sometimes  reduce  the  albuminuria;  it  may  be  employed  and  some- 
times "^^th  success  {v.  Treatment  of  Valvular  Disease).  The  use  of 
diuretics  is  indicated  by  increase  of  hydrops,  scanty  urine,  and  immi- 
nent uraemia.  The  refrigerants  (cream  of  tartar,  5  j)  or  potassium  citrate 
(gr.  XX  to  xxx)  are  the  only  safe  diuretics ;  they  are  thought  to  abstract 
water  from  the  tissues  and  to  convert  urea,  uric  acid,  and  similar 
products  into  more  readily  excreted  substances;  they  are  apparently 
most  active  in  the  effervescent  form.  Basham's  mixture  (liq.  ferri 
et  ammonii  acetatis)  as  a  tonic  and  diuretic  should  be  given  in  doses 
of  but  1  or  2  drams.  Diuretics  which  act  through  the  circulation  will 
be  considered  below. 

7.  Hydrops. — Hydrops  necessitates  treatment  because  it  prevents 
movement,  threatens  suffocation  by  pulmonary  or  laryngeal  oedema, 
increases  the  danger  of  secondary  infections,  as  erysipelas  or  cellulitis, 
embarrasses  the  circulation  by  pressure  on  the  afferent  capillaries  and 
efferent  lymphatics  and  venules,  interferes  wdth  digestion,  and  in- 
creases the  danger  of  uraemia,  (a)  Though  cathartics  may  eliminate 
fluids  as  well  as  solids,  drastics  must  be  given  with  due  care  for  the 
digestion  and  nutrition,  pulv.  jalaps  co.  5ss  to  5j  at  night,  or  Epsom 
salts  §ss  to  j  in  the  morning.  (6)  Sweats  are  generally  given,  possibly 
less  so  of  late.  Though  the  functional  relation  between  the  skin  and 
kidneys  cannot  be  overestimated,  profuse  sweating  eliminates  fluid 
rather  than  solids.  Leube  holds  that  sweats  concentrate  the  blood 
and  predispose  to  uraemia;  he  states  that  when  a  patient  sweats  one 
quart  (1,000  c.c.)  only  7  to  15  grains  (0.5  to  1  gm.)  of  urea  are  evacuated. 
The  author  has  more  often  seen  aggravation  of  symptoms,  or  a  fatal 


TREATMENT  OF  CHRONIC  NEPHRITIS 


789 


issue  result  from  sweating,  than  relief  and  hence  prefers  the  old-fash- 
ioned full  warm  bath,  recommended  by  Osborne  and  Liebermeister, 
to  the  more -active  methods.  In  this  form  of  treatment  an  ice-bag  is 
placed  on  the  head  to  prevent  brain  congestion.  Commencing  with 
water  at  body  temperature,  this  is  raised  five  or  six  degrees.  After 
twenty  or  thirty  minutes  the  patient  is  removed  and  wrapped — with- 
out drying — in  blankets.  A  hot-air  bath  may  be  given  by  placing  a 
lamp  under  one  end  of  a  stove-pipe  which  runs  by  an  elbow  into  a 
tent  built  over  the  patient,  as  illustrated  in  the  following  cut.    Another 

FiCx.  47. 


S^ 


Sweat  bath  employed  in  nephritis. 

method  is  the  alcohol  sweat,  in  which  hot  bricks  protected  by  flannel 
are  placed  around  the  heavily  covered  patient;  equal  parts  of  alcohol 
and  water  are  poured  on  the  bricks  and  the  patient  is  covered  again; 
the  heat  produces  a  steam  vapor  which  is  tolerated  fairly  well  unless 
the  heart  is  weak,  when  fatal  collapse  may  ensue.  It  is  often  unsafe 
to  give  pilocarpine  (v.  Acute  Nephritis)  because  it  produces  profuse 
salivation,  vomiting,  diarrhoia,  syncope,  and  pulmonary  oedema,  (c) 
Mechanical  relief  by  means  of  incision  is  superior  to  all  other  measures 
which  must  first  bring  the  fluid  with  all  its  urea  and  extractives  into 
the  circulation,  with  the  ever  present  danger  of  inducing  uraemia; 
i.e.,  the  already  impure  blood  is  again  contaminated  by  the  toxic 
deposits  in  the  oedematous  tissues.  If  the  kidneys  and  other  emunc- 
tories  cannot  relieve  the  blood,  how  can  they  remove  the  additional 
refuse  in  the  anasarcous  fluid,  which  maybe  amounts  to  quarts,  and 
comes  to  the  blood  from  the  tissues  ?  The  author  has  experimented 
with  mild  cases,  making  deep  incisions,  three  inches  long,  over  the 
lower  leg  (not  over  the  malleoli  where  infection  from  the  feet  is  likely) 
whenever  the  hydrops  is  at  all  extensive.    In  testing  the  fluid  evacuated, 


790  DISEASES  OF  THE  KIDNEY 

there  has  frequently  been  0.1  to  0.2  per  cent,  urea  which  may  serve 
as  a  measure  for  other  retamed  products  of  kindred  nature;  when 
quarts  seep  out  during  the  first  twenty-four  hours,  one  is  well  justified 
in  incising  the  legs,  despite  the  slight  danger  of  occasional  infection. 
Sweats  and  drugs  never  achieve  equal  results.  Free  incision  is  ob- 
viously less  dangerous  than  punctures  or  Southey's  capillary  tubes. 

8.  The  Circulation. — Treatment  often  resolves  itself  into  the  care 
and  stimulation  of  the  heart.     Mental  excitement,  nervous  strain, 
physical  exertion,  constipation,  and  tobacco,  coffee,  alcohol,  and  ex- 
posure to  heat  must  be  avoided.     The  more  the  heart  hypertrophies 
the  better  is  the  outlook,  although  ultimate  cardiac  dilatation  is  the 
inevitable  result  of  every  hypertrophy.     In  the  uraemic  seizures,  with 
precisely  the  same  symptoms  in  other  respects,  the  heart  may  vary; 
it  may  beat  as  strongly  as  in  an  apoplexy,  or  very  weakly,     (a)  With 
cardiac  over-action  observed  early  in  ursemia,  the  angiospasm  or  the 
high  tension  must  be  corrected  by  vasodilators.     Iodides  are  beneficial 
when  there  is  no  urgency;  they  should  be  given  in  doses  of  grs.  v  to  x 
t.  i.  d. ;     iodism,    and   especially   salivation,    may   result   from   renal 
retention.     When  extreme  tension  and  imminent  uraemia  exist,  tr. 
veratri  viridi  irgv  to  x  every  half  hour  for  three  or  four  doses  may  be 
given  (though  the  author  considers  that  the  drug  is  injurious)  or  large 
doses  of  nitroglycerine,  gr.  ^o,  until  results  are  produced.    The  author 
believes  that  the  vasodilators  are  often  given  to  excess,  as  hyper- 
trophy and  increased  arterial  tension  are  less  pathological  than  com- 
pensatory conditions.     Bleeding  may  so  relieve  the  intracranial  blood 
pressure  as  to  remove  for  a  while  the  uraemia,  but  too  often  it  does  not ; 
salines  may  be  given  afterward,  either  subcutaneously  or  by  rectum; 
they  serve  as    a  "lavage  of  the  blood"  and  stimulate  the  kidneys  if 
enough  sound  tissue  be  left  to  act  upon.    Increased  intracranial  tension 
may  be  relieved  by  lumbar  puncture;    the  normal  pressure  of  120 
mm.  (as  indicated  by  the  sphygmanometer)  is  often  increased,  some- 
times to  five  or  six  hundred  mm.;    during  the  last  year  the  author  has 
seen  marked  and  sometimes  protracted  relief  in  medical  and  eclamptic 
cases;   the  headache,  vomiting,  convulsions,  and  coma  are  often  de- 
creased or  entirely   relieved.      (6)  When  the   heart  is   weak,   rapid, 
irregular,  or  galloping,  cardiac  stimulation  by  digitalis  and  strychnine 
is  indicated.    Infusion  of  digitaKs  by  mouth  may  cause  vomiting  and 
TTjij  to  V  of  the  fluid  extract  may  then  be  given  hypodermatically  or 
by  rectum.     Its  combination  with  squills  or  calomel  is  inadvisable; 
the  latter  may  cause  the  most  intense  salivation;  in  one  case  necrosis 
of  the  entire  tongue  occurred.    Cardiac  unrest,  palpitation  or  dyspnoea 
should  be  relieved  by  a  hypodermic  of  morphine,  by  application  of 
ice  to  the  heart,  or  by  champagne,  nitroglycerine,  bromides,  and  valer- 
ian.    Venesection  lessens  the  molecular  concentration  of  the  blood 
(i.e.,  its  toxicity)  and  relieves  the  laboring  heart;  infusions  act  in  the 
same  way;  an  excess  of  salt  may  be  given  (v.s.  "dechlorination")  in 
the  infusions;    when  they  are  repeated,  the  salt  should  be  left  out, 
for  it  may  produce  oedema  of  the  lungs.     Pilocarpin  and  sweats  are 


PASSIVE  CONGESTION^  OF  THE  KIDNEY  791 

distinctly  contra-indicated,  because  they  over-tax  or  fatally  depress  the 
heart.  Von  Ziemssen  gave  champagne  and  digitalis  by  mouth  as 
long  as  the  patient  could  swallow,  and  then  digitalis  by  rectum  or 
hypodermatically  and  camphor  subcutaneously. 

9.  Vomiting. — Vomiting  and  diarrhoea  are  as  often  vicarious  as 
toxsemic  and  should  not  be  checked  at  once.  Gastric  lavage  and 
colonic  flushings  are  beneficial. 

10.  Convulsions. — For  convulsions,  hypodermics  of  morphine  should 
be  given,  as  advised  by  Loomis  and  Mackenzie;  the  author  never  saw 
harm  result  from  its  use,  though  medical  opinion  is  generally  against 
it.  Chloral  (gr.  xv  every  hour  for  not  more  than  four  doses),  aids  the 
morphine,  while  bromides  generally  act  too  slowly. 

11.  Operation. — Surgical  treatment  is  still  sub  judice.  It  is  certain 
that  many  cases  of  "  decapsulated  "  kidney  were  not  genuine  nephritis, 
but  rather  albuminuria  from  floating  kidney,  or  ascending  infection. 
Again,  it  is  still  a  question  whether  chronic  nephritis  is  merely  a  renal 
disease  or  perhaps  a  result  of  a  general  condition  of  the  blood;  this 
idea  was  advanced  by  Semmola,  and  is  not  yet  disproven. 


(0).  PASSIVE  CONGESTION— INFARCTION. 
1.  Passive  Congestion. 

Venous  hypersemia  is  an  important  renal  lesion,  contrasting  with 
arterial  hypersemia,  of  which  latter  little  is  definitely  known,  though 
it  occurs  in  renal  inflammation,  left  ventricle  hypertrophy,  diabetes, 
perhaps  also  in  nervous  lesions  and  after  the  administration  of  diuretics. 

Etiology. — (a)  Among  the  chief  causes  of  general  stasis  are  cardiac 
insufficiency  from  valvular  disease,  myocarditis,  and  pulmonary  em- 
physema. (6)  Local  stasis  is  much  less  important,  and  has  scarcely 
any  part  in  renal  pathology  (Cohnheim).  Berkmann  (1859)  described 
renal  stasis  and  thrombosis  of  the  renal  veins  occurring  in  the  new- 
born or  in  nurslings  after  severe  diarrhoea;  when  unilateral,  there  is 
renal  pain,  great  albuminuria,  some  hsematuria,  swelling  of  the  kidney 
and  decreased  urine;  most  cases  of  bilateral  thrombosis  die  from 
anuria  and  ursemia.  Thrombosis  of  the  cava,  and  pressure  by  large 
tumors  may  cause  passive  congestion  in  the  renal  veins. 

Pathology. — Anatomical  changes  result  from  slowing  of  the  arterial 
flow,  lessened  arterial  pressure,  and  to  a  less  degree  from  venous 
hyperaemia,  which  changes  alter  the  integrity  of  the  secreting  renal 
structures,  notably  the  glomeruli.  In  experiments,  arterial  insuffi- 
ciency causes  initial  glomerular  alteration,  while  venous  obstruction 
causes  primary  congestion  in  the  medullary  portion. 

Early  Changes. — The  kidney  is  swollen,  dark  red  and  firm,  and  its 
stellate  veins  are  prominent.  On  section  it  expands  beyond  its  close 
fitting  capsule,  which  is  readily  stripped  off.  The  organ  is  very  vas- 
cular and  may  drip  blood.    The  glomeruli  are  seen  as  dark  red  points 


792  DISEASES  OF  THE  KIDNEY 

and  the  medullary  bloodvessels  are  clearly  defined.  Microscopically 
the  conspicuous  changes  are  hypersemia,  occasionally  with  punctate 
hemorrhages,  fatty  and  cloudy  degeneration  of  the  epithelium  of  the 
tufts  and  convoluted  tubules,  escape  of  albumin  into  them,  forming 
hyaline  casts  in  the  tubules,  and  finally  some  thickening  of  the  vessels. 

Late  Changes. — Prolonged  stasis  leads  to  greater  atrophy  of  the 
secreting  structures  and  to  increase  of  connective  tissue;  this  "cyanotic 
induration"  has  been  rather  overdrawn  in  clinical  descriptions,  but 
may  result  from  extreme  and  protracted  stasis.  The  kidney  becomes 
pale  and  firm,  the  cortex  shrinks,  the  capsule  may  become  somewhat 
adherent,  and  connective  tissue  develops  in  the  medulla.  Micro- 
scopically, fibrillar  connective  tissue,  thickening  of  Bowman's  capsule 
and  epithelial  degeneration  are  found. 

Symptoms. — Aside  from  the  causal  heart  or  other  lesion,  and  the 
signs  of  stasis  in  other  parts,  the  urinary  findings  are  of  chief  interest. 
The  urine  is  decreased,  and  its  amount  follows  directly  the  heart's 
activity.  It  is  acid,  dark,  concentrated  (specific  gravity  1,025  to  1,030) 
and  it  has  a  lateritious  sediment  of  urates  and  often  of  uric  acid  crys- 
tals. Albumin  and  globulin  are  present,  usually  in  moderate  amounts. 
Urobilin  may  be  present.  Microscopically  a  few  leukocytes,  epithelial 
cells  and  hyaline  casts  are  found;  granular  casts  are  seldom  found 
and  should  arouse  suspicion  of  nephritis;  red  cells  are  usually  con- 
sidered common,  but  Leube  insists  that  they  almost  always  indicate 
nephritis  or  infarction. 

Diagnosis. — The  urinary  findings  are  significant  in  association  with 
the  causal  lesion;  oedema  begins  in  the  legs;  the  nutmeg  liver,  dyspnoea, 
cyanosis  and  pulmonary  stasis  are  present.  The  percentage  of  albumin 
runs  parallel  with  the  strength  of  the  heart,  increasing  with  its  failure, 
or  decreasing  if  digitalis  or  strychnine  improve  its  action.  If  cardiants 
increase  the  urine,  and  if  abundant  albumin  and  casts  still  remain, 
there  is  probably  coincident  nephritis.    (See  Table  pages  796  and  797.) 

The  treatment  is  that  of  chronic  valvular  disease  (q.v.). 


2.  Infarction — Embolism. 

Though  infarction  may  rarely  occur  from  local  disease  of  the  renal 
arteries,  acute  or  chronic  valvular  disease  of  the  left  heart  is  its  pre- 
disposing cause.  Sixty-six  to  75  per  cent,  of  all  embohsms  are  renal. 
Stoppage  of  a  renal  terminal  artery  causes  the  well  known  wedge- 
shaped  ansemic  infarct  in  twenty-four  to  thirty-six  hours;  the  local 
ischsemia  causes  fatty  degeneration,  necrosis,  and  a  finely  granular  tran- 
sudation into  the  connective  tissue  and  glomeruli.  After  a  while  fibrous 
substitution  occurs  with  ultimate  shrinkage  and  deformity.  After 
repeated  infarctions,  the  irregular  "embolic  contracted  kidney"  is  seen. 
As  in  other  infarctions,  the  process  may  be  innocent  (mechanical)  or 
less  commonly  suppurative. 


AMYLOID  DEGENERATION  OF  THE  KIDNEY  793 

Symptoms. — In  most  cases  there  are  no  symptoms.  Exceptionally 
a  diagnosis  is  possible,  based  on  (1)  the  valvular  lesion;  (2)  sudden 
onset  with  fever;  chills  and  vomiting;  (3)  lumbar  pain  and  tender- 
ness, and  (4)  hsematuria  and  albuminuria. 

There  is  no  treatment. 


(D).  AMYLOID   DEGENERATION  OF  THE  KIDNEY. 

Etiology. — The  etiology  of  amyloid  kidney  is  that  of  amyloid  liver 
(q.v.);  its  three  principal  causes  are  ulcerative  tuberculosis,  protracted 
suppuration  and  inveterate  syphilis.  The  most  plausible  theory  is 
that  toxins  produce,  either  in  the  blood  or  in  the  organ  involved,  an 
albumin  which  is  deposited  in  and  about  the  bloodvessels.  Amyloid 
kidney  was  first  described  by  Rokitansky  (1842)  and  its  symptom- 
atology was  developed  by  Wilkes,  Todd  and  Traube. 

Pathology. ^ — -Amyloidosis  seldom  occurs  in  the  kidneys  without 
associated  changes  in  the  liver  and  spleen.  To  the  naked  eye  the 
kidneys  generally  appear  enlarged,  weighing  together  even  as  much 
as  26  ounces  (870  gm.,  Johnson);  when  amyloid  degeneration  or 
infiltration  is  slight,  there  may  be  no  alteration  in  size  or  weight;  in 
some  cases  the  kidneys  are  large  from  coincident  chronic  parenchy- 
matous or  small  from  interstitial  nephritis.  The  capsule  strips  readily, 
showing  a  pale,  smooth  surface.  On  section  the  cortex  is  enlarged, 
glistening,  waxy,  and  pale  and  its  edge  translucent;  the  glomeruli 
stand  out  as  glistening  points,  and  become  brown  when  treated  with 
Lugol's  solution.  Microscopically  the  amyloid  substance  can  be  seen 
clearly;  it  is  so  named  because  of  its  starch-like  reaction,  though 
chemically  it  is  an  albuminoid.  It  is  either  deposited  from  the  blood 
in  the  small  vessels,  or  more  probably  formed  in  situ,  whence  it  is 
found  especially  in  the  glomeruli,  then  in  their  afferent  vessels  and  in 
the  straight  vessels  of  the  medulla.  The  renal  interstitium  is  involved 
secondarily,  and  the  epithelial  cells  never  suffer  directly,  though  the 
membrana  propria  may  be  affected  and  the  cells  may  suffer  secondary 
compression,  degeneration  and  atrophy.  As  the  changes  indicate, 
amyloid  disease  cannot  be  classified  with  Bright's  disease,  though  their 
association  (v.i.)  is  not  uncommon. 

Sjmiptoms. — Its  symptoms  are  variable,  (a)  Urinary  symptoms 
are  exceptionally  absent  (Rosenstein  and  Litten),  The  urine  is  gen- 
erally limpid  and  increased,  but  may  be  decreased  when  amyloid 
degeneration  is  associated  with  parenchymatous,  or  greatly  increased 
when  associated  with  interstitial,  nephritis;  some  writers  place  rather 
undue  importance  upon  variability  in  its  amount.  The  specific  gravity 
is  1,010  to  1,015.  Albuminuria  is  usual,  being  absent  only  in  those 
exceptional  cases  which  invade  the  vasa  recta  and  avoid  the  glomerular 
capillaries;  albuminuria  results  from  increased  permeability  of  the 
glomerular  vessels  and  may  amount  to  1  or  2  per  cent.;  Senator  has 
remarked  that  there  is  frequently  a  large  amount  of  globulin  in  the 


794  DISEASES  OF  THE  KIDNEY 

urine.  There  is  little  or  no  change  in  the  sohds  as  a  result  of  the 
amyloid  itself;  indicanuria  is  not  infrequent.  Microscopically  hyaline 
casts  may  be  present  and  perhaps  a  few  leukocytes  and  epithelia, 
but  the  sediment  is  scanty  in  most  cases;  the  so-called  waxy  or  amy- 
loid casts  found  in  severe  nephritides  have  no  relation  to  amyloidosis 
of  the  kidney.  (6)  Cardiac  hypertrophy,  uraemia  and  retinitis  do  not 
occur  in  renal  amyloidosis,  except  when  it  is  associated  with  nephritis. 
(c)  Amyloid  degeneration  of  both  the  spleen  and  liver  and  sometimes 
also  of  the  alimentary  tract  are  associated  in  66  per  cent,  of  cases; 
these  and  the  casual  disease  are  necessary  for  diagnosis,  (d)  (Edema, 
and  anosmia  which  is  almost  an  actual  cachexia,  are  usual  in  cases  of 
diffuse  developed  amyloidosis.  Hydrops  of  the  serous  sacs,  especially 
ascites,  is  quite  common  though  less  so  than  oedema,  and  usually 
occurs  as  a  late  or  terminal  event.  Differentiation  (v.  Table  on  pages 
796  and  797.) 

Prognosis. — Amyloid  disease  is  generally  incurable,  though  as 
stated  under  amyloid  liver,  light  grades  may  recede.  Amyloid  of  the 
kidneys  in  most  cases  runs  its  course  in  a  year  or  less,  particularly 
when  associated  with  parenchymatous  nephritis.  Cases  may  endure 
for  several,  even  fifteen  years,  but  these  are  generally  complicated  by 
contracted  kidney. 

Treatment. — Treatment  consists  chiefly  of  prophylaxis;  with  mod- 
ern surgical  treatment,  amyloid  disease  is  less  common  than  formerly. 
Early  treatment  of  tuberculosis  and  syphilis  decreases  the  percentage 
of  amyloidosis;  for  the  developed  disease  there  is  no  treatment. 


(E).  MALFORMATIONS  OF  THE  KIDNEY. 
Malformations  and  Structural  Anomalies  of  the  Kidneys. 

To  malformations  and  structural  anomalies  in  general,  but  little 
clinical  importance  is  attached.  Complete  absence  or  rudimentary 
development  of  both  kidneys  occurs  only  in  unviable  infants. 

One  kidney,  usually  the  left,  may  be  absent  or  rudimentary,  whereon 
the  normal  kidney  vicariously  hypertrophies;  the  enlargement  may 
be  mistaken  for  malignant  disease,  whence  its  removal  is  fatal.  Before 
operation  it  is  imperative,  at  least  in  doubtful  cases,  that  cystoscopy 
be  employed  to  determine  the  presence  of  two  ureters  or  that  a  pre- 
liminary incision  be  made  to  ascertain  that  there  are  two  kidneys. 
Two  ureters  may  come  from  one  kidney.  Ballowitz  collected  184 
cases  in  which  one  kidney  was  lacking;  61  per  cent,  occurred  in  males 
and  in  63  per  cent,  the  left  kidney  was  lacking.  According  to  Gerard, 
unilateral  absence  of  one  kidney  is  usually  associated  with  unilateral 
malformation  of  the  internal  genitalia  but  this  is  not  true  in  unilateral 
renal  atrophy  nor  in  cases  where  two  kidneys  fuse. 

Supernumerary  kidneys,  double  kidney,  deformation  from  lacing,  or 
scoliosis,  are  of  pathological  interest  only;    15  cases  of  supernumerary 


MOVABLE  KIDNEY  795 

kidneys  are  recorded    (Graser)   and  in   two  cases  there  were  four 
kidneys. 

The  "  hofse-shoe"  kidney  (ren  arcuatus)  due  to  the  fusion  of  both 
kidneys,  is  fairly  common.  Errors  in  diagnosis  are  common  especially 
if  the  kidney  is  dislocated,  and  are  inevitable  if  the  renal  pelvis  is 
inflamed  or  dilated.  Cases  are  reported  in  which  the  ren  arcuatus 
has  been  mistaken  for  a  tumor  and  extirpated,  obviously  with  fatal 
results. 

Movable  Kidney. 

Congenital  dislocation  occurs  twice  as  frequently  in  men  as  in 
women,  and  is  usually  left-sided,  in  which  respects  it  differs  from  the 
acquired  form.  It  frequently  coincides  with  congenital  anomalies  of 
the  genitalia  and  intestines,  and  is  of  more  anatomical  than  clinical 
interest.  The  kidneys  may  lie  one  upon  the  other  (dystopia  renum 
cruciata),  of  which  Chatelin  could  collect  but  15  cases.  The  kidney 
may  lapse  into  the  pelvis.    The  ureters  are  sometimes  quite  short. 

Acquired  dislocation,  described  by  Rayer  nearly  a  century  ago,  is 
much  more  common  and  important.  It  is  variously  called  movable 
or  floating  kidney,  ren  mobilis  sen  migrans,  ectopia  renis  acquisita, 
nephroptosis. 

Etiology. — (a)  Sex;  88  per  cent,  occurs  in  women,  as  shown  in 
Kuttner's  collection  of  667  cases;  Dietl  claimed  that  women  constituted 
99  per  cent,  of  the  cases.  (6)  Age.  Most  cases  occur  between  the  twen- 
tieth and  fiftieth  years.  Comby  reports  18  and  Abt  5  cases  in  children. 
(c)  The  actual  cause  is  disputed.  The  kidney  is  supported  by  the  fat 
around  it,  the  peritoneum  in  front  of  it  and  by  its  own  bloodvessels. 
Among  the  alleged  causes  are;  atrophy  of  the  perirenal  fat;  the  presence 
of  a  mesonephron  (Gerard)  surrounding  the  kidney  to  a  variable  extent; 
weakening  of  the  abdominal  walls  by  pregnancy  and  other  causes ;  alter- 
ations in  the  intra-abdominal  pressure  by  malpositions  of  the  uterus,  e.  g., 
prolapse  (Landau) ;  pressure  exerted  by  corsets  on  the  liver  (Cruveilhier) ; 
congenital  laxness  of  the  supporting  structures,  in  connection  with 
which  Stiller  claims  that  the  tenth  rib  is  usually  "floating"  like  the 
eleventh  and  twelfth  ribs  (costa  fluctuans  decima);  tumors  of  the 
kidney,  which  drag  it  downward;  trauma  or  sudden  efforts,  as  in 
lifting.  Several  of  these  causes  are  also  thought  to  produce  enterop- 
tosis,  in  connection  with  which  floating  kidney  is  very  frequently 
observed. 

Symptoms. — Symptoms  are  absent  in  many,  probably  in  most  cases; 
they  may  date  from  the  time  when  the  physician  incautiously  remarks 
upon  the  presence  of  "a  floating  kidney."  There  are  two  main  symp- 
toms, the  subjective  pain  and  the  objective  tumor. 

Pain. — Pain  may  be  merely  a  dragging  sensation  or  may  amount 
to  severe  renal  colic,  which  is  said  to  result  from  stretching  of  the  renal 
nerves;  it  may  be  lumbar,  abdominal  or  may  shoot  toward  the  heart, 
thigh  or  sciatic  region;  it  may  occasion  intercostal  neuralgia,  even  on 


796 


DISEASES  OF  THE  KIDNEY 


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798  DISEASES  OF   THE  KIDXEY 

the  opposite  side  of  the  body.  Pain  may  be  constant  or  intermittent, 
mild  or  severe  or  hke  a  crisis  (i'.  i.). 

Objective  Kidney  Findings. — On  bimanual  examination  with  one 
hand  over  the  kidney  in  front  and  the  other  pushing  it  up  from  behind, 
the  findings  vary;  (a)  frequently  the  kidney  is  not  painful  nor  tender, 
but  palpable,  which  condition  has  no  significance  especially  in  women; 
(6)  the  kidney  may  be  movable,  descending  on  deep  inspiration^  maybe 
to  the  navel,  where  it  can  be  retained  by  pressure  during  expira- 
tion; movable  kidney  is  found  in  20  per  cent,  of  women  (Tuffier); 
(c)  the  kidney  may  be  floating  (the  most  extreme  type),  in  which  it 
may  fall  or  wander  to  the  lower  abdomen  or  pelvis.  In  76  per  cent, 
of  cases  the  right  kidney  is  involved,  in  11  per  cent,  the  left,  and  in 
13  per  cent,  both  kidneys  (Kuttner);  the  right  kidney  has  longer 
vessels,  and  the  left  renal  vein  is  more  firmly  connected  with  the 
suprarenal  vein  and  the  pancreas.  When  the  kidney  is  grasped  a 
sickening  sensation  sometimes  results  as  when  the  testicle  is  com- 
pressed.  The  tumor  is  smooth  and  is  usually  recognized  by  its  shape. 
In  rare  cases  the  pulsating  renal  vessels  are  felt  (v.  Frerichs  and  Eich- 
horst).  If  not  clearly  felt  when  the  patient  is  lying  on  the  back,  pal- 
pation is  made  in  the  standing  posture  or  with  the  patient  lying  on 
the  left  side.  Little  confidence  can  be  placed  in  percussion  along  the 
spine,  though  occasionally  tympany  can  be  found  over  the  normally 
dull  area  along  the  spine  occupied  by  the  kidney;  the  renal  dulness 
merges  with  that  of  the  liver  and  spleen  above  and  extends  outward 
2.5  inches  (6  to  7  cm.)  on  the  left  and  3.5  inches  (8  to  9  cm.)  on  the 
right  side.  In  thin  subjects  the  sinking  in  of  the  back  and  the  tumor 
in  front  may  sometimes  be  clearly  seen.  In  rare  instances  the  kidney 
may  be  found  in  a  hernial  sac. 

Other  Symptoms  and  Complications. — (a)  The  same  train  of  neur- 
asthenic, hysterical  or  hypochondriacal  symptoms  are  present  as  in 
enteroptosis ;  Tuffier  believes  that  these  symptoms  are  causal  rather 
than  sequential.  Nervous  dyspepsia  is  particularly  common.  (6) 
Dietl  (1864)  described  attacks  of  sudden  severe  pain  and  collapse 
known  as  "  Dietl' s  crises";  they  are  marked  by  fever,  chill,  vomiting, 
collapse,  severe  pain,  sometimes  with  swelling  and  tenderness  of  the 
kidney,  scanty  urine  containing  blood,  pus,  uric  acid  and  oxalates, 
and  in  some  instances  peritonitic  manifestations;  Dietl's  theory  that 
the  kidney  became  "incarcerated"  between  the  connective  tissue  and 
peritoneum  is  now  abandoned;  Gilewski  maintains  that  the  ureter 
is  twisted,  forming  acute  renal  retention  and  hydronephrosis,  and  in 
one  of  Sutton's  cases,  the  ureter  was  found  twisted  three  times.  Lan- 
dau holds  that  the  renal  vessels  suffer  torsion,  and  ]Mosler  explains  the 
crises  by  acute  nephritis,  ureteral  stoppage  or  peritonitis,  (c)  D  ilata- 
tion  of  the  stomach  is  neither  causal  or  sequential.  It  is  only  a  co- 
ordinate and  not  at  all  a  common  coincidence,  (d)  Dysmenorrhoea, 
constijpation  and  enteroptosis  are  common  complications.  Colitis 
mucosa  is  reported  by  ^Morris.  Compression  or  actual  stenosis  of  the 
intestine,  icterus,  abdominal  aneurj^sm  by  tugging  through  the  renal 


ALBUMINURIA  799 

vessels  upon  the  aorta,  compression  of  the  cava  inferior  and  adhesions 
to  the  gall-bladder  are  rare  (and  questionable)  sequences.  Albumin- 
uria may  oc^ur  periodically,  on  palpation  of  the  kidney  or  when  the 
patient  stands  (orthostatic  type). 

Diagnosis. — The  diagnosis  is  rarely  difficult.  The  finding  on  biman- 
ual examination  of  the  sensitive  kidney-shaped  movable  tumor  is  more 
important  than  the  inconstant  subjective  or  ambiguous  neurasthenic 
symptoms.  Severe  pain  may  be  confused  with  a  tabetic  crisis,  appen- 
dicitis or  the  passage  of  gall-  or  kidney-stones.  The  kidney  may 
possibly  be  mistaken  for  some  other  movable  tumor,  as  omental, 
gastric,  intestinal,  and  gall-bladder  tumors  or  corset  liver.  Morris 
has  reported  cases  in  which  an  enlarged  gall-bladder  has  been  mis- 
taken for  movable  kidney;  both  tumors  are  movable,  may  induce 
icterus  or  dyspeptic  disturbances,  and  both  may  be  attended  by  colic 
and  a  dull  (or  resonant)  note  over  the  tumor.  Doubtful  cases  are 
usually  determined  by  repeated  examinations,  perhaps  under  anaesthesia. 
Particular  reserve  is  necessary  in  the  diagnosis  of  left-sided  floating 
kidney. 

Prognosis. — Death  is  an  extremely  rare  occurrence,  though  it  may 
result  from  "incarceration"  and  peritonitis. 

Treatment. — The  patient  should  never  be  told  of  a  movable  or 
floating  kidney,  because  the  symptoms,  chiefly  the  neurasthenic,  may 
date  from  the  diagnosis,  (a)  A  rest  cure  may  develop  adipose  tissue 
and  relieve  the  nervous  symptoms.  (6)  A  well-fitted  bandage,  with 
padding  to  prevent  renal  descent,  is  excellent  in  many  cases,  (c) 
In  obstinate  and  extreme  cases,  nephrorrhaphy  or  nephropexy,  as 
recommended  by  Hahn,  is  indicated.  According  to  Czerny  and  Giess, 
82  to  85  per  cent,  are  cured.  Tuffier  gives  results  of  163  cases  as 
follows:  absolute  recovery  53  per  cent.;  improvement  30  per  cent.; 
temporary  improvement  5  per  cent.,  and  failure  12  per  cent.  Frank 
gives  the  results  of  Hahn's  clinic  as  70  to  80  per  cent,  complete  recovery, 
15  to  20  per  cent,  decidedly  improved,  and  5  to  10  per  cent,  failures; 
the  mortality  was  under  1  per  cent.  Nephrectomy  is  seldom  indicated. 
(d)  The  crises  are  treated  by  morphine,  reposition  and  later  by 
operation. 


(F).  ALBUMINURIA  AND  OTHER  ANOMALIES  OF  RENAL 

SECRETION. 

I.  Albuminuria. 

Albuminuria  was  discovered  by  Cotugno  in  1770.  It  results  (a) 
from  leakage  of  albumin  through  the  glomeruli  and  tubules  (albumin- 
uria vera,  renalis)  or  (6)  from  admixture  of  blood,  pus,  semen  or  fluid 
of  tumors  (albuminuria  spuria).  The  genuine  form  will  be  flrst 
considered,  and  the  spurious  or  accidental  form  later  under  pyuria 
and  hematuria. 


800  DISEASES  OF  THE  KIDNEY 

The  most  common  albumin  is  serum  albumin  (or  simply,  albumin) 
with  which  serum  globulin  is  frequently  associated. 

Etiology. — (a)  Its  incidence  in  the  diffuse  renal  diseases,  the  nephri- 
tides,  amyloidosis  and  passive  congestion  has  already  been  discussed. 
(6)  Blood  alterations  are  frequent  causes;  as  (i)  blood  diseases  proper 
as  anaemia,  leukaemia,  pseudoleukaemia,  pernicious  anaemia,  scurvy, 
or  purpura  in  which  the  poverty  of  the  blood  or  toxins  induce  renal 
degeneration ;  (ii)  toxaemic  states,  as  the  acute  and  chronic  infections, 
in  which  "febrile  albuminuria"  (Gerhardt)  evidences  the  renal  degen- 
eration; this  condition  borders  very  closely  on  or  merges  into  mild 
cases  of  acute  nephritis;  (iii)  diabetes,  icterus,  and  poisoning  by 
lead,  mercury,  ether,  etc.  (c)  Nervous  maladies  possibly  act  by  lower- 
ing the  local  blood  pressure,  as  epilepsy,  exophthalmic  goitre,  migraine, 
and  the  psychoses,  (d)  Affections  of  the  digestive  tract,  as  intestinal 
incarceration,  hepatic  diseases,  and  lead  colic  may  produce  albumin- 
uria, (e)  In  the  new-born,  it  was  first  noted  by  Virchow.  It  is  almost 
regular  in  the  first  week  or  ten  days  of  life  (Ruge,  Martin)  and  occurs 
with  hyaline  casts,  urates  and  epithelium.  It  is  hardly  explained  by 
change  of  metabolism  or  of  circulation  or  by  uric  acid  infarcts.  Ribbert 
holds  that  it  is  due  to  imperfect  development  of  the  glomeruli.  (/) 
Pregnancy  is  an  etiological  factor;  it  occurs  in  40  per  cent,  of  cases  in 
the  last  few  months  of  gestation  (from  increased  tax  on  the  kidneys, 
and  from  pressure)  and  in  the  same  percentage  after  delivery  (from 
effort  and  strain),  (g)  Is  there  a,  " physiological  albuminuria"  ^  Var- 
ious types  are  described,  as  Pavy's  cyclical  albuminuria,  which  appears 
and  disappears;  intermittent  albuminuria;  adolescent  albuminuria, 
in  young  anaemic  subjects,  often  with  vasomotor  disturbances;  ortho- 
static albuminuria,  also  termed  postural  or  orthotic,  which  appears 
only  when  the  subject  stands.  Some  practitioners  bring  under  this 
caption  albuminuria  after  heavy  eating,  severe  exercise,  coitus,  mental 
strain  or  cold  baths.  Certain  clinicians  as  Senator,  Bradford  and 
Grainger  Stewart,  whose  names  alone  carry  weight,  insist  that  ther9 
is  a  physiological  albuminuria,  in  which  signs  of  nephritis,  as  casts, 
or  cardiovascular  changes  are  absent.  The  author  regards  every  case 
of  albuminuria  as  pathological;  its  cause  may  be  an  insidiously  de- 
veloping nephritis,  a  receding  nephritis,  stasis,  or  maybe  "consti- 
tutional," as  Martins  calls  it,  but  it  is  always  a  sign  of  glomerular  or 
tubular  lesion  (see  Prognosis),  however  slight  it  may  be.  The  amount 
of  albumin  in  this  type  rarely  exceeds  0.4  to  0.5  pro  mille  (Senator). 

Detection. — The  urine  must  be  clear  and  acid;  if  turbid  it  should 
be  filtered  and  if  it  then  remains  turbid  it  should  be  cleared  by  shaking 
with  magnesia  usta;  it  must  be  acidulated,  if  necessary,  with  acetic 
acid;   if  very  concentrated,  dilution  with  distilled  water  is  advisable. 

1.  Boiling  Test. — A  test-tube,  two-thirds  filled  with  urine,  is  held 
by  its  lower  part  and  the  upper  layers  are  boiled.  Albumin  produces 
clouding,  which  may  also  result  from  phosphates  and  carbonates 
(dissolving  when  nitric  acid  is  added),  from  balsams  (dissolving  in 
alcohol)  and,  it  is  said,  from  urotropin  and  formaldehyde.     Nitric 


ALBUMINURIA  801 

acid  should  not  be  added  before  boiling,  for  a  soluble  acid-albumin 
may  result. 

2.  Nitric  Acid  or  Heller's  Test. — Urine,  somewhat  diluted,  is  placed  in 
a  test-tube  or  conical  glass,  and  nitric  acid  is  run  under  it  by  a  pipette. 
The  fuming  or  nitroso-nitric  acid  is  obtained  by  heating  nitric  acid  in 
which  a  small  bit  of  wood  is  placed  (part  of  the  stick  of  a  match). 
Albumin,  globulin,  mucin,  and  albumose  are  precipitated  at  once  or 
after  a  few  minutes  at  the  contact  point;  albumose  dissolves  by  heat- 
ing, the  others  do  not.     These  tests  are  very  satisfactory. 

3.  Ferrocyanide  Test. — To  'a  test-tube  half  full  of  urine,  10  drops 
of  acetic  acid  are  added,  which  may  precipitate  uric  acid,  urates, 
oleoresins  or  nucleo-albumin  (mucin).  These  are  filtered  out  and  one 
dram  (5  c.c.)  of  a  10  per  cent,  solution  of  potassium  ferrocyanide  is 
added.  A  precipitate  indicates  albumin,  globulin  or  albumose,  which 
latter  alone  dissolves  on  heating. 

4.  Acetic  Acid  and  Salt  Test. — Adding  to  the  urine  acetic  acid  to 
an  acid  reaction,  and  then  an  equal  volume  of  saturated  sodium  chloride 
solution,  precipitates  albumin  and  albumose,  but  the  latter  dissolves 
on  heating.  The  above  tests  detect  albumin  in  dilutions  as  low  as 
one  part  in  10,000. 

5.  Spiegler's  Test. — This  should  be  used  if  more  delicate  tests 
seem  necessary.  Nucleo-albumin  (mucin)  is  removed  by  adding  15 
drops  (1  c.c.)  of  dilute  acetic  acid  and  filtering.  To  the  urine  is  added 
a  quantity  of  Spiegler's  reagent  (bichloride  mercury  8,  tartaric  acid  4, 
glycerine  20,  and  distilled  water  200,)  when  albumin  or  albumose 
develop  in  the  contact  zone.  One  part  in  350,000  may  be  detected. 
Jolles'  modification:  bichloride  10,  succinic  acid  20,  sodium  chloride 
20,  and  100  parts  of  distilled  water. 

Globulin  occurs  chiefly  in  renal  congestion,  acute  and  chronic  ne- 
phritis and  amyloid  degeneration.  It  dissolves  in  an  excess  of  acetic 
acid.  It  is  precipitated  by  boiling.  Flocculi  of  globulin  are  thrown 
down,  when  2  drops  of  dilute  acetic  acid  are  added  to  50  c.c.  (1.6 
ounces)  of  filtered  urine  diluted  10  times  with  distilled  water. 

Nucleo-alhumiji  (formerly  called  mucin)  occurs  in  acute  desquamative 
nephritis,  icterus,  poisonings  causing  necrosis  of  the  renal  cells,  and 
regularly  in  catarrh  of  the  urinary  passages.  It  is  precipitated  by 
boiling  and  by  acetic  acid,  and  unlike  globulin,  does  not  dissolve  in 
an  excess  of  acetic  acid.  Shreds  of  mucus,  voided  with  colic,  have 
been  observed  by  von  Jaksch  and  Baumueller;  the  condition  seems 
analogous  to  colica  mucosa  and  spasmodic  asthma. 

Peptone  or  albumose  is  of  httle  clinical  importance;  the  terms  include 
albumins  which  do  not  coagulate  by  heat.  When  the  urine  is  boiled, 
the  albumin  is  precipitated  and  filtered  out.  Albumose  in  the  filtrate 
causes  clouding  and  precipitation  on  cooling.  What  Kiihne  once  called 
peptone  is  now  termed  albumose.  (a)  Bence  Jones'  albumose  is 
rather  a  peculiar  albumin  than  an  albumose;  described  by  him  in  1848, 
albumosuria  has  also  been  called  Kahler's  disease.  Muffat  (1905) 
collected  38  cases.    Its  significance  is  uncertain;    it  has  been  found 

51 


802  DISEASES  OF  THE  KIDNEY 

in  osteomalacia,  and  in  multiple  myeloma.  It  is  precipitated  by  cold 
nitric  acid,  dissolves  on  heating  and  reappears  on  cooling.  (6)  Albumose 
may  be  found  in  various  acute  infections  (meningitis,  rheumatism, 
pneumonia),  septicaemia,  peritonitis,  empysema,  in  acute  yellow  atrophy, 
etc.  Albumin  in  the  kidney,  bladder  or  urinal,  may  be  converted  by 
pepsin  into  albumose. 

Diagnosis. — The  diagnosis  of  albuminuria  is  easily  determined  by 
the  tests  enumerated;  blood  or  pus  may  give  albumin  reactions  (acci- 
dental or  spurious  albuminuria,  v.  hsematuria  and  pyuria). 

Prognosis  and  Treatment. — These  are  etiological.  The  outlook  is 
not  favorable,  though  not  necessarily  bad.  In  seemingly  "physio- 
logical" cases,  the  condition  of  the  heart  must  be  w^atched  and  casts 
carefully  looked  for.  In  youth  and  adolescence  albuminuria  may  be 
"physiological"  but  in  middle  and  later  life  it  is  usually  nephritic. 
Shattuck  and  Osier,  however,  hold  that  "albuminuria  is  more  com- 
mon apart  from  Bright's  disease  than  is  commonly  supposed,  that  it 
increases  with  advancing  years,  and  that  a  small  amount  of  albumin 
with  finely  granular  casts  of  small  diameter  in  those  over  fifty  years 
of  age  is  of  small  importance."  Life  insurance  companies  are  sus- 
picious of  "physiological"  albuminuria,  for  figures  show  that  it 
entails  a  death-rate  which  is  double  the  average.  Albuminuria  is  said 
to  result  solely  from  high  arterial  tension,  but  the  author  is  inclined 
to  regard  these  cases  as  incipient  arteriosclerosis  or  contracted  kidney. 
Hawkins  reported  a  case  in  which  albuminuria  lasted,  without  any 
unhappy  symptoms,  for  forty-three  years  after  Bright  had  given  a 
fatal  prognosis. 

II.  Hsematuria. 

Etiology. — Like  albuminuria,  blood  in  the  urine  (hsematuria)  is 
only  a  symptom,  and  is  observed  in  many  diverse  conditions,  (a)  It 
is  most  frequently  renal,  (i)  General  conditions  may  cause  it,  as  intoxi- 
cations (by  quinine,  carbohc  acid,  turpentine,  or  salicyHc  acid),  acute 
infections  (of  which  malaria  is  the  most  common,  acute  exanthemata, 
particularly  the  hemorrhagic  types)  or  the  blood  diseases  (purpura, 
scurvy,  haemophilia,  leukaemia,  and  the  anaemias),  (ii)  Other  causes 
are  local  renal  conditions,  as  trauma,  vascular  maladies  (thrombosis  of 
renal  veins,  infarct,  aneurysm,  varicose  veins,  arteriosclerosis,  and 
rarely  passive  congestion);  inflammation  (acute,  chronic,  hemorrhagic 
and  suppurative  nephritis) ;  rarely  amyloidosis  or  parasites  (distoma, 
filaria,  nephrophages  sanguinarius) ;  tumors;  tuberculosis;  calculous 
ulceration  and  pyelitis;  sometimes  floating  and  cystic  kidney,  especially 
after  bimanual  examination,  (iii)  Haematuria  may  be  "idiopathic" 
or  "essential."  In  some  very  rare  cases  it  occurs  in  "apparently 
healthy  kidneys,"  to  which  phrase  there  has  been  a  just  objection. 
This  condition  has  been  called  renal  epistaxis  (Gull),  angioneurotic 
haematuria  (Klemperer)  and  renal  purpura  (Senator).  M.  L.  Harris 
collected  18  cases  in  which  simple  nephrotomy  gave  relief.     In  Esh- 


HEMATURIA  803 

ner's  series  of  48  cases  of  unilateral  renal  hsematuria,  nothing  was 
found  at  operation  in  33  per  cent.,  floating  kidney  existed  in  12.5 
per  cent.,  renal  pelvic  changes  in  19  per  cent.,  and  diffuse  renal  dis- 
ease in  24  per  cent.  (6)  It  may  occur  from  lesions  in  the  lower  urinary 
tract.  The  chief  types  of  these  lesions  are  stone  in  the  ureter  or  bladder; 
ruptured  varices  anywhere  in  the  urinary  tract;  stasis  from  liver  cir- 
rhosis or  thrombosis  of  the  iliac  veins;  inflammation  (pyelitis,  ureteritis, 
cystitis,  prostatitis  or  urethritis,  sometimes  called  "Russian  gonor- 
rhoea");  and  tuberculous,  malignant,  or  other  ulcerations. 

Symptoms  and  Diagnosis. — ^Hemorrhage  may  be  macro-  or  micro- 
scopic. The  urine  may  be  clear  or  turbid,  red  or  smoke-colored.  It 
is  usually  acid,  but  may  be  alkaline  when  there  is  copious  vesical 
hemorrhage.  The  color  is  generally  brighter  when  the  urine  is  alkaline. 
Confusion  mth  concentrated,  icteric,  carbolic,  fuchsin,  haematoxylin 
and  senna  urines  is  possible.  The  presence  of  blood  is  positively 
determined  (a)  by  the  microscope;  the  red  cells  remain  normal  for  a 
long  time  in  acid  urine,  but  may  become  pale  in  dilute,  and  mulberry- 
form  in  concentrated  urine;  (6)  by  the  spectroscope;  if  no  red  cells 
are  present  with  positive  spectroscopic  findings,  it  indicates  hsemo- 
globinuria  (v.i.);  and  (c)  by  chemical  tests  as  Heller's  (boiling  with 
caustic  potash,  which  throws  down  a  rusty  phosphate  and  hsematin 
precipitate),  the  Almen  guaiac  test  (acidulating  the  urine  and  adding 
old  turpentine  and  fresh  guaiac)  which  gives  a  blue  reaction  (also 
produced  by  pus)  and  Teichmann's  test  (treating  the  sediment  with 
sodium  chloride  and  glacial  acetic  acid,  slightly  heating  and  cooling, 
when  hsemin  crystals  are  deposited). 

Diagnosis  of  the  origin  and  cause  of  hsematuria  is  often  most  diffi- 
cult, (a)  In  cases  of  renal  origin,  the  blood  is  intimately  mixed  with 
the  urine,  as  much  with  that  first  voided  as  with  the  last.  The  color 
is  often  that  of  water  in  which  raw  meat  has  soaked  ("beef  water" 
color).  Clots  are  infrequent  in  renal  hsematuria,  save  from  trauma, 
tumors,  aneurysm,  or  varicosities.  The  red  cells  are  seldom  seen  in 
rouleaux-form  and,  according  to  Gumprecht,  are  fragmented  from 
action  of  the  renal  cells  on  the  red  disks ;  this  does  not  occur  in  vesical 
hemorrhage.  If  there  is  some  other  renal  lesion,  as  nephritis,  there 
is  more  albumin  than  the  red  cells  would  account  for,  and  albumin 
is  present  after  careful  filtering;  according  to  Goldberg,  if  there  is 
albumin  with  a  red  cell  count,  by  the  hsemocytometer,  of  less  than 
3,000  per  c.mm.,  the  albuminuria  is  renal.  Blood  casts,  granular  casts 
and  renal  epithelium  are  indicative  of  renal  origin.  (6)  Hsematuria 
originating  in  the  pelvis  and  ureter  is  more  often  marked  by  clots  and 
possibly  by  caudate  epithelium,  (c)  Blood  from  the  bladder  is  more 
apt  to  clot,  and  the  last  part  voided  is  more  bloody  than  the  first. 
Other  symptoms,  as  tenesmus,  alkaline  urine  reaction  and  perhaps 
pieces  of  tumor,  very  often  indicate  a  vesical  origin,  (d)  Urethral 
hemorrhage  stains  most  deeply  the  first  urine  voided.  It  must  always 
be  borne  in  mind  that  the  presence  of  blood  may  be  accidental,  from 
menstrual  or  other  contamination. 


804  DISEASES  OF   THE  KIDNEY 

Treatment. — The  treatment  is  etiological  and  can  be  but  briefly 
considered  here.  Rest,  and  sometimes  morphine,  are  indicated.  Aside 
from  the  local  treatment  of  vesical  disease,  urethritis,  and  calculous 
pyelitis,  tannic  acid,  ergotin  and  calcium  chloride  aa  gr.  v.  t.i.d.  may 
check  bleeding.  Aromatic  sulphuric  acid  ttjjx,  well  diluted,  is  also 
given  at  three-hour  intervals.  Adrenalin  solution  1  to  1,000  parts, 
given  by  the  catheter,  may  stop  vesical  hemorrhage.  In  essential 
(idiopathic)  renal  hsematuria,  simple  incision  of  the  kidney  is  fre- 
quently efficacious. 

III.  Haemoglobinuria. 

This  is  haemoglobin  in  the  urine  without  hsematuria.  Though  first 
described  by  Dressier  (1854),  most  of  the  early  accounts  are  English, 
from  Harley,  Dickinson,  Gull,  and  Pavy.  There  are  two  main  groups, 
the  toxic,  and  the  paroxysmal. 

Etiology. — ^The  toxic  form  may  follow  transfusion  of  blood,  injec- 
tions of  glycerin,  poisons  organic  and  inorganic,  as  potassium  chlorate, 
phosphorus,  mercury,  quinine  (in  malarial  cases  only),  carbolic  acid, 
carbon  monoxide;  it  may  also  result  from  burns,  severe  icterus,  pernic- 
ious anaemia,  scarlatina,  acute  nephritis,  Winckel's  disease  in  the  new- 
born, and  sestivo-autumnal  malaria.  The  paroxysmal  form,  of  which 
Oilman  Thompson  recently  collected  206  cases,  occurs  largely  in 
England,  France,  and  Germany;  96  per  cent,  are  males,  chiefly 
between  thirty  and  forty  years  of  age.  Cold  seems  to  be  the  most 
important  factor;  exercise,  excesses,  or  menstruation,  may  precipitate 
an  attack.  It  is  observed  in  horses  after  cold  and  exertion;  hsemo- 
globinsemia  and  hsemoglobinuria  appear,  paresis  of  the  hind  legs 
develops  and  death  results  from  disturbed  circulation  and  respiration. 
In  cattle  and  sheep  epidemics  occur  in  which  Babes,  Krogius  and 
others  have  found  a  hsematococcus.  In  the  majority  of  human  cases, 
hsemoglobinuria  is  preceded  by  hsemoglobinsemia,  though  genuine 
renal  hsemoglobinuria  (without  haemoglobin semia)  seems  to  occur  in 
some  cases  of  nephritis  and  from  certain  intestinal  nematodes. 

S37inptoms. — Symptoms  occur  only  after  destruction  of  at  least 
one-sixth  of  the  blood.  After  a  chill,  fever,  lumbar  pain  which  radiates 
to  the  legs,  cyanosis,  oppression  and  gastric  symptoms,  the  urinary 
findings  appear;  the  urine  is  dark  and  contains  clumps  of  blood 
pigment,  casts  and  epithelium  stained  with  haemoglobin  or  methaemo- 
globin,  albumin  and  sometimes  oxalate  of  lime  crystals  and  bile 
pigments.  In  most  cases  the  haemoglobin  is  already  altered  to  meth- 
aemoglobin,  as  shown  by  the  spectroscope.  There  may  be  slight 
jaundice,  oedema,  or  urticaria.  The  blood  shows  increased  coagulability 
and  diminution  in  the  number  and  redness  of  the  red  cells,  which  do 
not  form  in  rouleaux.  There  may  be  swelling  of  the  liver  and  spleen 
from  haemoglobin  deposits  in  them.  The  paroxysm  lasts  one-half  to 
several  hours,  and  in  the  interval  the  general  health  is  fairly  good. 


HEMOGLOBINURIA  805 

The  course  is  most  chronic.     No  death  is  known  from  the  paroxysm 
itself  and  very  rarely  from  the  disease. 

Treatment. — Prophylaxis  in  regard  to  colds  and  exertion  may 
modify  the  attacks.  Chovstek  was  able  to  abort  attacks  by  giving 
nitrite  of  amyl  inhalations.  Warmth  may  modify  the  seizure.  Mercury, 
iodides,  adrenalin,  calcium  chloride  and  thyroid  extract  have  been 
recommended. 

IV.  Pyuria. 

Etiology. — (a)  Pus  may  originate  from  'pyelitis  or  pyelonephritis. 
It  may  occur  intermittently  as  in  pyonephrosis,  or  continuously  as  in 
calculous  or  tuberculous  inflammations.  The  urine  is  usually  acid  in 
tubercle  and  colon  bacilli  infections;  it  is  acid  in  proteus  and  in  some 
infections  ascending  from  the  bladder;  the  staphylococcus  may  render 
the  urine  less  acid  than  normal  or  alkaline  {v.i.  pyelitis).  (6)  Pyuria 
may  result  from  cystitis;  the  urine  may  be  acid  or  alkaline  and  con- 
tains ropy  mucus,  and  triple  phosphates.  Pus  is  seen  especially  in 
the  last  part  of  the  urine  voided,  (c)  Urethral  pyuria,  which  is  usually 
gonorrhoeal,  is  greatest  in  that  part  of  the  urine  first  evacuated,  {d) 
Accidental  pyuria  occurs  from  leucorrhoeal  contamination,  and  is 
easily  excluded  by  examining  specimens  obtained  by  catheterization. 
Under  this  heading  may  be  brought  pyuria  from  rupture  into  the 
urinary  tract  of  appendicular,  pelvic,  or  psoas  abscesses;  much  pus 
is  voided  at  first,  but  it  gradually  lessens  and  disappears. 

Symptoms. — The  urine  in  pyuria  is  yellow-white,  turbid,  and  has 
a  sediment  which  is  sometimes  ropy  and  becomes  gelatinous  when 
caustic  potash  is  added.  The  reaction  is  often  ammoniacal,  due  to 
germs  decomposing  the  urea,  as  the  proteus,  and  some  staphylococci. 
Gas  may  be  voided  with  the  urine  (pneumaturia) ;  this  occurs  partic- 
ularly in  enterovesical  fistula  and  in  diabetic  cystitis.  Alkalinity 
was  formerly  thought  characteristic  of  cystitic,  and  acidity,  of  pyelitic, 
pyuria,  but  this  distinction  has  been  dropped.  Albumin  is  found, 
the  amount  of  which  in  simple  pyuria  corresponds  with  the  number 
of  pus  cells.  Albuminuria  may  be  absent  if  there  are  not  over  6-800 
pus  cells  to  the  c.mm.  It  is  less  or  may  disappear  when  the  urine 
is  filtered.  The  question  often  arises  whether  the  albuminuria  is 
simply  accidental  or  is  combined  with  renal  albuminuria,  for  instance, 
whether  cystitis  is  coincident  with  contracted  kidney.  Besides  con- 
sideration of  the  amount  of  urine,  its  specific  gravity,  cardiovascular 
findings,  and  retinitis,  besides  washing  out  the  bladder  and  ureteral 
catheterization,  a  study  of  the  characteristics  of  the  pus  cells  and 
their  number  is  of  great  value.  Senator  has  shown  that  leukocytes 
coming  from  the  renal  parenchyma  in  nephritis,  are  mononuclear,  and 
those  from  suppuration  are  polymorphonuclear.  Goldberg  found  that 
when  (a)  there  is  more  than  1  part  pro  mille  of  albumin  in  the  clear 
urine,  as  determined  by  Esbach's  method,  with  (6)  50,000  pus  cells 
per  c.mm.  as  determined  by  the  haemocytometer,  the  albumin  is  partly 


806  DISEASES  OF  THE  KIDNEY 

renal.  De  Lint  altered  Goldberg's  method  by  gravimetric  determina- 
tion of  the  albumin;  when  there  is  one  part  pro  mille  of  albumin, 
and  less  than  7,000  pus  cells,  the  albuminuria  is  (a)  renal,  and  (b) 
it  results  from  the  pus  alone,  when  there  are  more  than  40,000  pus 
cells;  no  conclusion  can  be  drawn  if  the  pus  cells  number  between 
7,000  and  40,000  per  c.mm. 

Treatment. — The  treatment  is  that  of  the  fundamental  tuberculosis, 
calculus,  pyelitis,  cystitis,  etc.  Salol  and  urotropin  aa  gr.  x  t.i.d.  are 
excellent_antiseptics  for  the  urinary  tract. 


V.  Chyluria. 

The  endemic  or  tropical  form  is  found  in  Florida  and  South  Carolina, 
Brazil,  the  Antilles,  Zanzibar,  India,  Egypt,  and  Japan.  It  is  due  to 
the  filaria,  which  was  first  recognized  by  Bancroft  and  Leurs  in  the 
scrotum,  by  Wucherer  in  the  urine,  and  by  Lewis  in  the  blood.  It 
enters  the  body  by  the  drinking  water  in  which  mosquitoes  have  on 
their  death  liberated  filaria  embryos.  The  filaria  plug  the  lymph  vessels, 
which  dilate  and  rupture  in  the  kidneys,  as  proven  by  Mackenzie's 
autopsy.  They  are  found  in  the  blood  at  night  (see  Animal  Para- 
sites). The  non-tropical  forms  are  not  understood  and  have  rarely 
occurred  in  Europeans  who  have  never  been  in  the  tropics;  the  rare 
autopsies  have  shown  no  marked  renal  alteration  (Roberts). 

The  urine  resembles  chyle,  is  weakly  acid  or  neutral  in  reaction, 
may  present  a  fatty,  creamy  surface  and  contains  2  to  10  per  cent, 
albumin  (serum  albumin,  globulin  or  albumose),  cholestearin,  lecithin, 
fat,  and  stearic  and  palmitic  acids.  Its  specific  gravity  is  normal. 
Sugar  is  seldom  found.  Microscopic  findings  are  fat  globules,  leuko- 
cytes, sometimes  red  disks  and  sometimes  the  filaria  parasites,  usually 
in  the  fibrin  clots,  which  sometimes  form  and  occasion  dysuria. 
Casts  are  never  found.  Chyluria  is  often  intermittent;  it  occurs  espe- 
cially at  night  and  may  be  initiated  by  exercise  and  changes  of  posture. 
In  some  cases  there  is  considerable  free  fat  in  the  blood  (liposmia). 
Its  course  is  chronic,  covering  months  to  years.  Recovery  is  the  rule, 
though  death  may  occur  from  anaemia  and  marasmus.  Treatment 
is  unsatisfactory.  Potassium  picronitrate  gr.  ^  t.i.d.  is  said  to  accelerate 
recovery.  Prophylaxis  regarding  drinking  water  must  be  considered 
in  the  tropics. 

VI.  Lipuria. 

Lipuria  or  adiposuria  is  symptomatic  of  (a)  lifoemia,  or  fat  in  the 
blood.  The  clearest  instance  is  after  bone  fractures,  contusions  of 
the  liver,  or  after  delivery  in  which  fat  enters  the  blood  from  the  pelvic 
cellular  tissue.  Fatty  foods,  as  cod-liver  oil;  acute  yellow  atrophy; 
diabetes ;  diseases  of  the  pancreas,  and  various  poisonings  and  tumors 


LITHURIA  807 

are  possible  causes,     (b)  It  is  also  symptomatic  of  renal  lesions  (from 
fatty  epithelial  cells,  degenerated  tumors,  or  fatty  pus  cells). 

Under  the  microsco'pe  small  fat  globules  are  seen,  which  stain  black 
with  osmic  acid,  or  red  with  the  alcanna  test.  The  fat  may  be  saponi- 
fied by  alkalis,  emulsified  by  albumins  or  dissolved  by  alcohol,  ether, 
xylol  or  chloroform.  Lipuria  is  often  simulated  by  bacteria  or  phos- 
phates, or  by  oil  from  catheters,  suppositories,  or  greasy  urinals. 


VII.  Phosphaturia. 

Phosphoric  acid  is  chiefly  excreted  in  combination,  mostly  with 
sodium  and  potassium  forming  the  alkaline  phosphates,  and  with 
calcium  and  magnesium  forming  the  earthy  phosphates.  The  sodium 
exceeds  the  potassium,  and  the  calcium  is  in  excess  of  the  magnesium 
salts.  Phosphoric  acid  is  chiefly  derived  from  the  food,  but  some  is 
derived  from  decomposition  of  lecithin,  nuclein,  and  protagon.  It 
averages  thirty  to  forty-five  grains  (2  to  3  gm.)  daily.  Amounts  over 
one  dram  (4  to  5  gm.)  or  alteration  of  the  normal  relation  of  the  phos- 
phorus to  the  nitrogen  (17  or  20  to  100)  are  pathological.  An  exces- 
sive deposit  which  occurs  in  dyspepsia,  is  not  synonymous  with  an  actual 
increase.  Phosphaturia  may  be  observed  in  neurasthenia,  pulmonary 
tuberculosis,  diabetes  (largely  from  the  diet),  acute  yellow  atrophy, 
leukaemia,  and  in  ansemia.  As  much  as  two  drams  (7  to  9  gm.)  daily 
have  been  reported  by  Teissier  and  Ralfe,  who  termed  the  condition 
diabetes  phosphaticus.  Earthy  phosphates  may  cloud  the  last  part  of 
the  urine,  which  is  mistaken  by  the  laity  for  "  spermatorrhoea."  The 
addition  of  an  acid  rapidly  clears  the  urine.  The  diet,  recommended 
for  this  condition,  consists  of  meat,  fish,  bread,  potatoes  and  apples. 
Coffee,  nux  vomica,  arsenic,  cod-liver  oil,  or  ammonium  benzoate  (gr. 
x  to  XXX  t.i.d.)  are  also  given. 

VIII.  Lithuria. 

No  subject  has  occasioned  more  clinical  absurdities  than  uric  acid. 
It  normally  bears  to  urea  a  ratio  of  1  to  70.  Futcher  has  found  a  ratio 
in  gout  of  1  to  300  or  500  (v.  Gout).  It  is  deposited  in  larger  amounts 
than  normal  when  the  urine  is  very  acid  and  the  mineral  salts  or  pig- 
ments are  decreased.  An  increased  precipitation  is  far  more  common 
than  an  absolutely  increased  excretion  of  uric  acid.  The  sediment 
is  clearly  seen  as  red  granules  resembling  red  pepper.  Uric  acid 
combines  chiefly  with  ammonium  and  sodium,  and  less  with  potassium, 
lithium  and  calcium,  which  form  urates  (sedimentum  lateritium)  of  the 
pink  or  "brick-dust"  color  so  frequently  seen  in  febrile  urine  and 
urine  of  high  specific  gravity  or  of  excessive  acidity.  They  are  soluble 
when  heated  and  precipitate  on  cooling. 


808  DISEASES  OF  THE  KIDNEY 


IX.  Oxaluria. 


Oxalates,  first  detected  by  Donne  (1838)  in  the  normal  urine,  amount 
to  less  than  10  mg.  daily.  Quantities  larger  than  this  daily  are  path- 
ological. Helen  Baldwin,  in  Herter's  laboratory,  decided  that  they  are 
not  formed  during  normal  metabolism;  they  must  then  be  taken  in 
vdih  the  food.  The  actual  conditions  of  oxaluria  are  in  doubt.  It 
has  been  observed  in  gout,  emphysema,  dyspepsias  (especially  in  hyper- 
acidity and  increased  intestinal  putrefaction),  neurasthenia,  icterus 
and  diabetes.  Oxalates  occur  as  octahedral  and  dumb-bell  crystals, 
which  according  to  Klemperer  occur  in  50  per  cent,  of  renal  calculi. 
Cantani  and  others  maintain  that  oxaluria  is  associated  with  nervous 
depression,  irritability,  lassitude,  hypochondriasis,  lumbar  pain,  sweats 
and  nervous  dyspepsia,  though  the  concensus  of  opinion  is  against  any 
definite  clinical  picture  or  diathesis.  Klemperer  has  recently  ad\T[sed  a 
diet  of  meat,  fat  and  vegetables  (except  spinach  and  cabbage);  he 
excludes  milk  and  eggs  and  administers  magnesium  sulphate  5ss  once 
daily.  Nitromuriatic  acid  rrj^ij  with  tincture  of  nux  vomica  rrj^x  is  an 
old  and  excellent  empirical  treatment. 

X.  Indicanuria. 

Potassium  indoxylsulphate  is  usually  present  in  small  amounts  in 
normal  urine.  It  is  colorless  as  a  rule,  but  may  be  voided  blue  or 
actually  give  a  violet  hue  in  alkaline  urine.  When  acid  or  some 
oxydizing  substance  is  added,  it  decomposes  and  frees  indigo.  The 
steps  in  its  production  are  as  follows:  the  action  of  the  pancreatic 
juice  on  albumins  produces  indol,  wliich  is  absorbed,  ox}"dized  in 
the  tissues  to  indoxyl  and  unites  with  potassium  sulphate  to  form 
potassium  indoxylsulphate.  Its  absence  in  some  pancreatic  diseases 
has  been  discussed.  It  has  been  rarely  found  in  urinary  calculi.  It 
is  increased  in  cachexise  in  which  albuminous  substances  are  decom- 
posed, in  intestinal  obstruction  particularly  of  the  small  bowel,  and  in 
carcinoma,  suppuration,  and  peritonitis.  Boiling  the  urine  and  adding 
nitric  acid,  as  in  the  ring  test  for  albumin,  gives  a  blue  ring;  adding 
half  a  dram  (2  c.c.)  of  chloroform  and  shaking  brings  down  the  ^-iolet 
or  blue-stained  chloroform. 


XI.  Other  Anomalies. 

Alkaptonuria  was  discovered  by  Baedecker.  It  is  a  crystalline, 
aromatic  body,  probably  derived  from  proteid  decomposition,  whose 
chief  clinical  significance  is  that  (a)  it  reduces  Fehling's  solution, 
thereby  simulating  glycosuria,  though  it  is  negative  to  polarization  and 
fermentation  tests;  and  (b)  it  imparts  to  the  urine  a  dark  brown  color, 


PYELITIS  809 

usually  apparent  only  after  it  has  stood  or  after  caustic  potash  is  added 
(alkaptonuria  by  derivation  means  urine  which  "absorbs"  an  "alkali" 
freely).  Adding  a  drop  of  a  very  dilute  solution  of  ferric  chloride 
causes  a  dull  green  color  which  at  once  disappears.  It  is  said  to  be 
homogentisic  or  uroleucinic  acid.  Sometimes  it  occurs  as  a  familial 
affection.  Garrod  collected  40  cases,  73  per  cent,  of  which  were 
males;  in  32  congenital  cases,  19  of  them  occurred  in  7  families.  Vir- 
chow  (1866)  described  a  case  of  ochronosis,  a  discoloration  of  the 
cartilages  and  hgaments.  Osier  described  2  cases  associated  with 
alkaptonuria,  making  in  all  9  cases  in  the  literature;  it  may  occur 
with  pigmentation  of  the  face,  chronic  arthritis  and  deformation  of  the 
lumbar  vertebrae. 

Hydrochinoyi,  from  carbolic  acid  poisoning,  may  cause  a  somewhat 
similar  discoloration. 

HcBmato 'porphyrinuria,  discovered  by  Hoppe-Seyler,  imparts  a  dark 
color  to  the  urine.  It  occurs  in  pulmonary  tuberculosis,  rheumatism, 
intestinal  hemorrhage,  sulphonal  and  lead-poisoning,  etc.  Hsemato- 
porphyrin  resembles  hsematin,  save  that  it  contains  no  iron. 

Acetonuria  is  of  clinical  importance,  chiefly  in  diabetes  (q.v.). 

For  fuller  details  the  reader  may  consult  works  on  clinical  diagnosis, 
such  as  the  recent  treatises  by  Simon,  Emerson  and  others. 


(G).  PYELITIS— PYELONEPHRITIS— SUPPURATIVE  NEPHRITIS. 

Pyelitis. 

Pyelitis  and  pyelonephritis  are  inflammations  of  the  pelvis,  and  pelvis 
and  kidney  respectively.    They  were  first  described  by  Rayer. 

Etiology. — Pyelitis  is  almost  invariably  mycotic.  The  kidneys 
usually  eliminate  bacteria  without  injury  to  their  structure  but  when 
the  general  vitality  or  the  local  resistance  of  the  kidneys  is  lowered, 
inflammation  of  the  pelvis  or  of  the  kidney  may  result.  Various 
bacteria  (v.i.,  Suppurative  Nephritis)  may  be  found,  including  the 
tubercle  bacillus  and  other  organisms,  (a)  Foreign  bodies,  as  large, 
hard,  or  sharp  calculi,  less  often  cancer  or  tubercle,  and  still  more  rarely 
parasites,  promote  infection.  (6)  Ascending  injections  from  the  lower 
urinary  tract  are  peculiarly  dangerous  when  associated  with  urinary 
obstructions,  as  urethral  stricture,  hypertrophied  prostate,  or  perhaps 
the  pressure  of  a  pregnant  uterus.  When  the  bacteria  which  produce 
cystitis  cause  decomposition  of  urea,  the  ammonia  evolved  acts  as  an 
additional  eroding  factor.  According  to  Rosving,  certain  streptococci 
act  in  this  way,  but  not  the  tubercle  or  colon  organisms.  Infection 
usually  ascends  from  cystitis  along  the  ureters,  producing  ureteritis, 
then  pyelitis  and  perhaps  a  pyelonephritis,  but  it  may  reach  the  kidney 
along  the  lymph  vessels,  the  microbes  entering  through  erosions  in 
the  vesical  mucosa.  James  Goodhart  has  shown  that  50  per  cent,  of 
cases  with  obstruction  to  the  flow  of  urine  die  of  renal  suppuration. 


810  DISEASES  OF  THE  KIDNEY 

(c)  Infection  may  be  hoBmatogenous  as  in  typhoid,  the  exanthemata,  or 
in  the  intestinal  catarrhs  of  infancy,  (d)  Less  common  factors  in- 
clude traumatism,  extension  by  contiguity  from  neighboring  inflam- 
mations, as  pyelonephritis  (pyelonephritis  is  usually  an  ascending 
process,  in  which  the  kidney  is  secondarily  involved,  and  only  rarely 
is  it  a  process  descending  from  the  kidney  to  the  pelvis),  toxic  factors, 
as  acrid,  irritating  diuretics  such  as  turpentine,  and  hemorrhagic 
diseases,  as  black  measles  or  scurvy;  cold,  venous  stasis,  and  diabetes 
are  somewhat  predisposing  factors ;  arteriosclerosis  promotes  the  form 
of  pyelitis  described  by  Ollivier,  which  is  attended  by  hemorrhage 
and  the  formation  of  fibrin  coagula.  Pyelitis  is  most  prevalent  in 
males  and  in  adults. 

Pathology. — Pyelitis  may  be  acute  or  chronic;  solitary  or  combined 
with  cystitis;  catarrhal,  suppurative  or  ulcerative;  unilateral  or  less 
often  bilateral.  Acute  catarrhal  forms  present  all  the  characters  of 
mucous  membrane  inflammation,  as  redness,  oedema,  desquamation, 
formation  of  mucopus  and  minute  ecchymoses.  Chronic  forms  show 
grayish  to  reddish-brown  pigmentation  and  thickening.  In  any  form, 
croupous  or  diphtheritic  inflammation  or  even  gangrene  may  develop. 
Urates  and  triple  phosphates  may  precipitate.  Small  cysts  may  form 
in  the  pelvis  or  ureter;  this  is  caused  by  retention  or  perhaps  by 
sporozoa;  the  small  lymph  nodes  may  enlarge,  and  in  rare  cases  the 
epithelium  may  hypertrophy  and  thicken,  causing  cholesteatoma 
(v.i.,  issues). 

Sjnnptoms. — (a)  There  are  no  certain  symptoms  in  the  rare  cases 
in  which  a  suppurative  nephritis  descends  to  the  pelvis,  (b)  In  the 
ascending  type,  early  vesical  symptoms  antedate  and  often  obscure 
the  pyelitis,  (c)  The  symptoms  are  most  clear  in  primary  pyelitis  from 
calculus  or  from  acute  hsematogenous  infection. 

Pyuria  is  the  chief  symptom.  The  amount  of  pus  is  usually  pro- 
portionate to  the  albumin  (v.  Pyuria).  Its  amount  varies  as  well  as 
its  constancy;  when  the  ureter  is  obstructed,  pyuria  is  suspended,  and 
when  the  obstruction  is  removed  the  pus  escapes  in  increased  amounts. 
Polyuria  and  a  low  specific  gravity  are  usual  in  chronic  cases;  the 
urine  may  be  doubled  or  tripled  in  amount,  simulating  diabetes 
insipidus;  polyuria  results  from  decreased  absorption  of  water  from 
the  medullary  portion  or  from  compensatory  hypertrophy  of  the 
sound  kidney,  or  sometimes  of  the  heart.  In  acute  cases  the  urine  is 
decreased.  There  may  be  other  urinary  findings.  The  urine  is 
usually  acid  but  quite  often  alkaline  (from  coincident  or  causal  cystitis, 
or  from  bacteria  decomposing  the  urea).  It  is  often  cloudy.  It  is 
true  that  large,  caudate,  club-like  epithelial  cells,  often  overlapping 
each  other  like  shingles,  are  present  in  moderately  severe  pyelitis, 
but  they  may  occur,  though  less  frequently,  in  ureteritis  and  cystitis. 
When  pyelitis  extends  to  the  papillse  or  higher  (pyelonephritis),  cylin- 
drical plugs  of  pus  ceils,  epithelium,  but  chiefly  of  cocci,  are  seen 
(Fischl).  Red  cells  (calculus),  triple  phosphate  or  uric  acid  crystals, 
fibrin  (croupous  or  diphtheritic  pyelitis),  and  various  bacteria  (perhaps 


PYELITIS  811 

tubercle  bacilli)  may  occur.  Pain  over  the  kidney  is  usually  dull, 
but  in  acute  cases  may  suggest  stone.  There  is  a  desire — probably 
reflex — to  urinate  frequently;  this  symptom  may  lead  to  an  erroneous 
diagnosis  of  cystitis.  Fever  and  rigors  are  not  uncommon,  especially 
in  severe  calculous  or  tuberculous  types  or  those  invading  the  kidney 
substance.  Temperature  is  sometimes  sudden  and  high  ("irritative") 
and  at  other  times  is  intermittent  from  septic  absorption. 

Complications. — (a)  There  may  be  extension  to  the  renal  substance 
{'pyelonephritis)  and  it  may  be  reduced  to  a  pulpy  inspissated  and  even 
calcified  mass.  (6)  Prolonged  inflammation  may  lead  to  fibrosis  of 
the  kidney  (Ackermann,  Albarran);  this  is  known  as  the  "ascending 
contracted  kidney."  (c)  Plugging  of  the  ureter  may  occasion  distention 
of  the  pelvis  by  retained  urine  {hydronephrosis)  or  pus  {pyonephrosis) , 
both  of  which  conditions  will  be  described  below,  {d)  Anuria,  de- 
scribed by  Morgagni  and  later  by  Israel,  is  occasioned  by  reflex  sup- 
pression of  the  sound  kidney,  or  by  extensive  lesions  in  both  kidneys. 
{e)  Amyloidosis  may  be  a  complication.  (/)  Intoxication  may  occur 
by  bacterial  toxins  and  renal  inadequacy.  The  condition  resembles 
uraemia  in  some  respects,  but  oedema,  retinitis,  and  convulsions  are 
absent.  Senator  described  a  dyspnoea  like  that  of  diabetic  coma. 
Treitz  and  v.  Jaksch  believe  that  intoxication  results  from  absorption 
of  ammonia  {ammonioemia)  from  decomposed  urea,  {g)  Perforation 
outward  causes  the  paranephritic  abscess  {v.i.).  In  some  cases  an 
interesting  condition  called  "spinal  paraplegia"  has  been  described; 
though  it  was  once  considered  reflex,  it  probably  results  from  an 
ascending  neuritis. 

Prognosis. — The  prognosis  is  influenced  by  the  basic  infection 
(whether  simple,  tuberculous,  or  calculous)  and  by  the  comphcations 
as  described.  In  acute  cases  the  outlook  is  generally  good.  Chronic 
cases  without  much  necrosis  may  last  many  years  and  may  even  recover. 

Diagnosis. — -Much  depends  on  careful  analysis  of  pyviria  {q.v.). 
Cystitis  may  be  confused  with  as  well  as  combined  with  pyelitis.  Their 
differentiation  is  often  difficult  from  examination  of  the  urine  alone; 
the  albumin  and  pus  correspond  in  both,  and  possibly  there  is  rather 
more  albumin  in  pyelitis;  no  absolute  reliance  can  be  placed  on  the 
reaction,  acidity,  or  alkalinity  occurring  in  either  condition,  though 
pyelitic  urine  is  probably  more  often  acid.  The  tailed,  clubbed,  or 
shingle-like  epithelia  are  more  common  in  pyelitis,  though  not  pathog- 
nomonic. Von  Bergmann's  method  consisted  of  thorough  vesical 
irrigation  and  then  gentle  compression  of  the  suspected  kidney  to 
force  into  the  bladder,  and  thence  into  the  catheter,  pus  or  cells; 
pain  over  the  kidney  and  extending  downward  is  significant;  the 
only  certain  method  is  cystoscopy  and  ureteral  catheterization.  In 
nephritis  the  urine  contains  more  albumin  than  is  explained  by  the 
pus,  though  the  amount  may  be  slight  in  interstitial  nephritis;  the 
leukocytes  are  mononuclear  and  the  presence  of  casts,  cardiovascular 
changes,  and  the  results  of  cryoscopy  are  usually  decisive. 


812  DISEASES  OF  THE  KIDNEY 

Treatment. — Prophylaxis  involves  care  in  the  use  of  catheters,  or 
irritating  diuretics,  the  expectant  treatment  of  gonorrhoea,  etc. 
Water,  milk  and  mineral  waters  should  be  used  freely  to  flush  out  the 
urinary  tract.  Pain  is  relieved  by  hot  applications  to  the  kidney, 
and  by  giving  five  grains  of  powdered  nutmeg;  opium  is  seldom 
indicated.  For  pyuria,  salol  and  urotropin  aa  gr.  x  p.c.  are  most 
efficient;  the  salol  somewhat  influences  the  pain.  Methylene  blue 
gr.  j  to  ij,  t.i.d.  may  be  also  given,  but  digestive  disturbances  must  be 
watched  for.  Potassium  chlorate  gr.  x  to  xx  t.i.d.  may  lessen  am- 
moniacal  fermentation  but  may  cause  intoxication.  These  remedies 
are  superior  to  lead  acetate,  sandal  oil,  or  turpentine.  Surgical  inter- 
ference may  be  necessary  when  ureteral  drainage  is  incomplete.  Ne- 
phrotomy is  the  best  operation,  nephrectomy  being  seldom  indicated. 


Suppurative  Nephritis. 

Its  etiology  is  partly  that  of  pyelitis.  The  microorganisms  encoun- 
tered are  the  staphylo-,  strepto-  and  pneumococcus,Bacilluscoli,  gono- 
coccus,  proteus,  typhoid  and  tubercle  bacillus,  and  actinomyces.  (a) 
The  embolic  form  results  from  suppurative  processes  elsewhere  and 
represents  merely  one  phase  of  septicopyemia  of  more  pathological 
than  clinical  interest.  The  suppurative  foci  are  nearly  always  bilateral 
and  are  chiefly  cortical;  the  glomeruli  are  filled  with  microorganisms 
and,  as  the  foci  enlarge,  they  show  as  yellowish  areas  through  the 
cortex;  some  deposits  may  also  occur  in  the  medulla;  the  kidneys 
are  enlarged  and  lax.  Clinically,  pyuria,  hsematuria  and  cylindruria 
are  seldom  seen,  and  a  diagnosis  can  seldom  be  made;  anuria  or  olig- 
uria may  result  from  multiple  glomerular  involvement,  (b)  The 
ascending  type  is  essentially  a  cystopyelonephritis,  which  has  been 
already  described,  and  forms  the  so-called  "surgical  kidney";  infec- 
tion and  urinary  obstruction  are  its  usual  antecedents;  pyuria,  poly- 
uria and  albuminuria  its  usual  symptoms;  and  suppuration  in  the 
medullary  rays  its  usual  anatomical  evidence;  very  rarely  necrotic 
renal  tissue  is  evacuated,  (c)  Suppuration  of  the  kidney  may  result 
from  its  invasion  by  contiguity  from  adjacent  pus  foci,  as  appendicular, 
peri-uterine  or  vertebral  foci;  much  pus  may  be  voided  at  once  with 
later  gradual  cessation  of  the  pyuria. 

The  diagnosis  is  always  uncertain,  save  when  sequestra  come  away, 
the  prognosis  always  ominous  and  the  treatment  always  expectant 
and  surgical. 

(H).   PERINEPHRIC  ABSCESS. 

A  distinction  is  sometimes  made  between  perinephritis,  inflammation 
of  the  fibrous  capsule,  and  paranephritis,  inflammation  (suppuration) 
of  the  fatty  capsule  and  surrounding  tissue. 


PERINEPHRIC  ABSCESS  813 

Etiology. — (a)  The  most  common  cause  is  suppurative  disease  of 
the  kidney,  as  pyehtis,  pyelonephritis,  pyonephrosis  (v.i.),  and  tuber- 
culosis, froBi  which  extension  occurs  by  actual  rupture  or  along  the 
blood  or  lymph  vessels.  (6)  Extension  by  contiguity  may  occur  from 
vertebral  caries,  appendicular,  pelvic  or  pancreatic  suppuration,  liver 
abscess,  cholecystitis  or  even  from  the  lungs  and  pleura,  (c)  It  may 
result  from  trauma  plus  infection,  {d)  The  so-called  idiopathic  cases, 
once  attributed  to  cold,  are  probably  embolic.  Most  cases  occur  in 
persons  between  thirty  and  forty  years  of  age,  and  70  per  cent,  occurs 
in  males. 

Symptoms. — (a)  The  onset  is  acute,  with  a  rigor  and  sudden  tem- 
perature in  the  embolic  (so-called  primary)  cases,  but  it  is  insidious 
in  the  secondary  group.  (6)  Fever  of  a  continuous  or  remittent  type 
is  usual,  though  it  may  be  absent  in  some  cases,  i.  e.,  absence  of  fever 
does  not  exclude  suppuration,  (c)  Fain  and  tenderness  are  experienced 
over  one  kidney,  somewhat  more  often  over  the  right  than  the  left. 
Sometimes,  though  seldom  without  coincident  involvement  of  the 
kidney  itself,  pain  shoots  along  the  ureter  to  the  pubes  or  thigh.  To 
relieve  tension  the  patient  frequently  lies  on  the  back  with  the  knee 
-flexed  and  the  thigh  rotated  outward.  It  may  be  here  remarked, 
though  we  are  discussing  suppuration  about  the  kidney  (paranephritis) 
that  pain  may  arise  from  simple  inflammation  of  the  fibrous  capsule 
(perinephritis);  this  is  relieved  by  simple  nephrotomy,  id)  Local 
findings  may  be  marked  or  absent.  In  some  patients  there  are  lumbar 
oedema,  redness  and  swelling.  The  physical  signs  anteriorly  are  seldom 
marked,  as  suppuration  usually  occurs  behind  the  kidney.  The  sur- 
geon finds  at  operation  a  diffuse  phlegmon,  and  less  often  diffuse 
serous  infiltration  or  circumscribed  abscess;  the  pus  may  be  odorless; 
it  may  smell  of  urine  when  the  abscess  has  arisen  from  perforation 
outward  of  a  pyelitic  lesion ;  a  faecal  odor  results  from  infection  (with- 
out perforation)  from  the  bowel  or  from  appendicular  abscess.  Ne- 
crotic fat  and  sometimes  altered  blood  are  voided,  (e)  The  urine  is 
negative,  unless  there  are  (i)  a  pyelitic  origin  and  (ii)  rupture  of  the 
abscess  into  the  urinary  tract.  (/)  The  chief  complication  is  rupture, 
which  occurs  in  about  a  quarter  of  the  cases;  in  15  per  cent,  it  occurs 
upward  (Kiister),  into  the  lungs  and  pleura,  and  in  8  per  cent,  it  is 
downward,  chiefly  into  the  intestine.  Burrowing  to  the  peritoneum, 
groin,  pelvis,  or  perineum  may  follow;  according  to  Gerota,  it  occurs 
along  the  ureter  toward  the  pelvis,  when  the  abscess  is  anterior  to 
the  renal  fascia  and  toward  the  lumbar  region  or  iliac  fossa  when  the 
abscess  is  behind  the  fascia.  Amyloidosis  may  result  from  neglected 
or  obscure  cases  of  paranephritis.  Serous  pleurisy,  subcutaneous 
emphysema,  compression  of  the  portal  vein,  icterus,  and  septictemia 
may  result. 

The  course  averages  two  to  four  weeks,  though  a  longer  duration 
is  not  uncommon. 

Diagnosis. — Diagnosis  depends  on  (a)  local  pain,  (b)  oedema  or 
swelling,  (c)  fever  and  (d)  exploratory  aspiration.    Lumbago  causes  no 


814  DISEASES  OF  THE  KIDXEY 

serious  confusion.  Other  affections  causing  occasional  confusion  are 
psoas  abscess,  appendicular  abscess  behind  the  kidney  or  rupture 
downward  of  empyema  though  these  are  more  often  etiological  factors 
than  separate  questions  for  differentiation. 

The  only  treatment  is  incision  and  drainage.    In  the  cases  of  Schede 
and  Schmieden  complete  recovery  occurred  in  73  per  cent. 


(I).  HYDRONEPHROSIS. 

Definition. — Hydronephrosis  is  a  sac-like  dilatation  of  the  pelvis 
and  calices,  with  accumulation  in  it  of  a  watery  fluid;  obstruction  to 
the  urinary  flow  is  its  cause  and  atrophy  of  the  renal  substance  is  its 
result.    It  was  first  described  by  Tulp  (1674)  and  named  by  Rayer. 

Etiology  and  Pathology. — There  are  two  forms,  the  congenital  and 
acquired,  (a)  The  congenital  form  is  most  often  due  to  anomalies 
in  the  ureters;  these  include  atresia,  stenosis,  valve  formations,  twists, 
compression  by  peritonitic  bands,  vestiges  of  INIiiller's  or  Gartner's 
ducts,  abnormal  bloodvessels,  imperfect  insertion  into  the  bladder,  or 
insertion  too  high  into  the  pehis,  in  the  lower  part  of  which  the 
urine  accumulates.  Of  the  latter  form  the  author  has  seen  two  cases 
in  young  men  and  J.  B.  ]\Iurphy  has  observed  four  others.  When 
there  are  double  ureters,  one  may  end  blindly  in  the  bladder  wall,  and 
dilating,  may  compress  its  fellow  of  the  same  side.  In  some  few  cases 
no  obstruction  is  apparent.  Hydronephrosis  may  occasion  dystocia 
and  is  rather  commonly  associated  with  other  congenital  malformations; 
65  per  cent,  of  congenital  cases  are  bilateral  (Roberts),  (b)  The 
acquired  form  may  be  bilateral  or  unilateral,  depending  on  its  cause. 
This  may,  in  rare  cases,  be  in  the  kidney  itself  (Rayer,  Chopart,  Chris- 
tian Fenger),  producing  partial  hydronephrosis.  Enumeration  of  all 
possible  causes  of  obstruction  is  unnecessary;  one  or  both  ureters 
may  be  compressed  by  malignant  pelvic  growths,  as  uterine  cancer, 
and  this  in  part  explains  the  large  proportion  (67  per  cent.,  Xewmann) 
of  bilateral  hydronephrosis  which  occurs  in  autopsy  figures;  in  clin- 
ical cases  62  per  cent,  are  unilateral  (Roberts).  Ureteral  obstruction 
may  arise  from  calculus,  tumors,  tuberculous  detritus,  ulceration, 
cicatrization,  floating  kidney,  or  rarely  clots  from  trauma  or  parasites. 
Large  sacs  are  usually  caused  by  affections  of  the  ureter.  Other 
possible  types  are  obstruction  from  urethral  stricture,  enlarged  pro- 
state or  more  rarely  phimosis  and  atresia  of  the  hymen. 

As  Cohnheim  contended,  a  slow  development  -v^dth  intermissions  is 
more  potent  in  the  production  of  large  sacs  than  is  acute  obstruction, 
for  slow  compression  permits  more  continued  renal  secretion. 

The  results  of  urinary  accumulation  are  (a)  distention  of  the  pelvis, 
(6)  flattening  of  the  papillae,  (c)  atrophy  of  the  renal  tissue,  though  some 
normal  tissue  usually  remains,  and  id)  the  formation  of  a  fibrous  sac. 

Symptoms.— The  chief  finding  is  a  fluctuating  renal  tumor,  (a)  It 
is  located  at  first  in  the  renal  region  but  later  assumes  an  abdominal 


HYDRONEPHROSIS  815 

importance.  (6)  Its  size  varies  in  different  cases,  being  largest  when 
the  ureter  is  obstructed  and  in  slowly  developing  cases  it  may  be  as 
large  as  the  head,  and  even  simulate  ascites;  Peter  Frank  mentions 
a  case  in  which  it  contained  60  quarts,  (c)  It  may  in  the  same  case 
vary  from  time  to  time;  this  is  known  as  intermittent  hydronephrosis , 
and  its  cliief  causes  are  valve  formation,  stenosis  or  abnormal  insertion 
of  the  ureter  into  the  pelvis.  The  amount  of  urine  is  (i)  normal  from 
hypertrophy  of  the  sound  kidney,  (ii)  decreased  in  bilateral  disease 
or  from  increased  pressure  in  the  diseased  kidney,  lessening  the  secre- 
tion from  the  sound  kidney  (Israel);  or  (iii),when  the  sac  evacuates, 
suddenly  very  abundant,  and  then  the  tumor  disappears;  this  point 
is  often  volunteered  in  the  patient's  history.  The  author  has  seen 
hsematuria  and  renal  colic  occur  in  hydronephrosis  due  to  an  insertion 
of  the  ureter  high  up  in  the  renal  pelvis,  (d)  Its  form,  on  bimanual 
palpation,  is  irregularly  oval;  in  moderately  severe  cases  the  kidney 
itself  may  be  palpated  as  well  as  its  irregularly  protuberant  calices. 
(e)  Sometimes  the  dilated  ureter  can  also  be  felt.  (/)  The  ballottement 
renal  is  a  repercussion  shock  obtained  by  tapping  the  tumor  with 
fingers  of  one  hand,  while  the  other  is  spread  broadly  over  it.  (g) 
Small  tumors  are  covered  by  the  colon,  which  imparts  a  modified  tym- 
panitic note  on  percussion.  Distention  of  the  colon  by  air  or  gas  brings 
out  tympany  over  the  tumor.  Very  large  sacs  push  the  colon  aside. 
The  ren  saccatus  may  develop  in  a  floating  or  horseshoe  kidney,  (h) 
Its  contents  are  albumin,  paralbumin,  mucus,  urea,  uric  acid  and  other 
urinary  constituents,  which  are  usually  absorbed  only  after  a  long  time. 
Diagnostic  puncture  is  not  always  safe,  (i)  Sometimes  it  is  tender 
from  tension  of  the  capsule;  pain  may  also  arise  from  torsion  of  the 
ureter,  (j)  Complications  include  rupture,  infection  (pyonephrosis), 
left  ventricle  hypertrophy,  and  anuria  or  uraemia  if  both  kidneys  are 
implicated. 

Diagnosis. — Diagnosis  is  quite  easy  (a)  by  recognizing  the  cause, 
if  possible,  as  stone  or  tumor;  (6)  by  careful  bimanual  palpation  and 
(c)  by  cystoscopic  proof  that  urine  does  not  flow  from  one  ureter. 
Differentiation  concerns  especially — 

1.  The  Exclusion  of  Other  Renal  Tumors. — -(a)  Pyonephrosis,  a  dilata- 
tion of  the  pelvis  and  calices  by  purulent  fluid  (instead  of  water-like 
fluid  as  in  hydronephrosis),  is  caused  by  obstruction  plus  infection 
(especially  from  pyelitis  with  obstruction).  It  occasions  the  same 
kind  of  tumor  as  to  location  and  physical  examination,  but  presents 
some  other  features;  it  is  generally  smaller  and  more  irregular  than 
hydronephrosis ;  its  walls  are  thicker  and  more  tender,  for  infection 
is  superimposed  on  obstruction;  there  is  more  renal  necrosis;  systemic 
septic  symptoms  prevail;  its  contents  are  pus,  pulpy  detritus,  triple 
phosphates,  bacteria,  disorganized  blood,  fat,  cholestearin,  foetid  am- 
monium compounds  and  even  gas.  Puncture  is  always  dangerous, 
in  doubtful  cases  more  so  than  operation.  Its  prognosis  also  is  clearly 
more  unfavorable,      (6)   Cystic  kidneys   (q.v.)  are  very  difficult    (or 


816  DISEASES  OF  THE  KIDXEY 

impossible)  to  differentiate,  (c)  ^Malignant  renal  growths,  and  (d) 
echinococcus,  T\'ill  receive  consideration  below. 

2.  Other  Abdominal  Tumors. —  (a)  Ovarian  tumor  is  connected  vdih 
the  uterus,  grows  upward,  and  may  be  associated  with  changes  in 
the  mammary  glands  and  genital  functions.  Ovarian  tumor  with  a 
long  pedicle  may  deceive,  but  it  pushes  the  caecum  backward.  The 
dulness  is  greater,  though  in  large  renal  sacs  the  colon  is  pushed  aside. 
The  slight  respiratory  excursion  and  hallottement  in  hydronephrosis  is 
of  quite  secondary  diagnostic  value.  Confusion  is  very  likely  to  occur 
when  hydronephrosis  develops  in  a  floating  kidney.  Exploratory 
puncture  is  an  unsafe  procedure;  when  made,  the  fluid  from  ovarian 
cysts  shows  a  high  specific  gravity  (1,020);  much  paralbumin  is 
present,  also  cylindrical  epithelium,  colloid  or  chocolate-colored  ma- 
terial and  of  course  no  urea.  Under  narcosis  the  entire  hand  may  be 
introduced  into  the  rectum  or  colon  to  determine  the  point  of  origin 
of  the  tumor,  though  this  method  is  severe,  and  is  seldom  necessary. 
(6)  Ascites  and  'pregnancy  are  readily  differentiated,  (c)  Encapsulated 
peritonitis  may  be  harder,  but  the  urinary  conditions  and  sac-like 
distention  are  usually  decisive,  (d)  Splenic  and  hepatic  tumors  are 
more  flat  on  percussion,  encroach  more  upon  the  lungs  and  are  above 
or  anterior  to  the  gas-distended  colon.  In  a  renal  growth  a  furrow 
and  tympanitic  loop  of  bowel  may  lie  between  it  and  the  liver  or  spleen. 

Prognosis. — The  prognosis  is  generally  unfavorable,  as  the  cause 
is  often  inaccessible  or  the  process  well  advanced.  The  prognosis. is 
better  in  cases  of  renal  stone  than  in  cancer  or  in  the  generally  inviable 
congenital  forms.    The  course  is  often  protracted  and  intermittent. 

Treatment.— Treatment  is  surgical.  Nephrotomy  is  indicated, 
while  nephrectomy  is  generally  considered  bad  surgery  since  Ayrer 
and  others  have  shown  that  some  sound  renal  tissue  nearly  always 
remains.  For  the  same  reason  ligature  of  the  renal  vessels  should  be 
avoided  (Nicolai).  The  mortality  resulting  from  nephrectomy  for 
hydronephrosis  is  5.7  per  cent.,  for  pyonephrosis  15.3  per  cent.  (Schmie- 
den); Rosving  reports  0  per  cent,  and  19  per  cent,  mortality  in 
his  cases  of  nephrotomy  for  hydro-  and  pyonephrosis,  respectively; 
34  per  cent,  of  his  cases  recovered  completely,  27  per  cent,  recovered 
though  with  fistula,  and  secondary  operation  was  necessary  in  20  per 
cent.  Fenger  advised  conservative  operations,  especially  in  partial 
hydronephrosis.  Reference  should  be  made  to  surgical  treatises  for 
details  of  operations  on  the  ureter,  excision  of  the  pehic  sac,  etc. 
Caspar  and  Klimmel  maintain  that  the  phloridzin  and  cryoscopic 
tests  are  of  great  value  in  determining  which  side  is  involved,  by  test- 
ing the  urine  obtained  from  each  ureter  by  ureteral  catheterization; 
Israel  has  a  very  different  opinion,  as  has  Rosving,  who  prefers  to 
cut  down  on  both  kidneys  before  extirpating  either  one. 


RENAL  CALCULUS  (NEPHROLITHIASIS)  817 


(J).  RENAL  CALCULUS  (NEPHROLITHIASIS). 

Etiology. — Stone  in  the  kidney  or  its  pelvis  results  from  deposition 
therein  of  the  solid  constituents  of  the  urine.  It  is  probable  that  stone 
formation  is  due  to  bacteria.  The  kidneys  usually  eliminate  bacteria 
without  changes  to  themselves,  but  sometimes  bacteria,  especially  the 
colon  bacillus  (Schmorl),  form  the  nucleus  of  stones.  Ebstein,  Moritz, 
Mendelsohn  and  others  have  shown  that  an  albuminous  cement  sub- 
stance is  found  even  in  very  slight  urinary  deposits  or  renal  sand. 
Renal  stone  has  been  known  since  the  time  of  Hippocrates. 

The  predisposing  factors  are  obscure,  (a)  A  sedentary  life  and  over- 
indulgence in  food  and  alcohol  are  apparently  predisposing  factors. 
Galen  noted  the  coincidence  of  gout  and  renal  calculus.  Stones  are 
said  to  be  uncommon  in  very  active  persons.  (6)  Most  cases  occur 
in  persons  between  thirty  and  sixty  years  of  age,  though  they  may 
develop  in  early  youth  or  old  age,  in  which  extremes  of  life  vesical 
calculus  is  more  common,  (c)  Seventy-five  per  cent,  of  cases  are  in 
males.  Stones  are  passed  more  easily,  and,  therefore  are  possibly  less 
often  detected,  in  women,  (d)  Renal  calculus  occurs  most  frequently 
in  Asia  and  there  are  certain  foci,  more  of  them  in  Europe  than  in 
America,  where  it  is  particularly  frequent,  as  central  Russia,  Holland, 
Italy,  Altenberg,  Munich,  Hungary,  Scotland,  west  France  and  south- 
east England,  (e)  Other  possible  factors  are  heredity,  which  is  espe- 
cially a  factor  in  formation  of  uric  acid  and  cystin  calculi;  paraplegia, 
(Miiller  reported  10  cases  of  spinal  fracture  with  calculus  formation); 
and  foreign  bodies  in  the  renal  pelvis,  as  blood  clots  from  trauma, 
and  such  parasites  as  the  distoma.  The  older  classification  of  primary 
and  secondary  calculus  has  been  abandoned. 

Chemistry  and  Pathology. — According  to  their  size,  these  urinary 
deposits  are  spoken  of  as  sand,  gravel  or  stones;  sand  and  gravel 
nearly  always  consist  of  uric  acid  or  its  salts.  They  may  range  from 
the  size  of  a  pea  to  that  of  a  hazel-nut.  The  heaviest  recorded  stones 
weighed  nineteen  and  thirty-six  ounces.  Though  they  are  most  often 
round,  oval  or  cylindrical,  they  may  be  dendritic  or  coral-shaped. 
Sometimes  they  are  facetted,  A  number  of  them  may  exist,  perhaps 
15  or  20;  in  rare  cases  1,000  to  2,000  may  be  found,  (a)  The  stone 
caused  by  uric  acid  and  urates  (described  first  by  Scheele,  1776)  is 
the  most  common  form,  constituting  66  per  cent,  of  renal  stones.  It 
is  hard,  smooth  or  slightly  uneven,  sometimes  facetted  or  lamellated, 
and  consists  of  uric  acid,  ammonium  and  sodium  urates,  urinary 
pigment,  and  a  small  amount  of  xanthin.  Its  broken  surface  is  amor- 
phous. Its  color  is  yellow,  red,  or  brown,  depending  on  the  amount 
of  urinary  pigment.  It  may  contain  some  oxalates  and  phosphates. 
Under  the  microscope  needles  are  seen.  Uratic  calculi  turn  carmine 
red  on  adding  nitric  acid  and  ammonia.  They  dissolve  in  caustic 
potash.  They  are  deposited  in  acid  urine,  but  the  exact  reason  for 
this  is  not  known;   the  normal  sodium  urate  may  lose  part  or  all  of 

52 


818  DISEASES  OF  THE  KIDNEY 

its  sodium  by  action  of  the  alkaline  phosphates,  so  that  free  uric  acid, 
and  the  less  soluble  bi-  and  quadriurates  are  formed;  Roberts  and 
Klemperer  consider  a  decrease  of  the  urinary  pigments  of  great  im- 
portance; disturbed  metabolism  or  indigestion  may  occasion  uratic 
deposits,  though  little  is  known  of  the  "uric  diathesis."  (b)  Oxalate 
stories  (Fouccoy  and  Vauquelin)  are  next  in  frequency;  Klemperer 
holds  that  oxalates  occur  in  even  50  per  cent,  of  cases.  They  are  very 
hard,  rough,  warty  or  prickly  (the  mulberry  calculus) ;  for  this  reason 
they  cause  more  pain  and  hsematuria  than  the  uratic  stones  and  are 
more  often  removed  surgically.  They  are  usually  single  and  gray, 
but  may  be  dark-colored  from  the  bleeding  they  induce.  Lamellation 
is  never  observed.  Uric  acid,  calcium  carbonate  or  xanthin  may  also 
enter  into  their  composition.  No  effervescence  occurs  on  adding 
acetic  acid,  unless  carbonates  are  also  present.  They  dissolve  in 
mineral  acids,  and  oxalate  of  lime  crystals  gradually  precipitate  on 
the  addition  of  ammonia.  Oxalates  precipitate  from  acid  urine,  (c) 
Phosjphatic  calculi  (Bergmann)  are  formed  in  alkaUne  or  neutral 
urine.  They  are  usually  calcium  salts,  but  if  the  urine  is  ammoniacal, 
triple  phosphates  may  be  formed.  iVdmixture  of  bacteria,  calcium 
carbonate  and  xanthin  may  be  noted;  phosphatic  stones  are  small, 
soft  and  clay-colored.  They  are  infrequent  and  usually  only  form  a 
coating  to  calculi  of  other  composition,  (d)  Other  jorms  are  rare. 
Calculi  of  (i)  calcium  carbonate,  and  more  rarely  ammonium  or  magne- 
sium carbonate,  may  occur  in  the  aged,  though  rarely  in  man  compared 
with  their  frequency  in  cattle;  they  are  white  and  dissolve  with  effer- 
vescence in  mineral  acids,  (ii)  Cystin  calculi  (Wollaston)  are  smooth, 
yellow,  and  waxy;  they  never  exceed  the  size  of  a  pea,  are  soluble  in 
acids  and  alkalies  and  deposit  hexagonal  crystals  when  dissolved  in 
acetic  acid  and  ammonia.  Only  60  cases  are  reported  (Riegler,  1904). 
(iii)  Xanthin  stones  (Marcet)  occur  almost  exclusively  in  children; 
only  10  cases  are  recorded;  they  are  smooth,  yellow  or  brown,  dis- 
solve in  nitric  acid,  and  on  evaporation  leave  a  residue  which  turns 
red  on  adding  caustic  potash,  (iv)  Only  3  cases  of  indigo  stones  are 
on  record,  (v)  The  fatty  stones  (urostealiths)  described  by  Heller 
probably  do  not  originate  in  the  kidneys,  but  result  from  fatty  sub- 
stances deposited  in  the  bladder;  they  are  85  per  cent,  fat,  and  are 
soft,  rubber-like,  and  combustible. 

Infarcts  may  be  considered  here,  (a)  Uric  acid  infarcts  occur  in 
gouty  subjects  and  in  50  per  cent,  of  the  new-born,  chiefly  in  the 
medullary  collecting  tubules,  but  sometimes  in  the  cortex;  they  are 
most  common  in  the  still-born  or  in  weakly  infants,  and  are  thought 
to  result  from  destruction  of  the  tissues  or  cells  (nuclein),  (6)  Lime 
infarcts  are  chiefly  phosphates  and  carbonates  but  sometimes  oxalates ; 
they  are  deposited  principally  in  the  pyramids  and  in  the  membrana 
propria  when  the  renal  cells  are  destroyed;  they  occur  in  the  aged, 
and  also  in  poisoning  by  mercury,  arsenic,  phosphorus,  or  bismuth. 
(c)  Pigmentary  infarcts  of  hsematoidin,  bilirubin,  haemoglobin  or 
methsemoglobin  are  uncommon. 


RENAL  CALCULUS  (NEPHROLITHIASIS)  819 

Sjmaptoms. — Stones  may  be  first  discovered  accidentally  at  autopsy, 
or  may  pass  without  symptoms,  though  very  exceptionally.  Gravel 
or  renal  sand  is  more  often  latent  than  is  stone. 

1.  Pain  is  the  most  common  symptom.  It  is  of  two  kinds:  (a)  The 
dull  pain  in  the  loin,  often  associated  with  local  tenderness  over  the 
kidney;  Fen  wick  describes  localized  pain  without  any  urinary  changes, 
indicating  that  the  stone  lies  in  the  medullary  substance.  Pain  may 
be  felt  over  the  opposite  kidney.  (6)  The  renal  colic,  which  arises 
from  incarceration  of  the  stone  as  it  attempts  to  leave  the  pelvis, 
where  it  nearly  always  originates;  it  is  often  preceded  by  pain  in  the 
loin  and  may  be  initiated  by  exercise,  as  riding,  or  by  indigestion  or 
alcoholic  indulgence.  Eichhorst  mentions  a  surgeon  who  had  renal 
colic  every  time  he  drank  white  wine.  The  pain  in  renal  colic  begins 
over  the  kidney  and  radiates  down  the  ureter  to  the  testis,  labia,  bladder 
or  urethra;  the  testicle  is  retracted.  It  may  rarely  radiate  to  the 
chest,  heart,  shoulder,  epigastrium  or  to  the  opposite  side.  During 
the  colic,  the  kidney  is  so  frequently  sensitive,  that  when  it  is  not  so, 
Israel  hesitates  to  diagnosticate  stone.  The  pain  is  cutting  and  is 
often  very  severe;  it  often  occasions  reflex  nausea  and  vomiting,  some- 
times chills,  sweats  and  fever,  or  in  children  convulsions,  and  rarely 
collapse,  or  even  death  in  most  exceptional  cases.  Vesical  tenesmus 
is  frequent.  If  the  stone  passes,  the  pain  is  greatest  as  it  enters  the 
bladder.  Constipation  of  a  spastic  order  is  much  more  frequent  than 
diarrhoea  or  involuntary  movements.  Some  observers  hold  that  renal 
colic  occurs  oftenest  at  night.  It  lasts,  wdth  intermissions,  a  few  hours, 
rarely  days;  movement  may  excite  recurrence.  The  patient  lies  on 
his  back  with  the  leg  drawn  up  and  the  abdominal  wall  rigid.  After 
the  attacks  there  may  be  dull  pain  {v.s.),  which  may  be  caused  by 
large,  numerous,  or  sharp  stones.  Eichhorst  records  a  case  in  which 
the  sole  symptom  was  the  patient's  attitude;  he  leaned  far  forward 
and  depressed  one  shoulder  to  avoid  the  pain  induced  by  the  erect 
attitude. 

2.  The  urine  is  almost  invariably  altered,  (a)  Hcematuria  occurs 
independently  of  pain  and  colic,  as  well  as  after  them.  Absence  of 
hsematuria  after  a  renal  colic,  speaks  strongly  against  a  diagnosis  of 
stone  (Israel).  It  is  often  macroscopic,  and  red  disks  are  always  found 
with  the  microscope  (Musser),  except  in  the  rare  cases  when  stone  is 

•  imbedded  in  the  renal  tissue,  or  there  is  permanent  occlusion  of  the 
ureter.  At  the  time  of  the  colic  the  scanty,  bloody  urine  is  frequently 
voided  with  considerable  tenesmus.  In  exceptional  cases,  early  pro- 
fuse hsematuria  may  result  from  vascular  erosion.  Musser  found 
hyaline  casts  in  nearly  every  case.  (6)  Anuria  (suppression  of  urine) 
is  not  common.  It  may  occur  (i)  with  stone  in  one  ureter,  and  disease 
or  atrophy  of  the  other  kidney,  (ii)  with  bilateral  calculi  (Albarran), 
(iii)  with  stone  in  one  ureter,  and  reflex  suppression  (Morgagni) 
of  the  other  (sound)  kidney  through  the  splanchnic  nerve,  or  (iv)  by 
urethral  stoppage  by  a  stone.  Legeau  (1891),  quoted  by  Dieulafoy, 
collected  30  autopsied  cases  of  calculous  anuria;    there  was  stone  in 


820  DISEASES  OF  THE  KIDNEY 

one  kidney,  and  the  opposite  kidney  (a)  contained  a  calculus  in  14 
cases,  (/3)  was  hypoplastic  in  3,  (y)  sclerotic  in  6,  (S)  its  ureter  was 
stenosed  in  6,  and  (e)  in  one  case  the  opposite  kidney  was  absolutely 
normal.  The  resulting  symptoms  resemble  those  of  ursemia.  How- 
ever, in  41  cases  collected  by  Herter,  convulsions  were  present  in  but 
12  per  cent.,  headache  in  14  per  cent.,  and  vomiting  in  29  per  cent. 
Consciousness  is  usually  preserved,  the  pupils  are  usually  narrowed 
and  the  temperature  is  low.  Roberts  speaks  of  this  condition  as 
"latent  uraemia";  11  cases  of  anuria  persisted  over  four  days,  18 
cases  seven  to  fourteen  days,  and  seven  over  fourteen  days,  Russel 
records  recovery  after  twenty-eight  days  of  anuria.  With  its  relief 
large  quantities  of  urine  are  voided,  (c)  Pyuria  results  in  protracted 
cases  from  pyelitis,  which  is  much  oftener  secondary  to  the  calculus 
than  primary.  Rather  infrequently  a  renal  intermittent  fever  is  ob- 
served, resembling  the  hepatic  intermittent  fever  of  gall-stones.  Pyeli- 
tis may  be  catarrhal,  suppurative,  ulcerative  or  perforative,  (d) 
Crystals  of  uric  acid,  and  oxalates  are  considered  especially  important 
in  the  diagnosis  by  some  writers,  as  Leube;  Ulzmann  regarded  the 
pointed  uric  crystals  as  particularly  suggestive  of  renal  calculus,  (e) 
Stones  in  the  urine  determine  the  diagnosis,  though  they  are  not 
frequently  found. 

3.  The  x-rays  may  disclose  renal  calculi.  It  is  certain  that  oxalate 
stones  throw  a  darker  shadow  than  uric  acid  stones.  Opinions  differ 
regarding  the  value  of  the  rr-rays.  The  difference  may  be  wholly 
technical,  as  Leonard  reports  the  unusual  figures  of  but  3  per  cent, 
of  errors;  he  found  calculi  in  the  ureter  twice  as  often  as  in  the  renal 
pelvis.    Kiimmel  insists  that  every  stone  casts  a  shadow. 

4.  The  physical  findings  are  generally  less  important  than  the 
urinary  findings  and  the  colic.  Local  tenderness  has  been  mentioned 
(v.s.,  Pain).  Enlargement  of  the  kidney  (hydro-  or  pyonephrosis) 
is  not  common.  Palpation  of  the  stone  in  the  ureter  is  rarely  possible, 
either  from  without  or  by  the  rectum  or  vagina,  though  once  the 
writer  felt  a  calculus  at  McBurney's  point.  Stones  have  rarely  been 
felt  to  crepitate  in  the  renal  pelvis  (Piorry).  Cystoscopic  examination 
and  catheterization  of  the  ureters  are  methods  which  can  be  employed 
only  by  the  most  expert,  and  have  their  disadvantages  as  well  as 
advantages.  M.  L.  Harris'  segregator  may  determine  which  kidney 
is  affected. 

Complications. — Ulcerative  pyelitis  may  lead  to  perforation  and  para- 
nephric abscess.  Pyelonephritis  may  develop.  Hydronephrosis  results 
from  mechanical  occlusion  of  the  ureter,  and  pyonephrosis  from  obstruc- 
tion with  infection.  Injury  to  one  kidney  may  be  compensated  by 
hypertrophy  of  its  fellow.  Amyloid  degeneration,  renal  tuberculosis, 
or  even  cancer,  from  irritation,  may  develop.  The  ureter  may  rupture 
from  ulceration  or  tension.  Pregnant  women  may  abort,  and  Troja 
instances  a  case  in  which  14  abortions  occurred  after  14  attacks  of  colic. 

Diagnosis. — The  diagnosis  is  based  on  (a)  the  association  of  tha 
pain  and  colic,  (b)  hsematuria,  (c)  pyelitic  pyuria,  (d)  a;-ray  findings. 


RENAL  CALCULUS   (NEPHROLITHIASIS)  821 

and  (e)  less  often,  the  anuria  and  acute  swelling  of  the  kidney.  The 
results  of  the  a;-rays,  if  positive,  are  definitive;  if  negative,  stone  is 
not  excluded.  It  is  said  that  a  diagnosis  of  stone  is  found  correct  in 
only  60  per  cent,  of  the  cases  operated  on. 

1.  Pain  and  colic  may  occur,  though  rarely,  in  other  renal  conditions, 
as  in  renal  embolism  or  passage  of  blood  clots,  parasites,  echinococcus 
vesicles,  malignant  tissue  or  tuberculous  detritus,  renal  aneurysm, 
capsular  thickening  and  floating  kidney.  In  one  case  previously 
operated  on  for  appendicitis,  the  author  made  a  diagnosis  of  calculus 
from  pain,  colic,  and  hsematuria;  the  operation  by  Murphy  revealed 
a  partial  hydronephrosis  from  high  insertion  of  the  ureter.  Confusion 
may  result  from  vertebral  disease,  the  crises  of  tabes  or  angioneurotic 
oedema,  intestinal  colic,  gall-stones,  appendicitis,  diaphragmatic  pleu- 
risy or  hysteria. 

2.  HoBmaturia  (q.v.),  associated  with  pain,  may  cause  an  error  in 
diagnosis,  which  is  usually  corrected  only  at  operation;  thus  acute 
congestion  and  particularly  capsular  fibrosis  may  be  found.  Israel 
states  that  there  is  a  unilateral  nephritis  (a)  with  colic,  (6)  with  albumin 
and  without  casts ;  (c)  with  casts  and  without  albumin ;  (d)  with  hemor- 
rhage, simulating  tumor;  but  (e)  the  bleeding  never  causes  the  colic. 
In  these  doubtful  cases  exploratory  incision  is  also  indicated.  The 
hsematuria  resulting  from  cancer  and  tuberculosis  does  not  improve 
with  rest  in  bed,  while  calculous  hsematuria  usually  does.  Hsematuria 
and  renal  colic  may  develop  in  chronic  nephritis  from  acute  renal  con- 
gestion (Israel). 

Prognosis. — The  prognosis  must  be  conservatively  made,  for  the 
course  is  usually  chronic  and  marked  by  relapses.  The  author  knows 
of  four  physicians  who  passed  calculi  without  symptoms  afterward, 
but  this  is  not  the  rule.  Rupture  of  the  ureter,  collapse  during  the 
colic,  pyelitis  becoming  pyelonephritis,  anuria  and  ursemia  must  be 
considered  in  making  the  prognosis.  Pyuria  is  a  more  ominous 
development  than  hsematuria. 

Treatment. — 1.  Prophylaxis  of  renal  calculus  must  be  indefinite, 
because  so  little  is  known  regarding  its  pathogenesis.  It  is  usually 
stated  that  regulation  of  the  diet  concerns  moderation  in  both  proteids 
and  carbohydrates;  as  in  nephritis  (q.v.)  foods  rich  in  nuclein  are  to 
be  avoided;  vegetables  may  be  allowed.  Acid  foods  and  alcohol 
should  be  interdicted,  water  is  given  freely,  and  exercise  must  be 
insisted  upon.  In  uric  acid  calculi,  the  alkaline  waters  are  valuable, 
as  those  .of  Karlsbad,  Vichy,  Marienbad,  Saratoga,  Bedford,  Poland 
and  Mountain  Valley.  Sodium  phosphate  gr.  x  or  bicarbonate  5ss 
t.i.d.  are  indicated.  It  is  questionable  whether  lithium  carbonate  is 
a  uric-acid  solvent;  it  is  given  in  doses  of  grs.  iij  to  v  t.i.d.  in  effervescing 
waters.  Piperazin  and  glycerin  possess  no  proven  solvent  powers. 
In  localities  where  calculi  develop  very  frequently,  the  drinking  water 
must  be  used  with  caution.  Of  course  stones  once  formed  cannot  be 
dissolved  by  drugs. 


822  DISEASES  OF  THE  KIDNEY 

If  the  oxalates  are  deposited,  treatment  is  the  same  as  in  oxaluria 
(q.v.).  In  alkaline  urines  (from  which  phosphates  are  precipitated) 
the  urine  must  be  made  acid  by  salol,  gr.  x  t.i.d. ;  acid  waters,  as 
Seltzer  or  Apollinaris  may  be  employed;  meats  should  be  restricted; 
urotropin  gr.  x  t.i.d.  is  excellent,  especially  in  bacteriuria.  Altogether, 
diatetic  treatment,  though  important,  has  in  the  author's  opinion,  no 
great  bearing  on  prophylaxis  or  treatment,  and  he  cannot  agree  with 
those  who  declare  that  these  measures  are  generally  efficacious. 

2.  The  colic  should  be  medically  treated  like  that  of  gall-stones 

3.  Surgical  intervention  is  indicated  by  (a)  anuria;  (6)  severe  pyel- 
itis; (c)  septic  or  aseptic  obstruction  of  the  ureter;  (d)  exhausting 
heematuria,  and  (e)  repeated  attacks  of  colic.  As  one  or  more  of  these 
conditions  is  present  in  most  cases,  successful  treatment  must  be 
surgical. 

The  ideal  operation,  advocated  by  Morris  (1880)  is  nephrolithotomy 
(nephrotomy),  closing  the  renal  wound  if  there  is  no  infection;  opera- 
tion on  the  aseptic  kidney  entails  a  mortality  of  3  per  cent,  and  opera- 
tion in  the  presence  of  infection  10  per  cent.  (Albarran);  in  these 
cases  the  pelvis  should  be  drained  (nephrostomy).  Tenny  (1904) 
collected  134  cases  of  ureteral  calculus;  122  were  operated  on,  with 
a  mortality  of  19  per  cent.,  or  of  47  per  cent,  if  pyelitis  was  present; 
anuria  is  a  serious  complication,  for  52  per  cent,  of  the  operated  cases 
die;  without  pyelitis  or  anuria,  the  fatalities  were  6  per  cent.  Rosving 
has  operated  without  a  death.  Medical  treatment  of  anuria,  with 
full  doses  of  nitroglycerine,  hot  packs,  cups  to  the  lumbar  region  and 
subcutaneous  saline  transfusions  should  not  last  more  than  a  day  or 
two,  for  delay  raises  the  mortality  from  operation;  nephrostomy  is 
indicated. 

(K).  TUMORS  OF  THE  KIDNEYS. 
I.  Cancer. 

Etiology. — The  etiology  is  obscure.  It  constitutes  but  2  per  cent, 
of  all  cancers  and  but  1  per  cent,  of  primary  cancers  in  adults  (Rubin- 
stein); 62  per  cent,  occurs  in  males,  and  32  per  cent,  in  the  first  ten 
years  of  life.  Its  frequency  in  children  was  noted  by  Bright  (though 
some  reported  cases  were  sarcomata),  and  it  constitutes  52  per  cent, 
of  renal  tumors  in  children  (Hirschsprung).  Weigert  observed  one 
case  in  a  new-born  child.  Cancer  in  the  pelvis  may  result  from  stone. 
In  the  Albarran  and  Imbert  series  of  380  renal  tumors,  cancer  con- 
stituted 50  per  cent.  . 

Pathology. — The  primary  form  is  usually  infiltrating,  and  the 
secondary  form  consists  of  nodules.  Medullary  cancer  is  more  com- 
mon than  scirrhus,  colloid,  and  other  forms.  It  usually  begins  in  the 
convoluted  tubules  of  the  cortex.  Its  growth  is  usually  limited  by  the 
kidney's  capsule.     The  kidney  is  nearly  always  enlarged,  its  average 


CANCER  ■  823 

weight  in  children  being  8^  pounds  (Guillet)  and  in  adults  10  to  15 
pounds  (or  even  30  to  50) .  The  opposite  kidney  and  the  sound  parts 
of  the  affected  viscus  may  show  compensatory  hypertrophy.  Hemor- 
rhages into  the  neoplastic  tissue  may  occur.  Local  invasion  of  the 
renal  veins,  ureter,  inferior  cava,  pancreas,  adrenals  or  intestine  and 
metastases  (58  per  cent.)  in  distant  organs  sometimes  develop. 

Symptoms. — Some  cancers  are  cHnically  latent,  particularly  secon- 
dary growths. 

1.  Renal  tumor  is  the  most  common  finding,  and  occurs  in  97  per 
cent,  of  eases  (Guillet).  It  begins  in  the  region  of  the  kidney,  but, 
being  resisted  by  the  firm  lumbar  tissues,  it  grows  forward.  Bimanual 
palpation  clearly  demonstrates  its  origin  in  most  cases.  If  large,  it 
may  fall  forward  over  the  spine.  It  is  tender  and  usually  firm,  though 
its  degeneration  may  occasion  slight  fluctuation.  The  form  of  the 
kidney  is  usually  preserved,  though  nodules  may  be  palpated.  It 
usually  attains  a  large  size  (v.s.),  compressing  and  dislocating  the 
liver  and  spleen  upward,  and  crowding  the  abdominal  viscera.  Fiir- 
bringer  reports  a  case  in  which  the  heart  was  pushed  up  to  the  clavicle. 
On  tapping  it  a  repercussion  wave  is  sometimes  noted  {ballottement 
rSnal).  Percussion  gives  a  dull  note,  except  so  far  as  the  intestines 
lie  over  it,  when  mixed  flatness  and  tympany  are  elicited.  The  colon 
overlies  the  kidney,  running  from  left  to  right,  from  above  downward; 
on  the  left  side  this  relation  is  more  clearly  distinguished;  on  inflation 
of  the  colon  with  air  or  gas,  its  tympanitic  note  in  some  degree  obliter- 
ates the  renal  dulness;  in  a  recent  study  by  Kofmann,  this  condition 
was  found  in  less  than  50  per  cent,  of  large  renal  tumors;  in  tumors 
on  the  right  side  the  colon  is  often  dislocated  laterally  or  even  down- 
ward. There  is  but  little  if  any  respiratory  excursion.  In  rare  in- 
stances the  tumor  may  pulsate  and  produce  by  pressure  on  the  aorta 
a  systolic  murmur,  which,  as  in  Richard  Bright's  case,  may  simulate 
aneurysm.  If  the  tumor  grows  into  the  ureter,  hydronephrosis  may 
augment  the  swelling. 

2.  Pain  is  an  early  and  frequent  symptom,  due  to  pressure  exerted 
on  the  lumbar  plexus.  For  this  reason  also  there  may  be  slight  sensory 
disturbance  in  the  legs.  Pain  is  usually  dull  and  only  rarely  is  it  lan- 
cinating or  colic-like,  due  to  passage  of  clots  or  bits  of  tumor  (v.i.). 

3.  II a^maturia  is  an  early  symptom.  According  to  Guillet  it  occurs 
in  50  per  cent,  and  is  the  first  symptom  in  25  per  cent,  of  cases;  Israel 
holds  that  it  occurs  in  92  per  cent,  and  is  the  first  manifestation  in  70 
per  cent.  It  is  less  frequent  in  children  (16  per  cent.)  than  in  adults. 
Sometimes  worm-like  blood  clots  are  passed,  with  great  colic;  they 
sometimes  measure  one-half  to  one  inch;  clots  in  a  clear  urine  are 
almost  pathognomonic  (Israel).  The  cystoscope  and  ureteral  cathe- 
terization prove  that  the  htiematuria  is  unilateral.  The  hemorrhage 
usually  originates  in  the  diseased  kidney  but  may  come  from  the  sound 
(though  hypera^mic)  kidney.  In  other  repects  the  urine  is  generally 
normal.  It  is  usually  held  that  albuminuria  corresponds  to  the  amount 
of  blood,  but  Albarran  asserts  there  is  more  albumin  than  the  blood 


824  DISEASES  OF  THE  KIDNEY 

accounts  for.  Very  rarely  bits  of  cancer  tissue  pass.  The  urea  is  in- 
creased as  in  all  cancers,  and  the  chlorides  are  sometimes  decreased. 
Pyuria  is  no  part  of  renal  cancer. 

4.   Cachexia  develops  in  most  cases,  but  not  in  all. 

Complications. — Compression  symptoms  include  paraplegia  dolor- 
osa, constipation,  intestinal  obstruction,  oedema  from  compression  of 
the  iliac  veins  and  ascites ;  varicocele,  which  was  first  noted  by  Guyon, 
is  said  to  seldom  occur  in  other  renal  tumors,  and  is  due  to  late  com- 
pression of  the  spermatic  vein  by  the  tumor  or  contiguous  lymph 
nodes.  Metastases,  enlarged  inguinal  glands,  rarely  growth  into  the 
lumbar  muscles  or  skin,  and  perforation  into  the  peritoneum  or  intes- 
tine, with  fatal  hemorrhage,  uraemia,  fever  from  cachexia  or  terminal 
infection,  may  be  observed.  According  to  Israel,  tumor  of  the  renal 
pelvis  causes  greater  hsematuria,  and  more  hydronephrosis  (therefore 
greater  variations  in  the  size  of  the  tumor) ;  it  sometimes  grows  down 
the  ureter  and  is  seen  with  the  cystoscope  to  project  into  the  bladder; 
particles  of  tumor  tissue  and  cells  are  more  often  obtained.  Albarran 
and  Imbert  collected  65  cases  of  tumors  in  the  pelvis  and  ureter;  27 
were  ureteral.  Savory  and  Nash  collected  60  cases  of  painful  villous 
tumors  in  the  pelvis. 

Course  and  Prognosis. — Death  is  invariable  without  operation;  it 
usually  results  from  cachexia,  in  two  years  in  adults  and  in  eight 
months  in  children  (Rohrer  and  Roberts).  Guillet  states  that  6  cases 
have  lived  longer  than  ten  years  and  1  lived  seventeen  years. 

Diagnosis. — The  following  are  of  clinical  importance:  (a)  renal 
tumor,  (6)  pain,  (c)  hsematuria,  and  (d)  cachexia.  Imbert  speaks  of 
the  complete  type  (tumor  and  hsematuria),  the  hsematuric  type  (without 
tumor,  6  per  cent.)  and  the  tumor  type  (without  haematuria,  23  per 
cent.). 

Differentiation  is  necessary,  from  (a)  liver  tumor,  which  encroaches 
much  more  upon  the  diaphragm  and  is  characterized  by  its  respiratory 
excursion,  by  the  location  of  the  tumor  within  the  edge  of  the  liver, 
and  by  such  complications  as  icterus  and  ascites.  The  colon  lies 
below  the  liver  and  there  are  no  urinary  findings.  Bimanual  palpation 
clearly  differentiates  uncomplicated  cases.  Between  a  kidney  tumor 
and  the  liver  a  furrow  and  loop  of  resonant  intestine  are  frequently 
found,  (b)  A  splenic  tumor  maintains  the  form  of  the  spleen,  lies  above 
the  colon,  (whose  distention  does  not  modify  the  splenic  dulness), 
moves  on  inspiration,  shows  the  characteristic  notches  and  seldom 
causes  confusion  except  when  it  so  rotates  that  only  its  convexity  can 
be  felt,  (c)  An  ovarian  tumor  projects  upward  from  the  pelvis,  with 
which  its  connection  can  be  demonstrated,  save  when  it  has  a  long 
pedicle.  It  is  more  central  and  sustains  no  characteristic  relation 
with  the  colon,  (d)  Retroperitoneal  growths  are  much  more  difficult 
to  differentiate,  especially  enlarged  lymph  glands  and  lymphosarcoma. 
They  are  generally  more  central  and  less  movable.  The  author 
recalls  an  enormous  tumor  which  was  considered  renal,  but  which 
proved  at  autopsy  to  be  a  retroperitoneal  lipoma,     (e)  Other  renal 


HYPERNEPHROMA  825 

conditions  must  be  differentiated,  (i)  Cystic  degeneration  (v.i.)  is 
usually  bilateral  and  runs  a  most  chronic  course,  (ii)  Sarcoma  cannot 
be  differentiated,  (iii)  Hydro-  or  pyonephrosis  (q.v.),  in  which  the 
tumor  varies  exceedingly  and  has  characteristic  urinary  changes,  (iv) 
Tuberculosis  is  distinguished  by  hectic  fever,  tuberculosis  elsewhere, 
pyuria,  and  finding  of  the  tubercle  bacilli. 

II.  Sarcoma. 

Sixty-six  per  cent,  occurs  under  ten  years  of  age;  G.  Walker  in 
145  cases,  found  that  most  cases  occurred  in  the  first  two  years  of  life. 
Albarran  and  Imbert  state  that  sarcoma  constitutes  20  per  cent,  of 
renal  growths.  It  is  slightly  more  common  in  girls  than  in  boys,  and 
in  the  left  than  in  the  right  kidney.  Cohnheim's  theory  of  embryonal 
inclusion  is  supported  by  the  occasional  presence  of  cartilage,  bone, 
and  striated  and  unstriated  muscle.  The  sarcoma  is  of  the  round, 
spindle  or  melanoid  cell  type  and  may  contain  furrows,  fatty,  vascular, 
and  even  carcinomatous  tissue.  It  may  weigh  6,000  gm.  Secondary 
sarcomata  may  develop  by  metastasis  from  other  organs,  or  by  invasion 
by  contiguity. 

Its  symptoms  are  essentially  those  of  carcinoma,  from  which  an 
intravitam  diagnosis  is  very  rarely  possible,  except  when  sarcomatous 
tissue  is  passed  in  the  urine  or  excised  at  operation.  Hsematuria  and 
cachexia  are  infrequent;  age  is  of  no  diagnostic  value,  and  glandular 
involvement  may  occur  in  either.  In  some  cases  a  remarkable  over- 
growth of  the  pubic  and  axillary  hair,  and  pigmentation  of  the  skin 
may  be  observed.  Operated  cases  live  on  an  average  sixteen  months 
and  non-operated  ones,  half  as  long  (G.  Walker)  but  death  is  frequently 
a  direct  result  of  the  operation. 

III.  Hypernephroma. 

P.  Grawitz  named  this  form  "struma  lipomatodes  aberrans  renis"; 
the  tumor  develops  from  aberrant  (included)  particles  of  adrenal 
tissue.  Small  tumors  are  not  a  rare  autopsy  finding.  They  constitute 
20  per  cent,  of  renal  tumors  and  consist  of  a  scanty  but  vascular 
connective  tissue  stroma,  containing  fatty  cells  like  those  of  the  adrenal 
bodies.  Hemorrhage,  cystic  degeneration,  a  tendency  to  invade  the 
veins^  and  a  large  proportion  of  glycogen  and  perhaps  cholestearin  or 
lecithin  are  considered  characteristic.  Fatty  cells  may  be  found  in 
the  urine.  Ha^maturia  occurs  in  80  per  cent,  of  cases.  Metastases 
may  develop.  Bone  metastasis  is  the  first  symptom  in  16  per  cent, 
but  may  develop  as  a  late  symptom  only.  Fever  is  noted  in  57  per 
cent.,  though  it  occurs  in  but  1  or  2  per  cent,  of  other  tumors  of  the 
kidney  (Israel). 


826  DISEASES  OF  THE  KIDNEY 


IV.  other  Tumors. 

Other  tumors  as  fibroma,  lipoma,  myxoma,  angioma,  and  rhabdo- 
myoma are  of  Httle  importance.  Hsematuria  occurred  in  only  one 
case,  an  angioma.  Thirty-three  cases  of  tumor  of  the  capsule  are 
on  record. 

Treatment  of  Renal  Tumors. — This  is  symptomatic  and  surgical. 
The  former  concerns  chiefly  the  management  of  pain,  by  means  of 
anodynes,  chiefly  opiates.  Surgical  treatment  alone  is  of  value.  The 
mortality  resulting  from  total  nephrectomy  in  Gross'  figures  was  61 
per  cent.;  in  Kiister's,  24  per  cent.  Schmieden  collected  329  cases; 
33  per  cent,  (average)  have  died  from  the  operation;  the  mortality 
in  the  first  decade  of  renal  surgery  (dating  from  Gustav  Simon,  1869) 
was  64  per  cent.,  in  the  next  43  per  cent.,  in  the  third  22  per  cent. 
The  mortality  of  nephrectomy  for  all  causes  is  at  present  17  per  cent, 
and  for  tumor  22  per  cent,  (in  children,  28  per  cent.).  Thirty-three 
recoveries  after  radical  operation  are  on  record,  one  patient  being 
alive  after  eighteen  years.  Israel  in  43  cases  reported  a  mortality 
of  18.6  per  cent.,  of  which  two-thirds  died  of  heart  paralysis;  8  cases 
(19  per  cent.)  enjoyed  permanent  recovery,  after  three  and  a  half  to 
fourteen  years.  Schede  in  18  operations  obtained  4  permanent  recov- 
eries (22  per  cent.)  after  four  to  nine  years.  Recurrence  after  two 
years  is  very  exceptional.  The  extraperitoneal  operation  is  three 
times  as  safe  as  the  transperitoneal.  Operations  are  usually  performed 
too  late;  advanced  cachexia,  very  large  tumors,  metastases  and  growth 
into  the  cava  are  contra-indications.  The  other  kidney  must  be  in 
good  condition  to  admit  of  operation. 


(L).  CYSTIC  DEGENERATION. 

Various  renal  cysts  are  observed,  (a)  Those  which  occur  in  chronic 
interstitial  nephritis  are  the  most  frequent;  they  result  from  snaring 
off,  by  fibrous  tissue,  of  the  tubules  and  glomeruli,  (b)  Parasitic 
cysts  (v.i.)  are  next  in  frequency,  (c)  Dermoid  cysts  are  very  rare; 
but  two  are  on  record,  (d)  Cysts  of  the  fatty  capsule,  retroperitoneal 
cysts,  and  degenerated  lymph  glands,  are  also  very  rare,  (e)  Complete 
cystic  degeneration  {hydrops  renum  cysticus,  degeneratio  renum  foly- 
cystica)  was  first  separated  by  Rayer  from  the  above  mentioned  var- 
ieties and  constitutes  cystic  degeneration,  as  it  is  generally  understood. 

Etiology. — Over  50  per  cent,  is  observed  in  men  between  forty 
and  fifty  years  of  age.  Luzzatto  found  but  two  cases  (in  187)  in  per- 
sons under  twenty  years;  Sieber  (1906)  collected  from  the  literature 
32  cases  of  cystic  kidneys  in  persons  under  and  211  in  those  over 
twenty  years  of  age.  Cystic  kidneys  are  observed  in  later  foetal  life, 
at  birth,  and  in  the  adult.     It  is  often  difficult  to  determine  whether 


CYSTIC  DEGENERATION  827 

they  are  acquired  or  congenital,  though  the  latter  conception  is  most 
favored;  the  cysts  are  thought  to  remain  latent  until  middle  life. 

Pathogenesis. — Three  main  theories  obtain;  (a)  that  they  are 
retention  cysts,  (6)  that  they  are  new  formations,  i.e.,  neoplastic 
(cystadenomata),  and  (c)  that  they  are  malformations.  The  neoplastic 
conception  is  probably  the  most  acceptable  hypothesis. 

Pathology. — Congenital  cases  are  almost  always  bilateral;  Lejars 
found  one  unilateral  case  in  67,  and  Luzzatto  41  in  226  cases.  The 
kidneys  may  contain  innumerable  small  cysts,  when  the  shape  of  the 
kidney  is  preserved,  or  it  contains  larger  cysts,  when  its  contour  is 
more  irregular.  According  to  Englander,  only  23  cases  of  unilocular 
cysts  are  on  record.  The  size  of  the  kidneys  may  be  that  of  a  child's 
head;  they  may  even  weigh  twenty-one  pounds.  In  congenital  cases 
it  sometimes  causes  dystocia.  On  section  the  kidney  is  honey-combed. 
The  cyst  walls  consist  of  thin  or  thick  fibrous  tissue.  The  cysts  usually 
contain  thin,  yellow,  transparent  fluid,  less  often  milky,  gelatinous  or 
brownish  contents  (altered  blood).  They  are  uni-  or  multilocular. 
They  are  lined  with  cells  like  the  urinary  tubules,  or  with  flat  polyg- 
onal cells.  The  cysts  contain  albumin,  oxalate  of  lime,  leucin-like 
crystals,  red  disks,  epithelial  detritus,  fat  granules,  and  rarely  urea  or 
uric  acid.  Between  the  cysts  vestiges  of  renal  tubules  or  glomeruli  are 
found,  which  here  and  there  may  be  vicariously  hypertrophied. 
Cysts  may  occur  in  the  pelvis,  ureter  and  liver  (v.i.).  In  congenital 
cases  other  deformities  are  sometimes  found,  particularly  in  the  genito- 
urinary tract,  brain  and  fingers. 

Symptoms. — In  congenital  forms  the  cystic  kidneys  may  cause  an 
obstruction  to  delivery ;  if  the  infant  is  born  alive,  death  from  asphyxia 
is  usual,  for  the  diaphragm  is  crowded  upward.  In  adult  forms,  90 
per  cent,  of  cases  come  to  autopsy,  undiagnosticated,  or  with  the 
diagnosis  of  some  other  renal  disease  as  nephritis.  The  symptoms 
may  be  classified  as  follows:  (a)  Renal  cysts  are  found  clinically  in 
29  per  cent,  of  cases  only  (Luzzatto)  or  in  12.4  per  cent.  (Sieber). 
Their  general  characteristics  are  those  of  solid  kidney  tumors,  but  they 
are  almost  always  bilateral  (v.s.).  Fluctuation  seldom  occurs.  In 
very  few  cases  the  individual  cysts  can  be  palpated;  in  a  case  which 
the  author  demonstrated  in  the  Chicago  Medical  Society  they  could 
be  clearly  palpated.  Echinococcus  cysts,  hydro-  and  pyonephrosis, 
sarcoma  and  cancer  of  the  kidney  are  only  distinguished  by  their 
unilateral  occurrence;  if  bilateral,  difi^erentiation  is  almost  impossible. 
(6)  The  urine  is  variable;  it  may  be  normal,  increased  or  decreased. 
The  urinary  findings  are  typically  like  those  of  interstitial  nephritis, 
i.e.,  the  urine  is  abundant,  with  few  solids,  low  specific  gravity,  and 
traces  of  albumin.  Red  disks  are  often  found  (20  per  cent.),  some- 
times in  great  numbers.  In  two  of  the  author's  cases  red  cells  appeared 
in  numbers  each  time  the  kidneys  were  palpated.  Leucin-like  bodies 
may  appear  in  the  urine,  or  in  exploratory  punctures;  Beckmann  first 
described  these  small  colloid  bodies  ("rosettes")  with  structureless 
centres  and  one  to  five  concentric  rings  and  clearly  radiating  striations. 


828  DISEASES  OF  THE  KIDNEY 

(c)  Cardiovascular  changes  (left  ventricular  hypertrophy  and  sclerosed 
arteries)  are  common  and  heighten  the  resemblance  to  contracted 
kidney.  The  changes  were  well  marked  in  the  three  cases  which  the 
author  was  able  to  diagnosticate,  (d)  Uroemia  is  the  common  cause 
of  death.  The  clinical  course  is  very  chronic  and  is  broken  by  attacks 
of  "  periodic  ursemia."  The  digestive  disorders  of  uraemia  (see  Chronic 
Interstitial  Nephritis)  are  very  frequent.  Lejars  observed  a  case 
living  fifteen  years,  and  Senator  one  living  twenty  years  after  the 
cysts  were  found. 

Diagnosis. — ^The  diagnosis  is  difficult  in  many  cases,  but  can  be 
made  when  there  are  (a)  bilateral  (perhaps  palpably  cystic)  renal 
sweUings;  (b)  the  cardiovascular  and  urinary  findings  of  contracted 
kidney,  with  hsematuria  and  colloid  "rosettes,"  which  are  obtained 
in  the  urine,  or  by  puncture;  (c)  uraemia  and  (d)  perhaps  renal  pain, 
and  tenderness  or  congenital  cysts  in  the  liver  (in  28  per  cent.,  accord- 
ing to  Lejars);  in  a  case  of  Dr.  W.  F.  Dickson  of  Chicago,  renal 
cysts  were  found  with  cystic  hver,  atrophic  heart,  and  pain  resembling 
appendicitis  (see  Echinococcus  of  the  Liver,  Differentiation). 
Hanot  and  others  describe  cases  resembling  calculous  colic. 

Treatment. — Operation  is  permissible  only  in  the  exceptional,  uni- 
lateral cases,  or  when  suppuration  develops.  About  one-third  of  the 
operated  cases  die  immediately,  and  in  few  are  any  lasting  results 
obtained.    The  treatment  is  that  of  chronic  nephritis. 

(M).  RENAL  PARASITES. 

Echinococcus  cysts  (see  section  on  Animal  Parasites)  of  the  kid- 
neys, occur  in  9  per  cent,  of  echinococcus  disease  (Neisser's  900  cases). 
In  970  cases  (Vegas  and  Cranwell),  the  liver  was  diseased  in  64  per 
cent.,  the  lungs  in  7  per  cent.,  the  spleen  in  3  per  cent.,  and  the  kidneys 
in  2  per  cent.  BaraduHn  in  1906,  collected  142  cases  of  renal  echino- 
coccus, 

Sjnnptoms. — (a)  A  renal  tumor  is  found  in  50  per  cent.,  when  the 
cyst  attains  large  dimensions.  It  is  easily  confused  with  other  cysts, 
hydronephrosis,  cancer,  or  tuberculosis  without  the  exploratory  punc- 
ture, and  the  urinary  findings.  Fluctuation  and  the  hydatid  thrill 
(see  Liver  Echinococcus)  are  not  often  found.  The  cyst  begins  in 
the  cortex,  and  usually  in  either  pole  of  the  kidney;  it  is  unilateral 
in  96  per  cent,  of  cases,  and  is  left-sided  in  62  per  cent.  If  the  cyst 
calcifies  it  may  be  seen  by  the  rc-rays.  The  opposite  kidney  may 
hypertrophy,  (b)  Exploratory  aspiration  may  show  (i)  fluid  or  pus, 
containing  urinary  constituents,  cholestearin,  succinic  acid,  much 
sodium  chloride  and  a  reducing  substance;  (ii)  vesicles,  booklets,  or 
particles  of  lamellated  membrane,  (c)  The  urine  may  contain  ves- 
icles, booklets,  membrane,  pus  from  pyelitis,  and  blood  from  rupture. 
As  many  as  lOO^vesicles  have  been  passed,     {d)  Passage  of  vesicles 


RENAL  PARASITES  829 

is  attended  by  colic,  as  severe  as  that  of  nephrolithiasis,  with  fever, 
chill,  and  vomiting. 

Complications. — Seventy-five  per  cent,  rupture,  chiefly  into  the  renal 
pelvis;  perforation  may  occur  into  the  intestines,  lumbar  muscles, 
lung  or  pleura ;  the  patient  may  feel  the  rupture.  The  toxic  substances, 
liberated  by  rupture  or  puncture,  may  cause  urticaria,  severe  heart 
symptoms  or  even  fatal  syncope.  Adhesions  to  the  liver,  spleen,  and 
intestine  may  form.  Suppuration  or  gangrene  may  develop  (pyone- 
phrosis or  paranephritis).  Obstruction  of  the  ureter  causes  hydro- 
nephrosis; vesicles  which  plugged  the  lower  end  of  the  ureter  have 
been  seen  with  the  cystoscope. 

Prognosis  and  Treatment. — The  course  is  very  chronic,  covering 
years  (even  twenty  to  thirty).  Suppuration  may  cause  pyaemia.  The 
cyst  may  shrink  or  calcify.  Bilateral  involvement  makes  the  prognosis 
unfavorable.  Spontaneous  recovery  by  rupture  into  the  urinary  tract, 
occurs  in  32  per  cent.  (Beraud).  Operation  should  be  extraperitoneal. 
Nephrotomy  is  indicated,  as  there  is  seldom  more  than  a  single  cyst. 
Nephrectomy  produces  a  higher  mortality  (8  per  cent.).  In  30  opera- 
tions (nephrotomy),  by  Schede,  there  were  no  fatalities;  87  per  cent, 
completely  recovered,  and  10  per  cent,  recovered  but  had  fistulse. 

The  Enstrongylus  gigas,  which  occurs  frequently  in  dogs  or  wolves, 
is  very  rare  in  man.  It  is  a  nematode  whose  ova  appear  in  the  urine. 
It  causes  pyelitis,  hsematuria,  colic,  tenesmus  and  sometimes  chyluria. 

The  Distoma  haematobium,  described  by  Bilharz  (1851)  in  Egypt, 
causes  endemic  hsematuria.  It  is  a  trematode  and  enters  the  alimen- 
tary tract,  by  the  drinking  water.  Reaching  the  veins,  its  ova  obstruct 
them  and  cause  pyelitis,  hsematuria,  tenesmus,  and  sometimes  form 
the  nucleus  of  renal  stones.    Salol  is  said  to  be  beneficial. 

The  filaria  has  been  mentioned  under  Chyluria. 

Tuberculosis  and  S3T)hilis  of  the  kidney  are  considered  under 
Infections. 


SECTION  VL 


DISEASES  OP  THE  BLOOD. 


Anaemia  is  a  reduction  in  the  blood  as  a  whole,  or  more  often  a 
reduction  of  its  important  constituents,  as  the  red  corpuscles,  their 
number,  haemoglobin  or  albumin.  Every  anaemia  has  a  cause,  yet  in 
our  present  ignorance,  we  adhere  to  the  older  division  of  anaemia 
into  primary  and  secondary  forms.  Primary  ancemia  includes  chlorosis 
and  pernicious  (progressive)  anaemia. 


(A).  CHLOROSIS. 

Definition. — Chlorosis  is  a  disease  of  haemogenesis,  occurring  almost 
invariably  in  women,  chiefly  in  the  developmental  years  and  in  the 
decennium  following,  in  which  the  cardinal  symptom  is  anaemia; 
the  red  cells  are  reduced  but  the  haemoglobin  is  disproportionately 
reduced;  chlorosis  develops  spontaneously,  usually  runs  an  uncom- 
plicated course,  tends  to  recur,  and  responds  to  therapy  by  iron. 
Chlorosis  is  a  disease,  while  anaemia  is  but  a  symptom. 

Etiology. — Its  etiology  is  uncertain,  (a)  Nearly  all  cases  occur  in 
women;  a  few  alleged  instances  in  delicate  men  are  recorded.  It 
develops  especially  in  girls  who  menstruate  before  the  pubes  and 
mammae  develop  (Niemeyer).  It  is  more  common  in  blondes  than 
in  brunettes.  (6)  Chlorosis  occurs  largely  between  the  jourteenth  and 
seventeenth  years.  Great  care  must  be  exercised  in  diagnosticating 
the  disease,  after  the  twenty-fourth  year  (chlorosis  tarda),  unless 
previous  attacks  have  occurred,  (c)  Heredity  is  undoubtedly  a  marked 
factor  (Bramwell).  Chlorosis,  tuberculosis  or  hysteria  is  not  infre- 
quently associated  in  the  family  history,     {d)  Malnutrition,  lack  of 

831 


832  DISEASES  OF  THE  BLOOD 

hygiene,  insufficient  or  excessive  exercise,  working  in  dark  quarters, 
nostalgia,  improper  clothing,  wearing  of  corsets,  and  emotional  or 
sexual  factors  (unsatisfied  desire,  masturbation),  are  indirect  causes. 
Various  theories  have  been  advanced  as  to  the  nature  of  the  disease, 
as  deficient  development  of  the  genitalia,  hypoplasia  of  the  vascular 
apparatus,  adynamia  of  the  blood-making  organs,  reflex  action  of  the 
nutritive  organs  from  genital  maturity,  inability  of  the  blood-making 
organs  to  respond  to  the  bodily  needs  at  puberty,  insufficient  absorp- 
tion of  iron,  dilatation  of  the  stomach,  constipation,  enteroptosis, 
auto-intoxication  from  the  internal  genitalia  at  the  time  of  puberty, 
and  intestinal  auto-intoxication. 

General  Symptoms. — Among  the  early  symptoms  are  rapid  tiring, 
dyspioea  and  palpitation,  which  are  rarely  absent  and  are  most  notice- 
able in  the  morning.  Pallor  is  the  earliest  and  most  constant  sign  and 
affects  the  skin  and  mucosae,  the  skin  being  of  a  yellowish-green  hue 
(chlorosis,  as  named  by  Varandel,  in  1670).  Sometimes  the  color  is 
maintained,  the  face  being  flushed,  probably  from  peripheral  irrita- 
bility of  the  vasomotor  system  (chlorosis  rvbra) ;  hence  the  mucous 
membranes  should  be  examined,  even  more  than  the  skin.  The 
eyes  are  often  brilHant.  Psychical  changes  are  noted  (Sydenham  and 
Morton),  as  stupor,  and  lack  of  mental  and  muscular  energy.  Associated 
symptoms  are  headache,  which  may  be  dull  or  sharp,  sometimes  mi- 
graine-like, or  increased  at  the  time  of  menstruation,  spots  before  the 
eyes,  tinnitus,  vertigo,  and  syncope  which  occurs  especially  on  stand- 
ing and  results  from  travel  and  exposure  to  the  sun,  but  less  from 
movement.  Menstrual  disturbances  are  frequent,  the  flow  being  often 
decreased,  most  markedly  in  younger  subjects.  Digestion  is  very 
frequently  disturbed,  and  there  may  be  anorexia,  perversity  of  appetite, 
craving  of  sour  articles,  hunger  between  meals,  pain  in  the  stomach, 
eructations  and  cardialgia.  Constipation  is  frequent.  The  hands  are 
cold,  the  skin  dry  and  the  peripheral  circulation  sluggish.  Circulatoiy 
symptoms  appear,  as  the  bruit  de  diable  in  the  neck  veins,  ancemic 
heart  murmurs  and  rapid  pulse. 

Special  S3niiptoms. — 1.  The  blood  is  fluid  and  its  coagulabiUty  is 
increased,  thereby  contrasting  with  pernicious  ansemia  and  leukaemia. 
The  red  blood  cells  are  decreased  ioligocythaemia)  and  average  three 
to  four  millions  at  the  first  examination ;  as  few  as  one  miUion  red  cells 
have  been  observed.  In  some  rare  cases  they  are  not  decreased  (Dun- 
can, Hayem,  Laache).  Formation  of  rouleaux  is  poorly  marked. 
The  red  cells  appear  pale  and  their  average  size  is  reduced.  Irregularity 
in  contour  {poikilocytosis)  is  not  frequent;  megalocytosis  and  micro- 
cytosis  are  rare;  normo-  and  megaloblasts  are  found  only  in  the 
severest  cases;  normoblasts  are  sometimes  present  in  "blood  crises." 
More  suggestive  than  the  red  cell  reduction  (oliogocythsemia)  is  the 
reduction  of  haemoglobin  (oligochromcemia) ,  which  is  reduced  more 
than  the  red  cells  (Duncan,  1867) ;  the  haemoglobin  averages  30  to  40 
per  cent.  This  reduction  in  the  color  index  always  suggests  chlorosis, 
is  most  marked  in  the  first  seizure  in  young  individuals,  and  is  less 


CHLOROSIS  833 

conspicuous  in  relapses  or  in  older  individuals.  Some  writers  claim 
that  the  reduction  in  haemoglobin  is  more  apparent  than  real,  because 
there  is  more  rapid  regeneration  of  the  cells  than  of  the  haemoglobin. 
The  white  cells  are  essentially  normal,  or  at  least  but  little  increased, 
therein  differing  from  many  other  forms  of  anaemia;  occasionally 
lymphocytosis  and  eosinophilia  occur.  The  iron  and  nitrogen  of  the 
blood  and  its  specific  gravity  are  reduced  proportionately  to  the  de- 
crease in  haemoglobin, 

2.  The  vascular  system  presents  various  symptoms,  (a)  Rokitansky 
and  Virchow  observed  hypoplasia  of  the  aorta  and  vessels,  which 
may  co-exist  with  hypoplasia  of  the  genitalia,  muscles  and  bones,  but 
cannot  be  regarded  as  causative,  (b)  Palpitation  is  almost  constant 
on  exertion;  the  apex-beat  is  strong  to  compensate  for  the  poverty  in 
haemoglobin,  (c)  Heart  murmurs  occur  in  two-thirds  of  the  cases; 
they  are  largely  functional  and  may  be  caused  by  insufficient  tension 
of  the  mitral  valve,  dilatation  of  the  left  ventricle  causing  relative 
mitral  insufficiency,  weakened  heart  muscle  (producing  a  muscular 
murmur  in  place  of  the  tone),  tricuspid  insufficiency  or  vibration  of 
the  pulmonary  artery.  The  murmurs  are  largely  systolic;  undoubted 
diastolic  venous  bruits  have  been  heard,  (d)  Dilatation  of  the  heart 
occurs  from  anaemia  or  myocardial  degeneration,  though  according 
to  Leube,  Grunmach  and  von  Noorden,  the  dilatation  is  not  real  but 
apparent,  being  due  to  retraction  of  the  lungs  away  from  the  heart, 
because  of  insufficient  lung  expansion;  this  has  been  confirmed  by 
the  rr-rays.  (e)  The  pulse  findings  are  not  constant;  the  pulse  may 
be  rapid,  throbbing,  or  excitable.  The  arterial  tonus  is  reduced, 
dicrotism  and  capillary  pulsation  are  frequent,  and  double  tones  have 
been  noted  in  the  crural  vessels  from  decreased  tension  and  diastolic 
recoil.  (/)  A  venous  bruit  {bruit  de  diahle)  in  the  neck  occurs  in  over 
50  per  cent,  of  cases,  and  more  frequently  than  in  other  anaemias; 
it  may  be  palpable  and  is  heard  more  frequently  over  the  right  jugular 
vein,  because  it  is  more  vertical  than  the  left;  it  also  is  heard  in  other 
veins,  and  in  sound  individuals.  It  is  increased  in  the  sitting  posture, 
by  turning  the  head  to  one  side,  and  by  deep  inspiration.  Its  explan- 
ation is  difficult;  it  is  referred  to  change  in  the  tonus  of  the  vessel, 
waves  in  the  veins  above  their  valves,  and  a  change  of  the  blood 
plasma,  {g)  Arterial  murmurs  may  be  heard,  as  over  the  subclavian 
artery;  pulsation  in  the  peripheral  veins,  angiospasm,  and  erythro- 
melalgia,  have  been  observed,  {h)  (Edema  is  seen  in  12  per  cent,  of 
cases,  and  is  usually  slight,  occurring  chiefly  about  the  ankles  and 
eyes,  and  rarely  in  the  serous  cavities. 

3.  In  the  respiratory  tract,  dyspnoea  is  a  common  complaint,  and  is 
described  by  Eichhorst  as  an  haematogenous  respiratory  insufficiency. 
The  respiration  rate  is  26  to  30.  Sometimes  a  paroxysmal  cough 
develops. 

4.  The  digestive  tract  is  involved  in  31  per  cent,  of  cases.  There 
is  sometimes  jator  ex  ore.  (a)  Pain  in  the  stomach  is  frequent;  it 
may  occur  near  the  ensiform  with  tenderness,  especially  in  nervous 

53 


834  DISEASES  OF  THE  BLOOD 

individuals.  It  sometimes  results  in  vomiting,  and  may  be  associated 
with  pyloric  cramp;  similar  pains  occur  in  the  transverse  colon. 
Sensitiveness  at  the  tip  of  the  twelfth  costal  cartilage  is  due  to  pressure 
from  corsets,  (b)  Dyspepsia  may  be  purely  nervous.  The  stomach 
is  exceptionally  dilated  and  atonic,  but  as  a  rule  no  motor  insufficiency 
occurs.  Corsets  and  chlorosis  may  cause  gastroptosis.  (c)  The  hydro- 
chloric acid,  formerly  thought  to  be  decreased,  is  increased  in  80  to 
95  per  cent,  of  cases;  nervous  irritability  is  its  most  probable  cause. 
(d)  It  is  said  that  constipation  is  usually  present,  but  it  is  probably 
no  more  frequent  than  in  the  average  case;  intestinal  fermentation 
may  co-exist  but  it  is  not  the  cause  of  chlorosis. 

5.  Inthe  sexual  sphere  there  jnaj  he  sjin.Y>tonis.  The  uterus  infantilis 
and  small  ovaries  are  not  causal,  but  are  coordinate  with  chlorosis, 
being  evidence  of  degeneration  or  hypoplasia.  Menstruation  is  de- 
creased or  absent  in  80  per  cent.;  menstrual  disturbance  is  neither 
the  cause  nor  result  of  chlorosis;  both  result  from  a  common  factor. 
Conception  is  unlikely  to  occur  during  a  chlorotic  attack.  Chlorotics 
are  often  first  treated  by  the  gynaecologist,  for  leucorrhoea  (in  22  per 
cent,  of  cases). 

6.  Special  senses.  The  usual  symptoms  of  anaemia,  as  spots  before 
the  eyes,  and  weakness  of  accommodation,  are  observed.  The  retinal 
vessels  may  be  transparent  or  pulsating;  retinitis  and  neuroretinitis 
with  degeneration  and  exudation,  or  "  choked  disk,"  occur  in  excep- 
tional cases  and  simulate  brain  tumor.    Retinal  hemorrhage  is  rare. 

7.  The  skin  is  usually  ansemic;  angiospasm,  coldness,  and  par- 
sesthesia  occur.  In  chlorosis  rubra  the  cheeks  are  flushed.  Seborrhoea 
and  acne  are  very  common.  Sweats,  urticaria,  eczema,  purpura, 
chloasma  and  trophic  disturbance  of  the  hair  and  nails  may  occur. 

8.  The  nervous  system  may  be  affected.  Chlorosis  often  brings  out 
a  latent  neurosis, — especially  hysteria, — and  psychosis,  the  latter  of 
which  is  frequently  curable.     Neuralgia  is  infrequent. 

9.  Metabolism  is  not  essentially  disturbed.  The  body-weight  is 
maintained,  less  from  decreased  oxygenation  than  from'  inactivity  or 
water  retention.  Some  cases  are  emaciated,  and  occasionally  an  actual 
gain  in  weight  is  noted.  The  urine  is  clear,  of  low  specific  gra\dty, 
often  alkaline  with  decrease  of  urea  and  uric  acid  and  sometimes 
albuminuria.  Fever  is  usually  held  to  indicate  a  severe  anaemia, 
though  Leube  has  found  it  frequently  in  mild  chlorosis.  When  present 
it  is  always  well  to  differentiate  "tuberculous  pseudochlorosis." 

Complications. — Chlorosis  may  induce  acute  infections,  as  typhoid, 
pneumonia,  influenza  and  scarlatina,  and  may  render  their  clinical 
course  severe.  Venous  thrombosis  complicates  2  per  cent,  of  cases, 
occurring  largely  in  the  femoral  veins,  sometimes  in  the  cerebral  sin- 
uses, and  axillary  and  other  vessels.  It  is  probably  inflammatory. 
In  Leichtenstern's  series  of  86  cases  with  thrombosis,  56  per  cent, 
involved  the  veins  of  the  leg  and  34  per  cent,  the  cerebral  sinuses. 
Pulmonary  embolism  occurred  in  25  per  cent,  of  52  cases  of  throm- 
bosis of  the  lower  extremities   (Welch).     Virehow  emphasized  the 


CHLOROSIS  835 

frequency  of  septic  endocarditis.  Rheumatic  endocarditis  with  organic 
valvular  lesion  is  frequent,  as  also  are  ulcer  of  the  stomach,  tuber- 
culosis and  Basedow's  disease.  The  spleen  is  enlarged  (in  37  per  cent, 
according  to  Chvostek,  or  in  16  per  cent.,  according  to  Leube).  The 
thyroid  gland  is  often  Toaoderately  enlarged.  Hemorrhages  are  not 
infrequent  from  the  nose,  stomach  or  intestine,  although  it  is  usually 
stated  that  they  occur  mostly  in  severe  or  pernicious  anaemias. 

Clinical  Course  and  Prognosis. — Simple  chlorosis  develops  rather 
suddenly  in  a  few  days  or  weeks.  It  runs  a  relatively  short  course 
of  two  to  three  or  four  months.  The  prognosis  is  generally  good.  The 
tendency  to  recurrence  is  great,  especially  in  unmarried  or  childless 
women ;  the  blood  may  not  return  absolutely  to  normal ;  this  is  shown 
by  persistent  pallor  or  irregular  menstruation.  Acute  chlorosis  is 
observed  especially  in  young  girls  after  their  first  menstruation;  it 
is  attended  by  severe  headache,  nervous  symptoms,  great  weakness 
and  optic  neuritis  or  "choked  disk,"  and  may  be  confused  with  organic 
disease,  as  brain  tumor.  The  periodic  type,  according  to  Von  Noorden, 
occurs  in  the  higher  classes  and  in  those  who  acquire  the  disease  in 
their  seventeenth  to  nineteenth  year.  The  course  may  be  chronic; 
the  disease  may  last  for  years  with  chlorotic  blood,  menstrual,  dyspep- 
tic, muscular  and  nervous  symptoms,  with  alternate  exacerbation  and 
amelioration,  indicating  an  essential  inactivity  or  hypoplasia  of  the 
blood-making  organs;  this  form  begins  early  in  life  in  individuals 
with  poor  development  of  the  bones,  muscles,  genitalia,  mammae,  and 
adipose  tissue;  marriage,  pregnancy,  and  iron  often  benefit  these  cases 
but  they  may  last  until  the  menopause. 

Diagnosis. — It  must  be  remembered  that  the  diagnosis  cannot  be 
made  by  any  single  symptom  but  by  the  entire  group  of  symptoms, 
both  positive  and  negative,  for  no  single  symptom  is  pathognomonic. 
The  diagnosis  is  based  upon  the  dncemia,  especially  when  there  is 
disproportionate  reduction  in  the  hcemoglobin,  when  the  color  index  is 
less  than  one,  and  the  white  cells  are  normal;  a  diagnosis,  however, 
cannot  be  made  from  the  blood  findings  alone.  (Rhomberg  has  de- 
scribed exceptional  cases  in  which  the  blood  was  normal.)  Chlorosis 
is  infrequent  before  the  twelfth  and  after  the  twenty-fifth  year,  unless 
the  attack  is  a  relapse.  Its  rapid  development  and  periodic  manifes- 
tation are  important  features.  Successful  treatment  with  iron  is  prac- 
tically diagnostic.  Secondary  anosmia  is  most  difficult  to  differentiate 
(see  Differentiation  under  Pernicious  Anemia)  ;  it  is  usually  at- 
tended by  some  leukocytosis.  Anaemia  from  intestinal  parasites, 
hemorrhage  from  latent  ulceration  of  the  stomach  or  bowel,  renal 
disease,  early  pregnancy  in  unmarried  girls,  the  anaemia  of  heart 
disease,  incipient  brain  disease,  rheumatism,  and  lead  and  arsenic 
anaemias,  must  be  considered.  Splenic  anaemia,  especially  in  children, 
requires  differentiation;  cases  of  chlorosis  with  enlarged  spleen  are 
regarded  as  a  transitional  form  between  chlorosis  and  splenic  anaemia 
proper.  Malignant  disease  usually  causes  little  diagnostic  difficulty 
after  careful  examination.     There   is    sometimes    great  difficulty  in 


836  DISEASES  OF  THE  BLOOD 

diflferentiation  from  incipient  tuberculosis.  Frequent  physical  exami- 
nation and  watching  of  the  temperature  usually  establish  the  diagnosis. 

Treatment. — Prophylaxis  includes  general  hygiene  and  proper 
nourishment,  in  that  development  of  adipose  tissue  to  a  reasonable 
extent  is  prophylactic.  More  albumin  shouid  be  given  to  growing 
children  than  to  adults,  although  fruit  and  vegetables,  for  their  iron, 
and  butter,  cream  and  oils,  rather  than  animal  fats,  should  also  be 
administered.  Physical  culture  and  trips  to  the  country  are  valuable, 
and  constipation  should  be  prevented.  Education  should  not  be  hur- 
ried; all  children  at  this  age  are  confined  too  much  to  the  school-room; 
they  should  be  kept  children  as  long  as  possible.  In  society,  and  in 
the  struggle  for  existence,  young  girls  too  often  overtax  their  strength. 

Specific  Therapy. — Iron  exists  in  the  haemoglobin  of  the  blood  cells, 
as  an  oxygen  carrier,  and  is  a  food  as  well  as  a  medicine;  it  is  found 
in  blood,  meat,  oatmeal,  peas,  spinach,  beans,  and  the  yolk  of  eggs. 
Milk  is  poor  in  iron. 

Physiological  Action  of  Iron. — (a)  The  tonus  of  the  nervous  system 
is  increased,  though  an  excess  produces  frontal  headache  from  con- 
stipation ;  some  persons  show  a  peculiar  intolerance  of  iron,  as  shown 
by  the  headache,  the  vertigo  and  the  palpitation  which  it  produces. 
(6)  It  affects  the  circulation;  locally  astringent,  it  coagulates  albumin 
and  contracts  the  bloodvessels.  It  increases  the  number  of  red  disks 
and  the  amount  of  haemoglobin,  (c)  Its  action  on  the  gastro-intestinal 
tract  is  as  follows:  iron  stains  the  teeth  because  of  the  acid  which  it 
contains.  Small  doses  stimulate  digestion,  improving,  by  their  astrin- 
gent action,  the  tone  of  the  tissues.  Hydrogen  is  generated  and  from 
it  sulphureted  hydrogen,  which  causes  eructations.  Small  doses  cause 
constipation,  but  large  doses  relax  the  bowels;  diarrhoea  also  some- 
times follows  small  doses.    Sulphide  of  iron  is  found  in  the  dark  stools. 

(d)  The  amount  of  urine  is  increased.  Iron  is  found  in  the  urine  in 
very  small  quantities.    The  kidneys  may  be  irritated  by  very  large  doses. 

(e)  In  regard  to  its  absorption,  there  is  great  conflict  of  opinion,  and 
experiments  are  incomplete.  There  are  four  theories :  (i)  That  iron 
is  absorbed  from  the  stomach  and  intestines  as  an  albuminate;  it 
reaches  the  blood  and  is  deposited  first  in  the  spleen  and  then  in  the 
liver,  whence  it  is  then  carried  Ly  the  bloodvessels  to  the  intestines 
for  elimination.  Although  Schmiedeberg  and  Kobert  insist  that  iron 
is  not  absorbed,  there  is  strong  clinical  evidence  that  it  is.  (ii)  That, 
being  an  astringent,  it  calls  forth  tonicity  of  intestinal  tissues  and 
stimulates  absorption  of  other  foods,  which  is  probably  also  true,  (iii) 
Bunge's  theory  is  that  in  anaemia,  hydrochloric  acid  is  deficient  and 
allows  fermentation ;  that  iron  acts  by  neutralizing  the  alkaline  sulphides 
(products  of  fermentation)  and  allows  iron  in  albuminous  food  to  be 
absorbed,  as  it  thus  escapes  union  with  sulphides.  This  theory  is  now 
abandoned,  (iv)  On  reaching  the  blood,  it  acts  as  a  stimulant  to  the 
blood-making  centres.  (/)  Elimination  occurs  by  the  intestines,  the 
kidneys  and  liver. 


CHLOROSIS  837 

Administration. — 'It  may  be  advantageously  combined  with  quinine, 
particularly  when  the  spleen  is  enlarged;  it  may  also  be  given  with 
oxygen,  normal  salt  transfusions,  and  massage;  the  patient  should 
have  rest  and  change  of  environment,  and  climate.  Soluble  prepara- 
tions would  seem  to  be  better  than  insoluble  ones,  but  Quevenne  has 
shown  that  they  are  precipitated  by  the  gastric  juice.  Headache  may 
occur;  it  is  obviated  by  using  laxatives,  bromides  or  ferrous  salts, 
which  derange  digestion  less  than  ferric  salts.  Iron  is  said  to  be 
best  absorbed  when  some  gastric  catarrh  exists  (Brunton),  hence 
some  practitioners  give  large  doses  at  first,  to  improve  absorption. 
There  are  only  38  to  45  grains  of  iron  in  the  body  and  the  ordinary 
daily  diet  contains  but  one-sixth  of  a  grain  of  iron,  but  the  nucleo- 
albumin  preparations,  which  are  sufficient  as  food,  are  not  sufficient 
as  medication,  because  they  do  not  stimulate  the  blood-making 
centres.    The  rules  for  administration,  according  to  von  Noorden  are: 

(a)  The  doses  should  not  be  too  small  (Niemeyer  and  Immermann). 

(b)  Every  physician  has  his  own  method,  therefore  no  one  form  espe- 
cially excels  any  other,  (c)  The  administration  should  be  regular, 
for  irregularity  is  injurious.  Statements  of  the  patient  that  she  has 
previously  taken  iron  should  not  be  regarded,  for  its  administration 
may  have  been  irregular,  (d)  Administration  should  continue  for  six 
weeks  to  three  months.  In  the  first  week  the  dose  should  be  gradually 
increased;  for  three  weeks  the  maximum  dose  should  be  given  and 
for  the  last  two  weeks  it  should  be  gradually  decreased,  (e)  If  iron 
is  not  beneficial,  it  should  not  be  repeated  but  other  methods  tried. 
(/)  Relapses  are  less  easy  to  treat  than  the  first  attack,  (g)  Idiosyn- 
crasy, as  gastro-intestinal  disturbance,  is  only  a  relative  contra- 
indication. The  administration  should  then  be  subcutaneous,  (h)  At 
mineral  springs,  hygiene  is  more  important  than  iron ;  the  water  should 
be  taken  on  an  empty  stomach,  for  the  gas  promotes  absorption  of 
iron.    When  bottled  it  is  precipitated  as  a  carbonate. 

Iron  may  be  given  in  the  following  forms:  Ferrum  redibctum  (reduced 
iron)  which  is  iron  gray  (if  it  is  black,  it  is  impure),  and  tasteless; 
it  is  least  astringent,  but  may  cause  eructation;  gr.  j.  (See  formula 
for  reduced  iron  given  under  Therapy  of  Valvular  Disease,  page 
428).  Pilula  ferri  carbonatis ,  a  ferrous  salt  nearly  free  from  astringency; 
grs.  ij  to  V.  Ferri  sulphas  (green  vitriol),  a  ferrous  salt  which  is  very 
astringent,  whence  its  use  in  chronic  diarrhoea.  It  stimulates  digestion. 
In  large  quantities  it  is  toxic,  causing  vomiting  or  diarrhoea.  Smart 
considers  it  the  best  form:  gr.  ij  should  be  given  with  one  dram  of 
magnesium  sulphate  p.c.  Ferri  sulphas  exsiccatus  gr.  ss  to  ij  (gm. 
0.03  to  0.12)  may  also  be  given.  Liquor  ferri  et  ammonii  acetatis 
(Basham's  mixture)  is  a  vascular  tonic  and  diuretic;  it  is  excellent  for 
chlorosis  in  the  obese;  3j  to  iv  should  be  given  after  meals,  well 
diluted.  Tinctura  ferri  chloridi  is  the  chloride  of  iron  plus  hydrochloric 
acid  and  alcohol,  which  develop  hydrochloric  ether.  It  is  yellow-red, 
astringent,  somewhat  corrosive  and  diuretic,  increasing  the  amount  and 
frequency  of  micturition.     It  is  used  to  best  advantage  when  the  tongue 


838  DISEASES  OF  THE  BLOOD 

is  white,  flabby,  and  indented.  In  weak,  anaemic  girls,  w^th  vomiting, 
neuralgia  and  epigastric  pains,  full  doses  should  be  given ;  when  poorly 
tolerated,  one  drop  in  a  full  glass  of  water  should  be  given ;  this  is  more 
beneficial  than  most  chalybeate  waters.  Syrwpus  ferri  iodidi  is  trans- 
parent and  has  a  greenish  color;  iron  and  iodine  given  separately  are 
usually  more  beneficial,  but  the  syrup  may  be  given  in  doses  of  30  to 
40  drops  in  adults  and  of  5  to  10  in  children.  Ferri  citras  in  doses  of  gr. 
V,  is  efficacious  in  children  and  in  persons  having  delicate  stomachs. 
Ferri  phosphas  solubilis,  gr.v,  is  almost  free  from  astringency  and 
taste.  The  organic  preparatio7is  are  generally  useless.  Ovoferrin, 
however,  is  excellent.  The  author  thoroughly  agrees  with  the  conclu- 
sions of  R.W.Wilcox:  (a)  It  is  the  exact  chemical  form  for  assimila- 
tion, (b)  It  is  not  dissociated  by  the  gastric  juice  into  the  astringent 
iron  chloride,  (c)  It  does  not  interfere  with  digestion,  but  has  a  notice- 
able effect  in  increasing  the  appetite,  (d)  It  does  not  irritate  the 
aHmentary  canal,  (e)  Its  effect  in  increasing  the  red  corpuscles  and 
the  haemoglobin  is  constant  and  progressive.  (/)  It  has,  aside  from 
its  blood-forming  effect,  a  demonstrable  tonic  and  reconstructive 
action,  which  can  be  explained  only  by  a  stimulating  influence  upon 
metaboHsm. 

Arsenic  may  be  given  with  the  iron  or  in  its  place;  it  acts  on  the 
blood-making  centres;  it  should  be  given  as  in  pernicious  anaemia 
uninterruptedly,  with  gradually  increasing  doses,  sustained  doses,  and 
then  decreasing  doses,  for  a  period  of  four  to  six  weeks. 

High  altitude  increases  the  number  of  red  cells  and  the  amount  of 
haemoglobin.  Phlebotomy,  sweating  and  organotherapy  (bone  marrow, 
splenic  and  ovarian  extracts),  have  been  suggested. 

Dietetic  Treatment. — Regular  meals  should  be  given  at  three-hour 
intervals.  The  amount  of  albumin  should  be  increased,  even  in  the 
obese.  The  heavy  English  breakfast  "^-ith  meat  is  the  best  one,  because 
the  albumins  are  absorbed  and  taken  up  by  the  tissues  more  rapidly 
than  are  fats  and  carbohydrates;  according  to  von  Noorden  two  to 
four  ounces  of  meat  should  be  given  with  some  bread  and  a  cup  of 
coffee.  In  administering  milk,  care  should  be  observed  lest  the  appe- 
tite be  spoiled,  lest  too  much  fat  be  deposited,  and  the  stomach  suffer 
atony.  Equal  parts  of  milk  and  cream  should  be  given.  Milk  should 
be  avoided  in  the  obese.  Alcohol  is  indicated  in  thin,  rather  than  in 
obese  individuals.  Patients  should  always  rest  before  and  after  eating. 
The  patient  should  retire  early.  In  thin  subjects  the  diet  should  be 
concentrated,  consisting  of  albumin,  vegetables,  fats,  alcohol  and  milk 
at  breakfast  and  at  bed  time,  but  without  increase  of  the  carbohydrates. 
Iron  produces  better  results  in  such  cases  after  limiting  the  amount  of 
water  to  about  one  quart;  the  latter  procedure  of  itself  is  said  to  be 
beneficial  in  chlorosis.  Sweats  may  produce  the  same  result.  When 
there  is  much  gastric  disturbance,  eight  meals  may  be  given  at  two- 
hour  intervals,  and  fluid  and  solid  meals  should  be  alternated.  Gastric 
disturbance  disappears  after  administration  of  iron  and  increase  in 
weight.     Hydrochloric  acid,  strychnia   and  belladonna  are  helpful. 


PERNICIOUS  ANEMIA  839 

Exercise  may  be  prescribed  in  convalescence,  but  in  moderate  and 
severe  cases  the  patient  should  rest  in  bed.  Hydrotherapy,  especially 
by  cool  rubbings  early  in  the  morning,  is  advantageous.  Cold  baths 
are  to  be  avoided,  because  they  produce  chills,  insomnia,  and  digestive 
disturbances.  Marriage  may  help  mild  cases,  but  produces  injurious 
results  in  the  severe  type. 


(B).  PERNICIOUS  AN.ffiMIA. 

Definition. — A  primary  anaemia,  in  which  are  observed  progressive 
diminution  of  the  red  cells,  with  changes  in  their  form  and  color, 
and  reduction  in  the  haemoglobin,  without  changes  in  the  white  cells; 
this  form  of  anaemia  is  due  to  haemolysis  and  to  defective  haemogenesis; 
it  is  characterized  by  pallor,  adynamia,  oedema  and  cardiac  symptoms, 
and  usually  results  in  death  from  vomiting,  diarrhoea,  hemorrhages, 
fever  and  exhaustion.  It  was  described  by  Andral  (1826)  and  Chan- 
ning  of  Boston  (1832);  Addison  gave  the  best  early  description,  and 
Biermer  later  drew  attention  to  the  subject. 

Etiology. — The  disease  occurs  in  0.2  per  cent,  of  cases,  especially 
in  the  third  and  fourth  decades  of  life,  although  also  observed  in  other 
periods,  as  in  nurslings,  and  very  late  in  life.  Baginsky  could  collect 
but  16  cases  in  children.  Sixty  per  cent,  occurs  in  males.  Although 
called  a  primary  or  essential  anaemia,  some  cases  are  undoubtedly 
secondary  which  may  properly  be  included  under  this  head,  because  the 
symptom  complex  is  the  same.  Bothriocephalus,  and  anchylostoma 
anaemia  present  identical  blood  findings,  symptoms,  and  pathology; 
not  merely  the  parasite  but  also  its  toxins  are  causative.  Pregnancy 
and  the  puerperium,  in  certain  localities  at  least,  are  causative.  Syph- 
ilis, poor  hygiene,  infectious  diseases,  as  typhoid  or  malaria,  and  diar- 
rhoea, vomiting,  repeated  loss  of  blood,  and  oral  or  gastro-intestinal 
sepsis  have  been  considered  factors.  The  precise  cause  of  the  blood 
destruction  (haemolysis)  is  not  known. 

S3maptoms. — 1.  The  Blood  Changes  (Sorenson,  1874). — The  amount 
is  decreased,  several  punctures  often  being  necessary  to  obtain  enough 
for  the  blood-count;  it  is  often  watery,  or  dark,  or  amber-colored  in 
some  instances.  The  specific  gravity  is  low,  even  1,027;  the  dry 
substance  is  reduced,  even  to  9  or  10  per  cent,  of  the  normal.  There 
is  an  increase  in  the  albumin  in  the  individual  red  cell  (hyperalbumin- 
semia  rubra,  von  Jaksch).  The  serum  does  not  contain  free  haemo- 
globin, as  has  been  asserted  by  Limbeck.  If  injected  into  normal 
individuals,  the  serum  has  a  globulicidal  action.  In  contrast  to  chloro- 
sis and  secondary  anaemias,  the  coagulability  of  the  blood  is  decreased, 
and  the  blood  may  remain  fluid  for  some  time  after  death;  Hayem 
holds  that  the  rarity  of  blood  plates  and  lack  of  retractility  of  the 
clot  are  the  most  characteristic  features  of  pernicious  anaemia.  The 
haemocjlohin  is  decreased;  it  is  rarely  more  than  50  per  cent,  of  the 
normal,  and  may  be  reduced  to  10  per  cent.    In  some  instances  severe 


840  DISEASES  OF  THE  BLOOD 

symptoms  may  be  present,  with, 65  to  70  per  cent,  haemoglobin.  In 
contrast  to  other  anaemias,  the  hcemoglobin  per  corpiiscle  is  proportion- 
ately increased,  i.e.,  the  color-index  is  more  than  one  (even  1.75). 
Laache  explains  the  phenomenon  in  that  certain  red  cells,  especially 
giant  forms,  contain  a  large  compensatory  individual  amount  of  haemo- 
globin, which  is  also  true  of  the  microcytes,  but  less  so  of  normal-sized 
red  cells.  The  relative  increase  of  the  haemoglobin  per  corpuscle 
is  thus  best  explained,  and  Limbeck's  assumption  of  a  hsemoglob- 
inaemia  is  not  generally  admitted.  Schmidt,  Ponfick  and.  others  of 
the  Dorpat  school,  maintain  that  the  free  haemoglobin,  acting  on  the 
white  cells,  produces  a  fibrin  ferment,  which  causes  fever,  hemorrhage 
and  capillary  embolism.  The  red  blood  corpuscles  are  greatly  reduced 
in  number,  the  average  being  1,200,000.  Plate  XIII.  Patients  often 
die  when  this  figure  is  reached.  Lower  counts  have  been  noted, 
as  143,000  (Quincke).  Poihilocytosis  is  marked,  the  irregularity  in 
form  and  size  of  the  corpuscles  being  great;  great  deformities,  as 
Litten's  horse-shoe  or  pessary-shaped  corpuscles  are  noted.  The 
individual  red  corpuscle  is  above  the  average  size,  i.e.,  11  to  13,  even 
16  to  18/x  instead  of  5  to  8/i,  the  highest  normal  measurement.  Megalo- 
cytes  may  be  observed  in  number,  with  less  marked  or  absent  umbili- 
cation.  Polychromatism  is  frequent.  Megalocytes  in  pernicious 
anaemia  are  evidence  of  megaloblastic  degeneration  of  the  bone-marrow 
(but  have  been  held  as  evidence  of  regeneration).  The  varieties  of 
nut^leated  and  non-nucleated  erythrocytes  are  depicted  in  Fig.  VIII, 
Plate  XIV.  Megaloblasts  are  found  but  rarely  in  large  numbers,  seldom 
more  than  six  or  eight  being  seen  in  a  single  preparation  (Ehrlich); 
in  rare  cases  they  may  be  abundant,  as  just  before  death,  whence 
their  generally  ominous  significance;  they  may  be  absent  for  months 
or  weeks  at  a  time.  Normoblasts  occur  in  relatively  light  cases,  espe- 
cially in  the  "blood  crises"  of  von  Noorden,  but  are  not  numerous. 
Microblasts  are  frequently  absent  and  are  not  umbilicated;  their  teleo- 
logic  significance  lies  in  the  increase  of  the  respiratory  surface  of  cells 
thus  afforded.  Cell  divisions  are  found.  (Plate  XIII,  Fig.  3.)  Granular 
deposits  (staining  with  basophilic  dyes),  in  the  protoplasm  are  noted,  as 
in  malaria,  cachexia,  leukaemia  and  suppuration;  according  to  Ehrlich, 
they  are  not  due  to  polychromatophile  degeneration  but  to  nuclear 
degeneration.  The  cells  may  stain  only  at  their  margins.  Decreased 
formation  of  rouleaux  is  observed  as  well  as  amoeboid  movement  of 
the  red  cells.  The  white  corpuscles  are  decreased  absolutely,  the  lowest 
record  being  1,500;  the  polymorphonuclears  are  decreased.  Leuko- 
cytosis is  a  distinct  complication,  is  often  ominous  though  not  necessarily 
fatal,  and  indicates  infiammation,  suppuration,  or  pneumonia.  Apart 
from  complications,  increase  in  the  leukocytes  may  take  the  form  of  a 
lymphocytosis,  the  lymphocytes  being  relatively  increased,  even  to 
62  per  cent,  of  the  total  white  cells.  The  leukocytes  are  readily  in- 
creased in  children  in  any  variety  of  anaemia.  Marked  decrease  of 
the  eosinophiles  is  an  unfavorable  sign  according  to  Neusser.  Pernic- 
ious anaemia  due  to  parasites  shows  increase  in  the  eosinophiles  from 


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PERNICIOUS  ANJEMIA  841 

1  to  4  per  cent,  (normal)  to  6,  36  and  even  50  per  cent.  (Walker).    (See 
Plate  XIV,  Fig  V). 

2.  Subjective  Symptoms. — The  most  marked  are  general  weakness, 
muscular  adynamia  on  exertion,  vertigo,  palpitation,  dyspnoea  and  the 
ordinary  signs  of  anaemia. 

3.  Skin. — The  skin  presents  a  peculiar  pallor,  often  of  a  lemon 
color,  which  is  somewhat  characteristic.  Slight  icterus  is  not  infre- 
quent. The  skin,  usually  dry,  may  become  drenched  upon  exertion. 
OEdema  is  invariable,  occurring  especially  about  the  ankles  and  eye- 
lids. It  is  usually  not  marked,  but  is  obstinate  and  may  produce 
pronounced  general  anasarca;  it  is  due  to  vascular  degeneration  and 
permeability.  Hemorrhages,  usually  punctate,  are  frequent  in  the  skin 
and  mucosae.  Large  hemorrhages  are  infrequent.  Pigmentation  is 
sometimes  as  marked  as  in  Addison's  disease.  The  author  once  saw 
herpes  zoster,  and  once  herpes  along  the  crural  nerve.  Sometimes 
before  death  the  skin  emits  a  foul,  cadaverous  odor  (Eichhorst). 

4.  Metabolism. — The  nutrition  is  generally  good  and  the  panniculus 
adiposus  is  maintained,  because  tissue  waste  is  lessened  and  water  is 
retained  in  the  tissues.  The  weight  and  strength  may  finally  decline 
with  persistent  vomiting  and  diarrhoea.  Opinions  differ  as  to  the 
destruction  of  the  albumins.  In  the  urine,  indican,  putrescin  and 
cadaverin  are  found.  Haematuria  and  glycosuria  are  rare.  Albumin- 
uria, due  to  tubular  degeneration,  is  frequent.  Albumosuria  is  some- 
times noted;  urobilin  is  frequently  increased,  and  this  sometimes 
imparts  a  dark  color  to  the  urine  and  indicates  haemolysis.  The  uric 
acid  is  sometimes  increased.  Leucin  is  almost  constant  and  tyrosin 
not  infrequent.  The  chlorides  are  decreased.  Acetone  and  diacetone 
are  sometimes  found.  The  iron  in  the  urine  is  sometimes  increased, 
and  the  phosphates  are  greatly  increased.  Fever,  present  in  80  per 
cent,  of  cases,  bears  no  constant  relation  to  the  severity  of  the  disease. 
It  may  rise  considerably;  the  temperature  may  fall  below  normal  in 
the  ante-mortem  coma.  The  type  is  irregular.  Its  cause  is  ill-under- 
stood; it  is  probably  due  to  the  production  of  a  ferment  from  the 
destroyed  red  cells,  or  according  to  Schmidt,  Ponfick  and  others, 
from  a  fibrin  ferment  formed  from  the  leukocytes  (v.s.). 

5.  The  Circulation. — Palpitation,  precordial  anxiety  and  dyspnoea 
are  observed,  but  sometimes  only  on  exertion  or  excitement.  The 
heart  impulse  is  irregular,  and  fallaciously  strong  to  the  palpating 
hand.  Its  outlines  are  usually  normal,  save  that  some  dilatation  of 
the  right  heart  may  occur  or  hydrops  pericardii  develop.  Frequently 
a  blowing  systolic  murmur  is  heard,  usually  with  a  clear  diastolic 
tone;  the  murmur  is  rarely  diastolic.  The  second  pulmonic  sound  is 
variable,  sometimes  accentuated.  No  parallelism  exists  between  the 
degree  of  anaemia  and  the  loudness  of  the  murmur.  Leube  reports 
a  number  of  cases  of  chlorosis  and  pernicious  anaemia  in  which  there 
was  relative  tricuspid  insufficiency;  the  positive  venous  pulse  was 
present  but  no  cyanosis.  A  venous  hum  in  the  neck,  carotid  pulsation 
and  thrills,  a  loud,  clear  systolic  tone  and  murmurs  and  double  tones 


842  DISEASES  OF  THE  BLOOD 

over  the  peripheral  arteries  are  often  present.  The  pulse  tension  is 
decreased,  and  its  rate  increased,  being  rarely  below  80  and  usually 
ranging  between  90  and  120.  Anatomically  the  heart  shows  vestiges 
of  hemorrhage,  degeneration  and  atrophy.  The  fatty,  "tabby-cat 
heart"  is  almost  constant,  though  absent  in  some  cases  (Litten). 
Degeneration  in  the  smaller  vessels  has  been  noted,  especially  in  those 
of  the  brain. 

6.  Digestive  Tract. — Anorexia,  distaste  especially  for  meats,  gastric 
achylia,  pain,  and  sensitiveness  throughout  the  alimentary  tract  are 
noted.  The  tongue  and  gums  are  sensitive,  and  circumscribed  or 
punctate  hemorrhages  are  often  noted  in  them.  Pain  in  the  mouth 
and  oesophagus  is  sometimes  due  to  the  administration  of  arsenic. 
The  gums  may  ulcerate,  erythema  bullosum  and  other  eruptions  may 
occur.  Vomiting  is  frequent  in  various  stages  of  the  disease,  and  is 
often  continuous  or  incoercible;  the  vomitus  consists  of  food,  greenish 
mucus,  and  sometimes  traces  of  blood.  Epigastric  pulsation,  moderate 
abdominal  distention  and  decreased  or  suppressed  secretion  of  hydro- 
chloric acid  are  observed.  The  author  once  saw  expansile  abdominal 
pulsation  which  was  wrongly  diagnosticated  as  aneurysm.  The  glands 
in  the  gastro-intestinal  tract  may  atrophy,  which  probably  toxsemic  con- 
dition is  coordinate  with  and  not  causal  of,  pernicious  anaemia.  The 
mesenteric  glands  are  not  infrequently  enlarged.  Constipation  or  often 
paroxysmal  diarrhoea  may  occur.  The  stools  are  not  characteristic, 
although  sometimes  acholic  from  poor  absorption  of  fat.  Parasites 
or  their  eggs  may  be  noted.  Leucin  and  tyrosin  crystals  are  frequent  and 
are  caused  by  diarrhoea,  but  are  not  in  any  sense  characteristic  of  the 
disease.  Fermentation  in  the  bowel  (with  indican  in  the  urine), 
some  oedema,  hemorrhage  and  follicular  swelling  in  the  bowel  are 
frequently  observed.  Some  ascites  is  found  in  the  terminal  stage  of 
the  disease.  A  deposit  of  iron  (siderosis)  in  the  liver,  in  the  outer  and 
middle  zones  of  its  lobules,  also  in  the  spleen,  marrow,  kidneys  and 
lymphatic  glands,  is  usual,  and  results  from  haemolysis;  it  is  very 
unusual  in  other  anaemias.  There  is  most  hepatic  siderosis  in  acute 
cases.    The  liver  is  often  slightly  swollen  and  tender. 

7.  Blood-making  Organs. — ^The  lymph  glands  are  not  usually  en- 
larged. The  prevertebral  haemolymph  glands  have  been  carefully 
studied  by  Warthin,  who  found  their  sinuses  dilated  and  evidences  of 
haemolysis  in  their  tissue  which  was  shown  by  increased  phagocytosis 
and  sometimes  hyperplasia  of  the  glands;  Warthin  holds  that  pernic- 
ious anaemia  is  a  haemolytic  disease  caused  by  an  unknown  poison 
which  stimulates  the  phagocytes  of  the  spleen,  lymph  nodes  and  haemo- 
lymph glands  to  increased  haemolysis.  The  hones  are  tender,  especially 
over  the  sternum  and  tibia  and  sometimes  painful,  and  their  fatty 
marrow  may  become  lymphoid;  this  is  not  characteristic  of  the  dis- 
ease, for  lymphoid  transformation  may  occur  in  other  forms  of  anaemia, 
in  cachexia  or  in  fevers;  in  pernicious  anaemia  the  red  cells  of  the 
marrow  are  abnormally  large,  abnormally  dark  from  increase  of  the 
haemoglobin,  and  are  oval  rather  than  round.    The  bone  changes  were 


PERNICIOUS  ANEMIA  843 

first  described  by  Wood,  Pepper  and  Tyson  (1875).    The  spleen  is 
not  enlarged,  save  from  accidental  causes. 

8.  Sexual  Sphere. — The  menses  cease,  otherwise  no  characteristic 
changes  are  observed. 

9.  The  Nervous  System. — The  psychical  functions  are  decreased, 
the  memory  is  weak,  and  psychoses,  delirium,  hallucinations,  mania 
and  intractable  insomnia  may  develop,  either  temporarily  or  antecedent 
to  the  terminal  coma.  Sometimes  improvement  is  noted  after  severe 
mental  symptoms  or  coma,  compared  by  Laache  and  von  Noorden 
to  a  crisis.  The  pupils  are  rather  wide,  and  sometimes  their  reflexes 
disappear.  Paresis,  apoplectiform  attacks,  cramps,  convulsions,  par- 
eesthesia,  aphasia,  vertigo,  or  in  women  and  children  the  hydrencepha- 
loid  state  may  develop.  The  cord  is  more  frequently  involved  than 
the  brain.  The  weakness  may  amount  to  paresis,  not  due  simply  to 
muscular  adynamia  but  to  spinal  changes.  The  picture  may  resemble 
tabes  as  concerns  the  eyes,  patellar  reflexes,  ataxia,  bladder  and  rectal 
changes,  pains,  ansesthesia  and  parsesthesia ;  or  the  symptoms  of 
spastic  spinal  paralysis  prevail,  as  increased  reflexes  and  spastic 
paresis.  Frank  Billings  in  36  personal  cases  finds  two  groups,  one 
in  which  the  nervous  symptoms  are  slight,  and  a  second  in  which 
they  are  so  conspicuous  as  to  even  overshadow  the  anaemia  itself. 
He  found  early  pareesthesia  in  all  his  cases,  usually  in  the  hands  and 
feet,  sometimes  in  the  mouth;  sometimes  hypersesthesia  or  disturbance 
of  the  temperature  sense;  10  cases  were  spastic  and  atactic;  three 
had  paraplegia  with  abolished  patellar  reflexes,  involuntaries,  oedema 
and  bed-sores;  the  sexual  function  was  decreased  in  males,  and 
amenorrhoea  was  regular  in  women ;  histologically  he  found  a  sclerosis 
of  the  posterior  and  lateral  columns,  which  was  most  marked  in  the 
lower  cervical  and  upper  dorsal  segments,  was  not  always  diffuse  but 
sometimes  focal,  and  involved  chiefly  the  white  substance,  but  did 
not  invade  the  entire  neuron,  and  was  probably  due  to  a  toxin. 

The  peripheral  nerves  present  few  symptoms.  The  discrepancy 
between  the  anatomical  findings  and  the  clinical  symptoms  is  remark- 
able, i.e.,  there  may  be  many  symptoms  with  few  autopsy  findings, 
and  the  converse  is  also  true;  consequently  it  is  probable  that  the 
spinal  and  nervous  symptoms  are  less  sequences  of  anaemia  than 
coordinate  toxic  manifestations.  Anatomically,  capillary  hemorrhages 
and  disseminated  foci  of  softening  may  be  observed  in  the  brain 
and  meninges.  Degeneration  is  found  in  the  upper  part  of  the  cord, 
or  possibly  throughout  its  length.  The  white  substance  suffers  more 
extensively  than  the  gray.  Small  foci  of  degeneration  with  some 
secondary  connective  tissue  growth,  occur  about  the  bloodvessels, 
which  foci  may  fuse  into  plaques  of  small  size  with  secondary  degen- 
eration, hence  the  symptom  complex  of  a  systemic  disease;  the  changes 
usually  occur  in  the  posterior  column,  which  rarely  wholly  escapes. 
The  bloodvessels  may  suffer  degeneration,  widening,  thickening  or 
indeed  obliteration. 


844  DISEASES  OF  THE  BLOOD 

In  the  eyes,  the  general  symptoms  of  anaemia  occur;  the  patient 
thinks  he  sees  floating  spots;  hemorrhages  in  the  retina  are  almost 
constant;  occurring  on  a  pale  background,  with  tortuous  veins,  and 
a  strong  light  reflex  from  the  vessels,  the  hemorrhages  form  a  striking 
picture  (see  Plate  VI,  Fig.  9).  They  are  punctate  or  larger  and  their 
resorption  is  infrequent.  The  other  senses  are  obtunded;  labyrinthine 
hemorrhage  with  vertigo  is  recorded. 

Clinical  Course  and  Prognosis.— The  pallor  and  weakness  which 
are  first  observed  increase  insidiously,  and  later  dyspnoea,  weak  heart- 
action,  cedema,  complete  anorexia,  langor  and  violent  gastro-intestinal 
disturbance  and  finally  capillary  hemorrhages  and  fever  develop; 
this  vomiting  and  diarrhoea  may  at  times  resemble  acute  poisoning. 
In  other  instances  remissions  may  occur  with  treatment  or  independ- 
ently of  it,  perhaps  after  violent  gastro-enteric  manifestations.  The 
symptoms  may  partially  or  wholly  disappear,  as  in  Ehrlich's  case, 
where  the  red  cells  in  seventeen  days  rose  from  1,340,000  to  4,115,000. 
According  to  Laache,  in  simple  anaemia  the  red  corpuscles  gain  more 
rapidly  than  the  haemoglobin,  but  in  pernicious  anaemia,  improvement 
increases  both  equally.  The  disease  with  remissions  may  cover  a 
period  of  years,  the  longest  duration  being  ten  years.  Death  usually 
occurs  within  half  a  year. 

The  prognosis  is  usually  poor  when  megaloblasts  are  present  in 
numbers  or  when  the  color  index  is  over  one.  In  some  cases  the 
blood  is  rapidly  regenerated;  and  200,000  new  red  cells  may  appear 
in  the  blood  within  a  day. 

Cabot's  description  of  the  disease  recognizes  two  forms. 

The  Severe,  Rapidly  Fatal  Type — ^and  the  Less  Severe,  Slow  Type. 

(a)  Extreme  progressive  anaemia.  Remissions. 

(6)  Color  index  high.  Normal  or  low. 

(c)  Red  cells  increased  in  size.  Normal. 

(d)  Degenerative  changes.  None. 

(e)  Many  megaloblasts.  Many  normoblasts,   few  megaloblasts. 
(/)    Lymphocytosis.  Normal  ratio  of  the  various  white  ceUs. 

Death  usually  occurs  in  coma  or  possibly  from  cerebral  hemorrhage, 
or  other  rare  complications,  as  valvular  disease,  gastric  carcinoma, 
tuberculosis,  nephritis,  sepsis,  sarcoma,  or  leukaemia.  Pye-Smith  col- 
lected 20  cases  of  recovery.  According  to  Schauman,  the  mortality 
in  the  parasitic  form  is  17  per  cent. 

Diagnosis. — No  single  finding  is  absolutely  characteristic,  though  the 
pallor,  apathy,  adynamia,  oedema,  weak  heart,  retinal  hemorrhages, 
maintained  nutrition,  and  the  blood  findings  are  highly  suggestive. 
The  yellow  color  is  very  often  described  as  icterus  and  mistaken  for 
it.  The  increased  diameter  of  the  red  cells  may  also  be  found  in 
icterus,  and  Ewing  states  no  importance  should  be  attached  to  the 
increase  of  diameter,  unless  33  per  cent,  of  the  red  disks  show  it. 
Megaloblasts  are  highly  suggestive.  The  diagnosis  must  be  made  from 
the  negative,  as  well  as  from  the  positive  findings. 


PERNICIOUS  ANEMIA 


845 


Differentiation. — (a)  From  metastatic  bone-tumors,  in  which  the  white 
cells  are  increased  (not  merely  the  polymorphonuclear  but  the  neu- 
trophile  and  eosinophile  marrow  cells);  (6)  from  parasitic  anosmia,  for 
which  the  stools  should  be  examined  for  parasites  and  their  eggs ;  (c) 
jever,  if  dominant,  may  suggest  typhoid  or  meningitis ;  acute  endocarditis 
may  be  simulated  by  the  fever,  anaemia,  heart  murmurs  and  cardiac 
insufficiency  of  pernicious  anaemia;  id)  from  latent  carcinoma,  the 
gradual  cachexia,  anorexia,  nausea,  vomiting,  heematemesis,  and  de- 
crease or  absence  of  hydrochloric  acid  may  suggest  gastric  carcinoma, 
but  the  blood  examination  with  thorough  physical  examination  usually 
determines  the  point;  (e)  spinal  disease,  Addison's  disease,  and  hemor- 
rhagic pleuritis,  are  usually  excluded  with  ease;  (/)  from  other  anosmias. 
The  following  is  constructed  after  Cabot's  table : 


Pernicious 
Anemia. 


Chlorosis. 


Secondary  Anemia. 


Red  Cells  Number. 
Shape. 

Size. 
Hsemoglobin. 

Staining. 
Nuclei. 


Rouleaux. 
Color  index. 

Leukocytes. 

Lymphocytes. 
Myelocytes. 

Adult  Leukocytes. 

Coagulation. 


Average    num- 
ber 1,000,000. 

Poikilocytosis 
great,  sausage- 
shape,  etc. 

Average  increased, 
some  dark. 

Increased  per  cor- 
puscle yet  many 
Ponfick's  shadow 
corpuscles. 

Polychromatophile 
ceUs. 

Micro-,  megalo-, 
normoblasts. 
Megalo-  more 
numerous  than 
normoblasts  and 
constitute  major- 
ity of  nucleated 
R.  B.  C, 

Not  present,  or 
decreased. 

High  color  index 
(not  in  chronic 
nor  mild  cases). 


W.  B.  C.  decTeased, 
except  in    blood 
crises,  hemor- 
rhage, suppxira- 
tion. 


Lymphocytosis 
(relative). 

Small    number 
only. 


Rarely  increased. 
Usually  de- 
creased. 

Slow. 


Rarely   under 
2,000,000. 

Somewhat   de- 
formed. 


Diminished,  light 
colored. 

Reduced    per 
corpuscle. 


Megaloblasts  rare 
though   recorded. 
Normoblasts 
more    than 
megaloblasts. 


Index  less  than  1 : 
always  low:  lower 
than  in  secondary 
ansemias. 

Usually  normal. 


Lymphocytosis. 

Rare;    less  than 
in  pernicious 
anaemia. 

Decreased. 


Rapid. 


Findings  as  in  chlorosis.    May  be 
1,000,000  or  less,  though  rarely. 


Various,  not  increased. 


Normoblasts  far  more  than  megalo- 
blasts in  malignant  diseases. 

Normoblasts  common  (more  than  in 
chlorosis). 


Relatively  low  (this  rule  does  not  hold 
positively). 


Polymorphonuclear  leukocytosis  in  ma- 
lignant disease,  when  R.  B.  C.  are'low 
in  number,  e.  g.  one  million,  speaks  for 
secondary  ansemia;  positive  of  more 
value  than  negative  findings  (i.  e.  no 
leukocytosis). 

Rarely  increased  (no  decrease). 
Myelocytes  very  rare. 

Usually  increaseu. 

Often  rapid. 


DISEASES  OF  THE  BLOOD 

Aplastic  anoemia  may  resemble  pernicious  anaemia  in  its  low  blood 
count,  reduced  hsemoglobin  or  even  its  color  index.  It  was  named 
by  Ehrlich  because  the  bone  marrow  was  white  or  yellow  and  aplastic. 
In  the  blood  there  are  no  evidences  of  regeneration  such  as  nucleated 
red  cells.  The  white  cells  may  number  only  200  per  c.mm,  and  80  to 
90  per  cent,  of  them  are  lymphocytes.  There  may  be  hemorrhages, 
fever,  or  hyperplasia  of  the  spleen  and  lymph  glands. 

LeukanoBmia  (see  Differentiation  of  LEUKiEMiA). 

Treatment. — l.  Hygienic. — The  patient  should  have  absolute  rest 
in  bed,  and  if  possible,  should  be  in  a  warm  climate.  An  excessive 
nitrogenous  diet  is  usually  given,  which  is  unwarranted  because  it 
increases  tissue  waste;  besides,  patients  have  an  instinctive  disinclina- 
tion to  nitrogenous  foods,  and  albumins  frequently  produce  diarrhoea. 
A  vegetable  diet  is  better  tolerated,  with  bread,  zwieback,  beef  tea, 
peptones,  milk,  honey,  or  porridge.  Nutrient  enemata  are  indicated 
in  the  gastric  crises.    In  pregnant  women,  labor  should  not  be  induced. 

2.  Haematinic. — (a)  Transfusion  of  defibrinated  human  blood  has 
been  practised  (Quincke,  Hoffman,  Landos),  though  it  is  seldom 
beneficial.  Human  blood  may  be  transfused  in  toto  (Ziemssen).  (6) 
Lupine  recommends  the  physiological  salt  solution,  based  on  Mara- 
gliano's  findings  that  the  serum  in  cases  of  pernicious  anaemia  has  a 
globulicidal  action  on  the  red  blood  cells.  The  serum  destroys  the 
haemoglobin  in  pernicious  anaemia  (the  blood  of  a  patient  clears  in  a 
test  tube  on  standing).  Salt  solution  should  be  given  frequently,  and 
acts  temporarily  on  the  serum,  (c)  Phosphorus  is  without  value  and 
iron  is  often  injurious,  (d)  Arsenic,  recommended  by  Bramwell,  is 
said  to  have  cured  the  disease,  though  most  cases  have  not  been  fol- 
lowed out  thoroughly;  it  is,  nevertheless,  the  best  remedy  known.  It 
probably  acts  by  irritating  the  blood-forming  centres.  Birsch-Hirsh- 
feld  explains  its  action  by  assuming  that  it  operates  in  some  way  upon 
the  serum,  which  in  this  disease,  destroys  the  corpuscles,  while  Litten 
holds  that  it  increases  the  number  of  white  cells. 

Physiological  Action  of  Arsenic. — (a)  The  smallest  dose  merely 
increases  the  appetite.  (6)  Small  doses  stimulate  the  appetite  by  gas- 
tric irritation,  by  increasing  secretion  and  stimulating  peristalsis; 
tissue  waste  and  elimination  of  nitrogen  is  lessened.  It  is  an  altera- 
tive, increases  the  muscular  strength  and  endurance,  improves  the 
quality  of  the  blood,  the  complexion,  sexual  powers,  and  lung  capacity, 
(c)  Continuous  administration  produces  constitutional  effects,  as  puffi- 
ness  of  the  eyes,  which  is  first  seen  in  the  morning  (Wier  Mitchell); 
this  may  be  followed  by  general  oedema,  due  to  vascular  and  some- 
times renal  alteration.  Administration  should  be  stopped  when  puffi- 
ness  is  observed,  (d)  Large  doses  result  in  anorexia,  nausea,  diarrhoea, 
abdominal  uneasiness  or  colic,  and  sympathetic  headache. 

The  circulation  is  stimulated  by  small  doses.  Arsenic  is  absorbed 
by  the  bloodvessels,  and  possibly  unites  with  the  red  cells.  Full  doses 
lessen  the  force  and  rate  of  the  heart,  for  they  act  directly  upon  the 
heart  muscle.     Arterial  pressure  is  reduced  by  peripheral  vasomotor 


ACUTE  POST-HEMORRHAGIC  ANEMIA  847 

paralysis.  Respiration  and  digestion  are  stimulated  by  small  and 
depressed  by  large  doses,  although  some  deny  the  stimulant  action  of 
any  dose.  Elimination  is  very  rapid,  and  is  effected  mostly  by  the 
kidneys  and  intestinal  mucosa,  but  also  by  the  skin,  bile,  lungs,  saHva, 
and  mother's  milk. 

Administration. — Children  tolerate  large  doses,  though  the  aged 
stand  the  drug  poorly,  and  their  digestion  suffers ;  after  the  fifth  year, 
adult  doses  are  given ;  girls  tolerate  the  drug  better  than  boys.  When 
susceptibility  is  marked,  a  few  drops  of  laudanum  may  be  added,  but 
its  administration  should  always  be  stopped  when  (a)  the  eyes  become 
puffy,  or  (b)  itch,  and  (c)  the  tongue  becomes  furred.  It  may  be  given 
in  the  following  forms: — (i)  Acidum  arsenosum  (now  officinal  as  arseni 
trioxidum)  gr.  35  p.c,  with  ext.  glycyrrhizse  and  (black  pepper)  piper 
aa  gr. iv  ("Asiatic  pill")-  (See  formula  under  Treatment  of  Valvu- 
lar Disease,  page  428).  (ii)  Liquor  potassii  arsenitis  (Fowler's  solu- 
tion, 1786) ;  for  hypodermic  use  it  must  be  sterilized,  because  fungi  are 
likely  to  grow  in  it.  Even  with  great  care  abscess  may  develop. 
Minims  v  equal  gr.  z^o  of  ac.  arsenosum.  Treatment  should  commence 
with  min.  iij  and  each  day  the  dose  should  be  increased  a  drop  until 
minims  x  or  xij  are  given;  rarely  can  larger  doses  (ttj^xv-xxv)  begiven. 
(iii)  The  cacodylate  of  soda  (Clin)  pills  (aa  gr.  ^)  may  be  given  one  to 
five  times  daily. 

3.  Symptomatic  Treatment. — This  includes  opiates  for  diarrhoea,  car- 
diants  for  weak  heart,  and  dilute  HCl  for  gastric  achylia. 


(0).   SECONDARY  AN.ffiMIA. 
1.  Acute  Post-Hemorrhagic  Anaemia. 

Etiology. — It  may  result  (a)  from  trauma  of  large  vessels;  (6)  from 
post-partum  hemorrhage,  abortion,  or  tubal  pregnancy;  (c)  from 
haemoptysis,  aneurysm,  cardiac  disease,  or  tuberculosis;  or  from  inter- 
nal aneurysmal  ruptures,  as  into  the  pleura;  (d)  from  carcinomatous 
ulcerations  in  the  uterus,  gastro-intestinal  tract,  etc. ;  (e)  from  round 
ulcer  of  the  stomach  or  duodenum ;  (/)  from  varicosities,  as  in  the  leg, 
stomach,  or  oesophagus,  and  liver  cirrhosis;  (g)  from  conditions  of 
the  blood,  as  epistaxis  in  typhoid;  from  pancreatitis,  hemorrhagic 
states,  or  constitutional  diseases. 

Symptoms. — 1.  The  blood  is  (a)  hydrcemic,  the  loss  of  fluid  being 
supplied  by  the  tissues,  and  its  specific  gravity  is  lowered.  (6)  The 
red  disks  are  reduced  to  50  per  cent.,  or  even  to  20  per  cent.,  are  often 
irregular  in  contour  (poikilocytosis),  pale  and  poor  in  haemoglobin; 
their  diameter  may  be  increased;  generally  there  are  some  normo- 
blasts, (c)  The  hcemoglobin  is  lessened  even  more  than  the  red  cells. 
(d)  The  leukocytes  at  first  show  a  moderate  increase;  the  polymor- 
phonuclears are  decreased,  and  the  mononuclears  increased.  In 
sudden  anaemia  with  rapidly  resulting  death,  the  red  cells  are  seldom 


848  DISEASES  OF  THE  BLOOD 

nucleated,  and  there  is  no  leukocytosis,  because  the  bone  marrow 
makes  no  effort  to  regenerate  the  blood.     (See  Plate  XIV,  Fig.  3.) 

2.  There  is  marked  ancemia  of  the  skin  and  mucous  membranes. 
Some  oedema  results  from  chemical  changes  in  the  blood,  or  malnu- 
trition and  increased  permeability  of  the  vessel  walls.  The  pulse  is 
weak,  and  becomes  frequent  with  the  least  exertion.  Nevertheless, 
the  vasomotor  system  very  readily  accommodates  itself  to  a  loss  of 
one-quarter  of  the  blood  volume;  a  greater  loss  produces  cardiac 
weakness.  Sometimes  the  heart  action  seems  more  violent  and  respir- 
ation deeper  and  more  rapid  than  normal. 

3.  The  digestive  glands  are  less  active. 

4.  Albuminuria  develops  in  a  few  hours  after  a  large  hemorrhage. 
No  obvious  microscopic  change  in  the  renal  epithelium  is  detected, 
whence  it  seems  that  albuminuria  is  due,  either  to  undue  permeability 
of  the  renal  vessels,  or  possibly,  to  albumins  absorbed  from  the  tissues. 

5.  The  nervous  and  eye  symptoms  may  be  marked.  Amblyopia  and 
amaurosis  were  known  to  Hippocrates;  they  are  at  first  functional, 
but  usually  8  to  10  days  later  degeneration  or  inflammation  of  the 
retina  develops;  as  the  blood  pressure  rises,  retinal  hemorrhages  may 
follow".  The  patient  often  sees  spots  before  the  eyes.  Occasional 
nervous  manifestations  include  aphasia,  or  vertigo;  delirium  and 
hallucinations  are  chiefly  terminal  events;  in  some  cases,  lasting 
psychoses  develop. 

6.  The  autopsy  findings  in  fatal  cases  are  fatty  degeneration,  par- 
ticularly of  the  heart,  endothelium  of  the  vessels,  liver,  brain,  stomach, 
and  kidney  cells,  which  is  usually  caused  by  imperfect  oxygenation. 
Hemorrhages  in  the  uterus,  gums,  and  retina,  are  due  to  impaired 
nutrition  of  the  vessel  walls.  The  bone  marrow  changes  from  a  yellow 
to  a  red  color,  and  abounds  in  normoblasts. 

Prognosis. — The  patient  may  survive  the  loss  of  more  than  one- 
third  or  one-half  of  the  blood ;  Hayem  reports  recovery  after  the  num- 
ber of  red  cells  fell  to  550,000.  Men  stand  hemorrhage  better  than 
women  and  young  children,  though  the  loss  of  a  pint  may  cause  death 
in  arteriosclerotics.  Recovery  is  more  rapid  in  acute  than  chronic 
hemorrhage.  In  moderately  severe  hemorrhage,  recovery  may  be 
practically  complete  within  a  week;  water  and  albumin  are  readily 
yielded  to  the  blood  by  the  tissues ;  the  red  cells  regenerate  more  slowly, 
and  the  haemoglobin  is  the  last  element  to  reach  normal.  Increase  in 
the  coagulability  of  the  blood  is  a  favorable  prognostic.  According  to 
Bierfreund,  a  loss  of  10  to  15  per  cent,  of  the  blood  is  restored  in  eight 
days;  of  16  to  20  per  cent.,  in  twenty  days;  of  21  to  25  per  cent.,  in 
twenty-two  days,  and  of  more  than  25  per  cent.,  in  twenty-nine  days  or 
more. 

Treatment. — This  has  been  considered  under  gastric  ulcer,  and 
intestinal  hemorrhage  in  typhoid;  the  essentials  are  absolute  rest, 
morphine  to  insure  quiet,  and  salt  infusions  only  in  case  of  extreme 
cardiac  failure. 


/■i^/ 


Fcff.v/n 

a 

b 

J 

k 

m 

ff 
^ 

PLATE  XIV. 

BLOOD. 

(Ehrlich  triple  stain.) 
(Prepared  by  Dr.  I.  P.  Lyon.) 

Fig.  I.     TYPES    OF    LEUCOCYTES. 

a.  Polymorphonuclear  Neutrophile.  b.  Polymopphonuelear  Eosinophile.  c.  Myelocyte 
(Neutrophilic),  d.  Eosinophilic  Myelocyte,  e.  Large  Lymphocyte  (large  Mononuclear), 
/.  Small  Lymphocyte  (small  Mononuclear). 

Fig.  II.     NORMAL   BLOOD. 
Field  contains  one  neutrophile.     Reds  are  normal. 

Fig.  III.     ANEMIA,   POST-OPERATIVE  (secondary). 

The  reds  are  fewer  than  normal,  and  are  deficient  in  haemoglobin  and  somewhat 
irregular  in  form.  One  normoblast  is  seen  in  the  field,  and  two  neutrophiles  and  one 
small  lymphocyte,  showing  a  marked  post-haemorrhagic  anaemia,  with  leucocytosis. 

Fig.  IV.     LEUCOCYTOSIS,   INFLAMMATORY. 

The  reds  are  normal.  A  marked  leucocytosis  is  shown,  with  five  neutrophiles  and 
one  small  lymphocyte.  This  illustration  may  also  serve  the  purpose  of  showing  the 
leucocytosis  of  malignant  tumor. 

Fig.  V.     TRICHINOSIS. 
A  marked  leucocytosis  is  shown,  consisting  of  an  eosinophilia. 

Fig.  VI.     LYMPHATIC  LEUKEMIA. 

Slight  anaemia.  A  large  relative  and  absolute  increase  of  the  lymphocytes  ('chiefly 
the  small  lymphocytes)  is  shown. 

Fig.  VII.     SPLENO-MYELOGENOUS   LEUKEMIA. 

The  reds  show  a  secondary  anaemia.  Two  normoblasts,  are  shown.  The  leucocytosis 
is  massive.  Twenty  leucocytes  are  shown,  consisting  of  nine  neutrophiles,  seven  myelo- 
cytes, two  small  lymphocytes,  one  eosinophile  (polymorphonuclear)  and  one  eosinophilic 
myelocyte.  Note  the  polymorphous  condition  of  the  leucocytes,  i.e.,  their  variations 
from  the  typical  in  size  and  form. 

Fig,  VIII.     VARIETIES   OF    RED    CORPUSCLES. 

a.  Normal  Red  Corpuscle  (normocyte).  b,c.  Anaemic  Red  Corpuscles,  d-g.  Poikiloeytes. 
A.  Mierocyte.  i.  Megalocyte.  j-n.  Nucleated  Red  Corpuscles.  j,k.  Normoblasts.  I.  Micro- 
blast.    m,n.  Megaloblasts. 


CHRONIC  SECONDARY  ANEMIA  849 


2.  Chronic  Secondary  Anaemia. 

Etiology. — Its  possible  causes  are  numerous;    the  chief  types  are 

(a)  hemorrhages  like  those  listed  under  acute  post-hemorrhagic  an- 
aemia, but  frequent  and  persistent,  as  chronic  hemorrhoidal  bleeding. 

(b)  Poor  hygiene;  overwork,  long  hours  in  poorly-ventilated,  sunless 
offices  or  factories;   insufficient  food,  or  food  poor  in  iron;  or  worry. 

(c)  Exhausting  discharges,  or  loss  of  albumin,  as  frequent  pregnancies 
with  prolonged  lactation,  albuminuria,  respiratory  or  alimentary 
catarrh,  or  protracted  suppuration,  with  its  attendant  loss  of  nuclein. 

(d)  Toxoemias;  acute  infections,  as  typhoid,  diphtheria,  rheumatism, 
or  malaria,  in  which  the  activity  of  blood-making  centres  is  diminished, 
and  food  is  poorly  assimilated;  chronic  infections,  as  syphilis  and 
tuberculosis;  gastro-intestinal,  and  possibly  other  intoxications;  neo- 
plasms acting  as  mechanical  obstructions  (as  those  of  the  oesophagus, 
or  pylorus),  affecting  sometimes,  the  bone  marrow  by  metastases  de- 
posited there,  sometimes  causing  repeated  losses  of  blood  or  elaborat- 
ing toxins,  which  break  down  the  tissue  albumins;  in  neoplasms  the 
reduction  of  the  blood  in  red  cells  and  haemoglobin  averages  55  to  66 
per  cent,  of  normal;  parasites  (oxyuris,  ascaris,  echinococcus,  etc.); 
and  poisons  (alcohol,  lead,  arsenic,  or  phosphorus)  may  produce 
angemia. 

Symptoms. — The  blood  is  pale,  and  its  specific  gravity  is  lowered. 
As  a  rule  the  red  disks  and  haemoglobin  are  reduced  in  rather  close 
parallelism,  though  occasional  exceptions  occur.  The  haemoglobin 
may  fall  to  18  or  14  per  cent,  of  normal,  and  the  red  cells  may,  in  rare 
instances,  approach  the  count  of  pernicious  anaemia.  The  red  cells 
stain  unequally,  and  their  umbilication  is  clearer,  so  that  the  haemo- 
globin may  even  appear  as  a  slight  peripheral  ring.  They  show  less 
poikilocytosis  than  in  acute  post-hemorrhagic  anaemia,  and  many  of 
them  are  undersized.  Some  nucleated  erythrocytes  appear,  but  less 
than  in  the  acute  post-hemorrhagic  form.  The  white  cells  vary  with 
the  causal  conditions.  As  a  rule,  the  polymorphonuclear  neutrophiles 
are  increased,  and  the  eosinophiles  (normally  4  to  6  per  cent.),  are 
decreased.  The  latter  are  often  increased  in  parasitic  anaemias,  up  to 
10,  or  even  50  per  cent.  In  some  chronic  anaemias,  the  leukocytes  are 
diminished. 

As  to  general  symptoms,  it  is  frequently  difficult  to  decide  whether 
they  result  from  the  anaemia,  or  from  its  cause.  An  anaemic  skin,  mus- 
cular adynamia,  irritable  weakness,  and  a  tendency  to  oedema  and 
hemorrhage  into  the  skin,  mucosae,  and  serosae,  may  be  noted.  The 
appetite  is  poor  or  easily  satiated,  and  tenderness  over  the  stomach, 
cardialgia,  nausea,  and  decrease  or  increase  of  the  HCl  may  be  ob- 
served. The  intestinal  functions  are  usually  normal,  though  the  motor 
power  may  be  tardy.  The  aromatic  sulphates  of  the  urine  are  fre- 
quently increased.  Rather  exceptionally  symptoms  resembling  those 
of  pernicious  anaemia  may  develop,  as  alteration  of  the  bone  marrow, 

54 


,;850  DISEASES^  OF  THE  BLOOD 

fatty  heart,  cerebrospinal  degeneration,  atrophy  of  the  gastro-intestinal 
cells  and  retinal  hemorrhage,.  The  differmtiation  from  primary 
anaemias  has  been  considered  under  pernicious  anaemia. 

Treatment. — The  treatment  depends  upc»n  the  c^use,  for  which 
thorough  and  repeated  search  should  be  made  in  doubtful  cases.  The 
hygiene  of  the  home  and  place  of  work  should  receive  consideration. 
Fresh  air,  sunlight,  and  proper  food  are  often  difficult  to  obtain  for  the 
lower  classes.  Iron  and  arsenic  are  valiaable  in  simple  types  {v. 
Chlorosis  and  Pernicious  Anemia). 


(D).  LEUKEMIA. 

Definition. — Leukaemia  (leukocythsemia)  is  a  disease  of  hsemogen- 
esis,  characterized  by  an  increase  of  the  leukocytes,  a  decrease  in  the 
red  cells  and  haemoglobin,  hyperplastic  alteration  of  the  bone  marrow, 
lymph  glands,  and  spleen,  and  by  secondary  infiltration  into  various 
organs  and  tissues.  It  was  discovered  by  Bennett,  and  independently 
by  Virchow  (1851). 

Classification.— The  older  classification  embraced  (a)  the  splenic, 
and  (b)  the  glandular  (Virchow)  types  to  which  Neumann  added  (c) 
the  medullary  form;  Behier  described  (d)  a  gastro-intestinal  form,  and 
Phillippart,  Nachter,  and  Kaposi  (e)  a  dermal  variety.  This  classifi- 
cation is  clinical,  but  that  of  Ehrlich  is  based  on  the  blood  findings; 
the  splenic  form  is  not  recognized  by  him,  and  he  classifies  the  disease 
as  follows : 

1.  Lymphatic  leukaemia,  (i)  The  acute  form,  which  runs  a  very 
rapid  course,  and  resembles  an  acute  infection,  with  lymphaemia, 
moderate  or  no  splenic  enlargement,  fever,  hemorrhages,  lymphatic 
enlargement,  and  stomatitis,  (ii)  The  chronic  form,  with  lymphaemia, 
enlarged  spleen  and  glands,  and  a  protracted  course. 

2.  Myelogenic  leukaemia  with  great  polymorphism  in  the  blood 
findings  (v.i.). 

Acute  Lymphatic  Leukaemia. 

Acute  lymphatic  leukoemia  {acute  lymphcemia)  includes  nearly  all 
acute  leukaemias.  The  term  does  not  imply  that  the  lymph  glands 
alone  are  the  cause,  because  there  is  considerable  and  growing  evidence 
that  the  bone  marrow  may  be  the  seat  of  the  causal  change,  and  that 
it  may  contain  a  parent  cell  for  both  leukocyte  and  lymphocyte.  The 
chief  pathological  finding  is  hyperplasia  of  the  lymphadenoid  tissue. 
The  course  is  that  of  a  rapid  infective  disease,  usually  with  an  acute 
onset,  lymphaemic  blood  findings,  asthenia,  and  often  fever;  it  is  fatal 
in  a  few  days  to  a  few  weeks.  The  disease  occurs  at  any  age,  but  espe- 
cially in  children,  and  66  per  cent,  of  cases  are  in  males.  The  bacterio- 
logical findings  are  inconstant;  the  amoeba  described  by  Lowit  lacks 
confirmation,  and  is  considered  an  artifact  by  most  haematologists. 


ACUTE  LYMPHATIC  LEUKEMIA  851 

The  disease  is  infrequent;   Fussel  and  Taylor  have  collected  but  56 
cases,  but  it  is  certain  that  many  cases  escape  detection. 

Sjonptoms. — Prodromal  symptoms  may  be  observed,  as  headache, 
pain  in  the  neck,  spleen,  joints,  or  head,  epistaxis,  mental  obscuration, 
dyspnoea,  or  stomatitis,  after  which  four  cardinal  findings  develop : — 

1.  Evidences  of  lymphadenoid  change  are  observed,  as  lymph  gland 
intumescence,  which  is  very  frequent,  although  not  invariable,  is 
usually  moderate,  and  sometimes  disappears  after  the  initial  swelling; 
splenic  enlargement  occurs  in  66  per  cent.,  and  is  of  slight  degree,  save 
in  children,  in  whom  it  may  be  enormous;  tonsillar  hypeHrophj  occurs 
in  50  per  cent.,  sometimes  with  hemorrhage  and  necrosis.  Reed 
recently  published  a  case  of  acute  lymphsemia  without  glandular  en- 
largement. 

2.  Hemorrhages  are  most  characteristic  and  frequent;  they  occur 
(a)  in  the  skin,  as  petechise  or  larger  effusions,  with  necrosis  or  ulcera- 
tion in  areas  of  lymphsemic  infiltration;  (b)  in  the  mouth,  gums,  palate, 
and  pharynx,  as  petechise,  erosions  or  extensive  necrosis,  developing  in 
areas  of  lymphsemic  infiltration;  (c)  in  the  retina  in  practically  100 
per  cent,  with  the  same  anatomical  basis;  (d)  visceral  hemorrhages, 
in  the  brain,  cerebral  nerves,  labyrinth,  and  spleen;  (e)  from  mucous 
surfaces,  the  vagina,  urinary  passages,  and  intestines;  and  (/)  from 
the  serous  membranes. 

3.  Necrosis  in  the  infiltrated  foci  of  the  mouth  occurs  in  70  per  cent., 
and  is  per  se  highly  suggestive  in  the  diagnosis  (Bradford  and  Shaw). 

4.  LymphcBmia  is  the  crucial  finding.  The  ratio  between  the  white 
and  red  cells  is  1  to  2,  10  or  20,  though  the  absolute  number  of  lympho- 
cytes may  reach  918,000  to  the  cubic  mm.  In  general,  the  increase  of 
leukocytes  is  less  than  in  the  splenomedullary  form,  and  averages 
350,000.  The  polymorphonuclears  are  usually  normal  or  decreased, 
the  eosinophiles  constitute  about  1  per  cent,  of  the  white  cells,  a  few 
myelocytes  may  be  found,  but  the  salient  increase  is  in  the  lymphocytes, 
and  chiefly  in  the  larger  forms ;  the  lymphocytes  may  constitute  90,  or 
even  99  per  cent,  of  the  leukocytes.  The  red  cells  vary  between  1  and 
3  million,  and  some  nucleation  occurs  (although  frequently  absent, 
Wertheim,  Hayem,  Neumann,  Rieder).  The  hsemogiobin  usually  falls 
below  50  per  cent.,  or  much  lower  in  peracute  cases.  (For  varieties  of 
leukocytes,  see  Plate  XIV,  Fig.  I.  For  blood  picture  see  Plate  XIII, 
Fig.  2  and  Plate  XIV,  Fig.  VI.) 

Other  findings  are  pallor,  frequent  pulse,  priapism,  swollen  and 
infiltrated  liver,  increased  flow  of  urine,  with  increased  urea  and  uric 
acid  (increased  nuclein  destruction);  albuminuria,  nephritis  and  endo- 
carditis are  sometimes  observed.  Edsall  found  the  nitrogen  output 
enormously  increased  (from  autolysis).  Lymphomatous  masses  may 
cause  dyspnoea.  The  fever  is  irregular,  both  in  type  and  occurrence. 
Intercurrent  sepsis  reduces  the  splenic  and  lymphatic  enlargement, 
the  white  cells  decrease  even  to  normal,  and  sometimes  an  ordinary 
polymorphonuclear  leukocytosis  replaces  the  typical  blood  findings. 
The  bone  marrow  is  constantly  involved,  especially  in  the  long  bones; 


852  DISEASES  OF  THE  BLOOD 

it  is  mostly  red  and  jelly-like  in  color,  more  rarely  red-gray,  and  is 
the  seat  of  hemorrhage.  The  typical  granular  neutrophile  myelocytes 
are  few,  while  large  and  small  lymphocytes  abound  as  in  the  circu- 
lating blood;  this  is  known  as  "the  lymphoid  marrow."  Opinions 
vary  as  to  whether  the  lymphatic  or  the  medullary  lesions  are  the 
primary  change.  Lymphatic  deposits  occur  in  the  mouth,  stomach, 
intestines  (simulating  typhoid  ulcers),  muscles,  liver,  kidneys,  and 
thymus.  The  patient  is  usually  emaciated.  Fatty  and  degenerative 
changes  in  the  heart  and  other  viscera  are  observed. 

Diagnosis. — Though  the  splenic  and  lymphatic  enlargements, 
petechise,  stomatitis,  fever,  ulceration  and  hemorrhages  are  frequently 
most  suggestive,  the  blood  findings  alone  are  distinctive;  they  exclude 
typhoid,  purpura,  scurvy,  trichinosis,  erythemata  with  mouth  changes, 
diphtheria  (for  which  lymphsemia  is  often  mistaken),  septicaemia, 
severe  acute  anaemias,  and  chloroma  (v.i.). 


Chronic  Lymphatic  Leukaemia. 

Chronic  lymphatic  leukcemia  is  rarer  even  than  acute  lymphsemia, 
and  runs  a  clinical  course  of  from  months  to  years,  with  lymphadenoid 
hyperplasia  and  lymphsemia;  it  is  closely  associated  by  some  writers 
with  malignant  lymphoma  and  Hodgkin's  disease.  (Thus  Pinkus 
describes  (a)  the  genuine  lymphatic  leukaemia  with  marked  lymphaemia 
and  (6)  lymphatic  pseudoleukaemia  with  no  striking  disproportion 
between  the  number  of  red  and  white  cells,  but  with  a  relative  increase 
of  the  lymphocytes  compared  with  the  other  white  cells.  Pinkus' 
views  have  not  yet  attained  general  recognition  and  confirmation.) 

Etiology. — No  uniform  or  constant  bacteriological  cause  has  been 
proven.  Lowit  described  an  amoeba  (haemamoeba  leukaemiae  parva 
[vivax]),  which  most  authorities  consider  an  artefact. 

Sjrmptoms. — The  symptoms  begin  insidiously  and  the  disease  may 
be  first  detected  by  (1)  swelling  of  the  lymph  glands,  usually  in  the 
neck,  which  may  reach  enormous  dimensions.  The  axillary  glands 
are  large,  though  the  inguinal  are  less  massive;  glandular  swelling, 
as  a  rule,  extends  from  above  downward.  Sometimes  the  internal 
glands  alone  are  swollen,  and  in  very  rare  cases  the  lymphatics  are  not 
enlarged.  The  glands  are  discrete  without  periadenitis,  are  oval  and 
soft,  being  much  less  hard  than  in  pseudoleukaemia.  Sometimes 
moderate  pain  is  experienced  and  there  may  be  compression  of  vital 
structures,  as  the  vagus,  trachea,  and  portal  vein.  The  glands  continue 
to  grow  until  death,  unless  an  intercurrent  affection  as  erysipelas, 
causes  them  to  shrink  temporarily. 

2.  Splenic  hyperplasia  and  intumescence  is  practically  constant, 
though  generally  less  extreme  than  in  the  myeloid  type,  or  in  Hodgkin  's 
disease.  The  spleen  often  projects  from  beneath  the  costal  arch  but  an 
inch  or  so,  it  grows  as  the  disease  progresses,  and  is  usually  propor- 
tionate to  the  duration  of  the  disease.    In  a  case  of  Virchow,  the  spleen 


CHRONIC  LYMPHATIC  LEUKEMIA  853 

was  not  enlarged.  Intercurrent  sepsis,  cholera,  erysipelas,  etc.,  may 
cause  the  splenic  tumor  to  temporarily  disappear,  together  with  the 
lymphsemia  and  the  lymph  nodes,  but  all  three  findings  may  persist  in 
such  infections.  Diarrhoea,  and  treatment  by  arsenic  or  quinine,  may 
likewise  effect  splenic  reduction.  Perisplenic  adhesions  and  thickening 
are  common,  and  the  organ  is  soft  or  hard  according  to  the  duration 
of  the  disease.  The  tonsils  are  often  swollen,  in  which  hemorrhages, 
with  or  without  necrosis,  are  frequently  observed. 

3.  The  changes  in  the  hone  marrow  cause  few  symptoms;  pain  is 
rarely  found.  The  essential  character  of  the  marrow  alteration  is 
undetermined. 

4.  The  hlood  reveals  an  absolute  and  a  relative  lymphcemia.  The  red 
and  white  cells  may  have  a  ratio  of  100  to  1,  and  yet  the  lymphocytes 
constitute  90  to  99  per  cent,  of  all  the  white  cells.  They  are  mostly 
small  lymphocytes  (Pinkus),  whereas  the  larger  forms  occur  in  the 
acute  lymphatic  leukaemia.  (Ehrlich  holds  that  large  lymphocytes 
predominate.)  Many  of  them  are  altered,  degenerated,  or  swollen. 
The  neutrophile  polymorphonuclears  (normally  constituting  70  per 
cent,  of  the  white  cells),  are  reduced  to  10,  or  even  2,  or  1  per  cent. 
Myelocytes  are  usually  absent.  The  red  cells  average  4,000,000,  but 
may  reach  2,000,000,  and  seldom  lower.  The  lymphocytosis  may 
temporarily  disappear  during  infection,  and  in  one  instance  this  was 
permanent.     (See  Plate  XIV,  Fig.  1.) 

5.  The  skin  may  itch  or  be  the  seat  of  papular  eruptions,  or  urticaria. 
Lymphomata  form  in  the  skin,  sometimes  of  considerable  size;  or 
infiltrated  reddish  deposits  may  precede  the  lymphsemic  blood  findings. 
(Edema  occurs,  while  hemorrhages  are  rarer.  Facial  growths  are 
observed  similar  to  those  of  chloroma  {v.  Medullary  Form,  Diag- 
nosis), or  to  the  symmetrical  swelling  of  the  lachrymal  and  salivary 
glands. 

6.  The  heart  is  degenerated,  as  are  the  vessels,  from  all  of  which 
hemorrhages  may  occur,  as  in  the  acute  type.  Intraperitoneal  hemor- 
rhages from  ruptured  adrenals  are  often  reported.  The  nerve  trunks 
may  degenerate  with  bulbar,  spinal,  and  nerve  trunk  symptoms. 
Retinitis  leukaemica  or  optic  nerve  involvement  may  impair  vision. 
The  liver  is  swollen  from  degeneration,  and  from  lymphatic  infiltra- 
tion. Dyspnoea  is  most  common,  and  occurs  early  from  the  anaemia, 
mechanical  compression  of  the  air  tubes,  vessels  or  nerves,  or  from 
leuksemic  changes  within  the  follicles  of  the  mouth  and  air  passages. 
Renal  infiltration  is  frequent. 

Course. — The  course  of  the  disease  is  slow;  it  develops  gradually 
and  passes  slowly  into  cachexia,  though  now  and  then  extension  in 
the  glands  is  "explosive"  (Trousseau).  Remissions  and  intermissions 
of  weeks  or  months  are  not  uncommon.  Intercurrent  disease  may  be 
fatal,  as  pneumonia,  and  mechanical  stasis,  suffocation  and  acute 
exacerbations  of  the  disease  itself  may  hasten  the  course. 


854  DISEASES  OF  THE  BLOOD    - 

Diagnosis. — The  diagnosis,  suggested,  perhaps  by  the  skin  lesions, 
lymphomata,  splenic  enlargement  or  hemorrhagic  tendency,  is  posi- 
tively made  only  by  the  blood  examination. 


Myeloid  Leuksemia. 

Myeloid  leukcBmia  (myelsemia,  myelogenic  or  medullary  leuksemia),  is 
the  most  common  form  of  leuksemia,  and  occurs  for  the  most  part  be- 
tween the  twentieth  and  fiftieth  years;  67  per  cent,  of  cases  occurs  in 
males.  Bacteriology  has  shown  no  cause,  and  Lowit's  theory  concern- 
ing the  hsemamoeba  leuksemise  magna,  has  been  vigorously  contested. 
The  disease  is  frequent  among  the  Polish  Jews,  and  the  poorer  and 
working  classes.  A  history  may  be  obtained  of  malaria,  syphilis,  ty- 
phoid, influenza,  stomatitis,  tonsillitis,  digestive  disturbance,  pregnancy, 
disturbed  menstruation,  the  climacteric  and  trauma,  though  they  are 
probably  only  accidental  occurrences.  The  disease  has  been  noted  in 
three  generations.  Leuksemia  has  been  also  observed  in  the  horse, 
dog,  cow,  pig,  and  cat. 

Symptoms. — 1.  Blood. — The  specific  gravity  is  decreased  from 
1,055  to  1,045-36;  it  is  watery,  or  sometimes  chocolate-colored;  it 
coagulates  slowly  (on  accourft  of  the  peptone  present  from  the  white 
cells,  although  observations  differ  on  this  point).  In  extreme  cases  the 
eoaguia  are  white  (leuksemia)  or  slightly  greenish.  Large  white  clots 
are  observed  at  autopsy,  and  Virchow  thought  that  he  had  incised  an 
abscess  when  he  opened  the  left  ventricle  in  his  first  autopsy.  Acidity 
develops  after  puncture  from  lecithin  and  glycerophosphatic  acid. 
Microscopically  the  white  cells  are  enormously  increased,  even  as  much 
as  1  to  1,  or  in  Robin's  case,  2  whites  to  1  red  cell.  The  highest 
count  which  the  author  has  seen  was  in  Mercy  Hospital  in  1904;  the 
whites  numbered  950,000,  and  the  reds  1,900,000  (1:2).  Sometimes 
one  must  even  look  for  the  red  corpuscles.  Amoeboid  movement  is 
greatly  decreased.     (Plate  XIV). 

The  characteristics  of  the  white  cells  are :  (a)  The  large  mononuclear 
neutrophiles  ("mark  cells,"  myelocytes),  which  are  found  early,  and 
amount  to  30  per  cent,  or  more  of  the  leukocj^tes.  In  themselves  they 
are  not  absolutely  pathognomonic,  having  been  found  (in  small  num- 
bers) in  pneumonia,  ursemia,  chlorosis,  skin  diseases,  syphilis,  and  in 
normal  blood.  (6)  Mononuclear  eosinophils,  which  occur  in  other 
diseases,  but  in  myeloid  leuksemia  are  absolutely  increased,  though  not 
necessarily  relatively  increased.  They  are  absolutely  necessary  to  the 
diagnosis,  (c)  The  "mast  cells,"  which  must  be  absolutely  increased; 
they  are  polymorphonuclears  with  basophile  granulations,  which  do 
not  show  with  the  tri-acid  stain.  Often  they  are  relatively  increased, 
from  0.28,  the  normal  percentage,  to  1,  or  indeed,  18  per  cent.  They 
are  constant  in  this  type,  (d)  The  polymorphonuclear  neutrophiles 
and  eosinophiles,  which  are  sometimes  increased,  but  are  more  often 
normal  or  decreased,     (e)  Atypical  leukocytes,  dwarf  forms  and  white 


'  MYELOID  LEUKEMIA  855 

cells  containing  mitoses,  fat  globules,  or  red  cells,  may  also  be  found. 
(See  Plate  XIV,  Fig.  I.) 

The  red  cells  are,  as  a  rule,  decreased  to  two  or  three  million,  though 
leuksemic  patients  are  not  always  anaemic  and  an  excess  of  red  cells  has 
been  described  by  Quincke  and  Litten.  Toward  the  end  the  red  cells 
may  decrease  to  even  300,000,  and  thus  resemble  pernicious  anaemia. 
The  reds  may  become  degenerated,  necrotic,  polychromatic,  or  acquire 
amoeboid  movement,  nuclei,  and  mitoses.  Nucleation  occurs  more 
frequently  than  in  any  other  anaemia  (Ehrlich),  normoblasts  being  the 
most  common  form.  The  haemoglobin  tends  to  crystalize.  The  color 
index  is  1,  or  less  than  1  (0.5  to  0.7).  (See  Plate  XIII  Fig.  I.  and  Plate 
XIV,  Fig.  VII.) 

2.  Splenic  Enlargement. — This  is  usually  the  first  symptom  to  attract 
attention;  it  appears  with  the  blood  findings  and  is  most  constant; 
spleniculi,  if  present,  are  enlarged.  Instead  of  a  weight  of  5  to  7  ounces, 
18  to  28  pounds  are  reported;  from  the  normal  measurements,  3  to  5 
inches,  dimensions  of  15  inches  are  frequently  observed.  Splenic  pul- 
sation was  observed  by  Gerhardt.  The  form  of  the  organ  is  preserved. 
The  size  varies  (a)  during  intermissions;  (b)  without  cause;  (c)  from 
administration  of  arsenic  and  quinine,  and  (d)  from  diarrhoea  or  hemor- 
rhages. It  is  enlarged  after  meals.  A  systolic  murmur  is  sometimes 
heard.  The  notches  are  usually  clearly  palpable,  and  the  edges  are 
plump,  rounded,  and  hard.  Crackling  under  the  fingers  and  tenderness 
indicate  soft  adhesions  (perisplenitis).  Firm  adhesions  may  develop 
and  the  capsule  may  thicken.  Though  at  first  soft,  it  later  becomes 
very  firm.  The  pulp  and  trabeculae  hypertrophy,  and  new  lymphoid 
deposits  are  clearly  marked  against  the  reddish  pulp.  It  may  reach 
to  the  navel,  or  into  the  pelvis,  displacing  other  organs.  Pruss  and 
Westphal,  on  puncture,  found  the  Charcot-Neumann  crystals.  The 
author  has  seen  three  cases  of  leukaemic  floating  or  wandering  spleen, 
two  of  which  had  been  operated  on  as  uterine  tumors.  Rupture  is  a 
rare  complication., 

3.  Glands. — The  glands  are  enlarged  in  33  per  cent.  According  to 
the  most  recent  views,  the  glands  are  heteroplastic,  due  to  new-formed 
myeloid  tissue,  "metastases"  from  the  bone-marrow.  Though  soft 
at  first,  they  later  become  hard.  Caseation  and  suppuration  are  most 
infrequent.  As  in  the  other  types  of  leukaemia,  recurrent  compression 
of  the  vagus,  trachea,  portal  vein,  and  bronchi,  may  result.  Retro- 
sternal dulness  has  been  observed. 

4.  Bones.^ — Bone  changes,  recognized  first  by  Neumann,  occur  in 
the  spongy  and  long  bones  (ribs,  tibia,  sternum,  and  vertebrae).  The 
bone  is  mostly  rarefied  and  there  may  be  tender  places,  or  yielding  areas 
which  are  more  important  than  tender  ones.  The  histological  changes 
in  the  marrow  are  (a)  the  lymphoid  (Neumann),  in  which  the  marrow 
resembles  currant  jelly,  is  reddish,  and  consists  of  small  lymphocytes; 
it  is  sometimes  hemorrhagic;  the  normal  fatty  appearance  disappears. 
(b)  The  pyoid;  which  is  seen  mostly  in  the  myelogenic  type;  the  mar- 
row is  not  transparent,  but  gray;   its  cells  are  rich  in  protoplasm  with 


856  DISEASES  OF  THE  BLOOD 

one  or  many  nuclei.  In  both  forms  nucleated  red  cells  abound,  also 
eosinophile  cells,  large  cells  with  neutrophile  granules  and  large 
nuclei, 

5.  Vascular  System, — The  heart  is  moderately  distended  with  white 
clots,  and  as  Virchow  described  in  his  first  autopsy,  opening  the  heart 
was  like  incising  an  abscess.  The  muscle  is  pale  and  fatty,  and  nodules 
of  leuksemic  infiltration  in  the  myocardium,  foci  of  hemorrhage,  and 
pericardial  nodes  and  transudation  are  frequent.  Cardiac  disloca- 
tion from  pressure  by  enlarged  glands  and  spleen,  anaemic  bruits, 
venous  pulsation,  bruit  de  diable,  palpitation,  systolic  murmurs  from 
pressure  by  the  glands  on  the  vessels,  and  centripetal  venous  pulse 
(Senator)  are  observed.  The  radial  pulse  is  rapid,  and  either  soft  or 
tense.  Dyspnoea  results  from  weak  heart,  vagus  pressure,  nodules  in 
the  lung,  bronchitis,  hydrothorax,  pressure  of  the  spleen  on  the  dia- 
phragm, tilting  of  the  heart  upward,  and  compression  by  the  glands, 

6.  Respiratory  Tract. — Nodules  are  frequently  seen  in  the  larynx, 
trachea,  thyroid,  and  thymus,  often  with  hemorrhage,  sometimes 
resulting  in  tracheal,  bronchial,  or  laryngeal  stenosis.  In  the  lungs 
(Deiter)  lymphoid  nodules  may  necrose  and  cavities  like  those  of 
caseous  tuberculosis  (Boettcher)  may  appear.  Small  myeloid  foci  of 
leukocytes  may  resemble  miliary  tuberculosis  (Virchow).  Bronchitis 
with  many  eosinophile  cells  in  the  sputum,  nodes  along  the  pleural 
vessels,  and  pleural  hemorrhage,  transudation  and  exudation  have 
been  observed. 

7.  Fever. — Fever  is  less  frequent  than  in  the  acute  type,  but  occurs 
in  the  majority  of  cases.  It  is  rarely  high;  temperature  may  be  normal 
for  months,  or  it  may  resemble  recurrent  fever,  typhoid,  sepsis,  or 
malaria,  though  it  follows  no  one  type. 

8.  Digestive  Canal. — Anorexia,  thirst,  stomatitis,  or  pharyngitis 
with  ulceration  of  the  lymphoid  deposits,  dysphagia  from  glandular 
pressure  on  the  oesophagus,  eructations  and  vomiting  are  occasional 
symptoms.  Diarrhoea  is  very  common,  leucin  and  tyrosin  being  found 
in  the  stools.  An  enteric  type  is  described  by  Behier  and  others,  in 
which  the  bowel  symptoms  are  conspicuous;  the  lymphadenoid  struc- 
tures in  the  ileum  are  prominent,  and  Friedreich  once  confused  this 
type  with  typhoid  on  account  of  the  ulceration,  enlargement  of  the 
spleen,  and  hemorrhage  from  the  bowel.  The  abdominal  lymph 
glands  may  be  enlarged,  though  the  others  may  remain  normal.  The 
liver  is  much  enlarged,  especially  when  the  spleen  is  enlarged.  In 
Welch's  case  it  weighed  13  pounds,  and  in  another  it  weighed  25 
pounds.  Its  surface  is  smooth,  its  consistence  increased,  and  its  edges 
plump.  Myeloid  proliferations  or  deposits  occur  in  the  liver  as  in  the 
spleen,  and  dislocate  or  deform  the  rows  of  hver  cells.  The  portal 
lymph  nodes  may  be  enlarged.  Icterus  is  infrequent  and  ascites  is 
common  from  cachexia  or  lymph  nodes  (leuksemic  peritonitis).  The 
fluid  contains  many  white  cells  and  the  myelocytes  predominate  as  in 
the  blood. 


MYELOID  LEUKEMIA  857 

9.  Kidneys. — The  kidneys  are  frequently  involved;  there  may  be 
"myeloid"  infiltration  and  cloudy,  fatty,  and  amyloid  alteration.  The 
urine  is  decreased,  pale,  and  strongly  acid.  The  uric  acid  (Virchow) 
may  amount  to  45  to  105  grains  (3  or  7  gm.,  Laache),  though  usually 
20  grains  (1.5  gm.),  (normally  8  grains,  or  0.5  gm.).  Normally  uric 
acid  is  as  1:50-80  of  urea,  but  in  leukaemia,  it  is  1:16  (Salkowski). 
According  to  Stadthagen,  the  uric  acid  results,  not  from  decreased 
oxydation  of  the  albumins,  but  from  increased  formation  of  the  acid. 
The  xanthin  bodies  are  increased.  Albuminuria  is  usual  only  in  the 
last  stages.  The  amount  of  urea  depends  on  the  degree  of  cachexia. 
Priapism  occurs  from  nervous  causes,  as  hemorrhage,  or  from  throm- 
bosis of  the  dorsal  vein.    Amenorrhoea  is  frequent  in  women. 

10.  Nervous  Symptoms. — Nervous  symptoms  may  develop,  as  delir- 
ium, neuralgia,  headache,  syncope  or  vertigo,  mania  or  rarely  bulbar 
palsy,  facial  paralysis,  apoplexy,  or  symptoms  like  those  of  brain  tumor. 

The  Eye. — Lymphoid  nodules  may  develop  in  the  orbit,  possibly  with 
exophthalmus.  The  retinitis  leukcemica,  first  described  by  Liebreich, 
is  not  a  genuine  inflammation,  but  a  leuksemic  infiltration  and  occurs 
in  25  to  33  per  cent.;  the  retina  is  pale,  its  arteries  small,  and  veins 
large;  the  papilla  is  "washed"  and  yellow,  or  orange  colored  spots 
with  red  borders  appear;  hemorrhages  also  occur  (Plate  VI,  Fig.  9). 

The  Ear. — Vertigo,  deafness,  tinnitus,  and  an  atactic  gait,  may  result 
from  growths  in  the  labyrinth;  sudden  deafness  from  hemorrhage  is 
described  by  Steinbruegger,  Pepper,  Wagenhausen,  and  Lanois;  the 
author  saw  three  such  cases  within  one  year. 

11.  Skin. — The  skin  is  less  involved  than  in  lymphsemia,  but  there 
may  be  acne,  pigmentation,  oedema,  pruritus,  lymphoderma  pernic- 
iosa,  diffuse  or  tumor-like  infiltrations,  or  sweats. 

12.  Hemorrhages. — These  are  less  frequent  than  in  acute  leukaemia 
or  in  pseudoleukaemia,  though  Hosier  found  them  in  52  per  cent. 
Epistaxis  is  the  most  common,  and  may  be  fatal.  Stomach  and  bowel 
hemorrhages  are  next,  and  those  from  the  respiratory,  genito-urinary, 
and  other  tracts  are  rarer.  They  also  occur  in  the  skin,  joints,  muscles, 
subcutaneous  tissues,  or  brain,  where  they  may  be  single  or  multiple. 
The  writer  has  seen  three  massive  hemorrhages  under  the  skin  of  the 
thorax,  one  in  Leube's  clinic,  and  two  in  his  own  practice.  Death  has 
followed  the  extraction  of  teeth  (Chapelle)  in  a  leuksemic  subject. 
The  writer  saw  Kolisko  autopsy  a  case  in  which  a  slow  ascending  paral- 
ysis followed  hemorrhage  between  the  spinal  pia  mater  and  arachnoid. 

Complications. — Complications  are  nephritis,  pneumonia,  endo- 
carditis, amyloid  degeneration,  diabetes,  and  gangrene.  Sussmann 
could  collect  but  25  cases  of  complicating  tuberculosis;  this  number 
was  increased  by  Dock  to  27;  at  the  time  of  writing,  the  author  saw  a 
case  with  E.  W.  Andrews,  in  which  a  left-sided  tuberculous  pleurisy 
developed;  tubercle  bacilli  and  mononuclear  white  cells  were  recovered 
from  the  blood-stained  fluid. 

Diagnosis. — The  diagnosis  was  formerly  a  matter  of  great  difficulty, 
because  the  difference  between  leukaemia  and  leukocytosis  was  made  one 


858  DISEASES  OF  THE  BLOOD 

of  degree  only,  and  various  limits  were  placed  (as  a  ratio  of  1  leukocyte 
to  50  erythrocytes),  beyond  which  leukocytosis  was  said  to  cease  and 
leukaemia  begin.  The  mere  number  of  white  cells  is  no  criterion,  because 
a  ratio  of  1  to  15  or  20  may  be  leukocytosis  (as  in  Strauss'  case  of 
gastric  cancer),  and  on  the  other  hand,  1  to  200  may  be  leukaemia 
(von  Noorden).  Leukocytosis  from  digestion,  fasting,  marasmus, 
pregnancy,  acute  infections,  or  in  the  death  agony,  is  of  the  ordinary 
polymorphonuclear  neutrophihc  type.  (Plate  XIV,  Fig.  IV.)  Leukocy- 
tosis is  a  symptom,  but  leukaemia  is  a  disease.  It  is  clear,  then,  that 
increase  in  the  variety  of  white  cells  is  the  definitive  test.  The  poly- 
morphism of  the  blood  is  striking;  according  to  Lazarus,  there  must 
be  (a)  mononuclear  leukocytes  with  granulations  (myelocytes);  (b) 
increased  mono-  and  polynuclear  eosinophiles;  (c)  absolute  increase 
in  the  "mast  cells,"  and  (d)  nucleated  red  cells  must  be  readily  found. 
The  gross  splenic,  medullary,  or  lymphatic  lesions  are  of  but  presump- 
tive value  in  diagnosis,  and  the  polymorphic  blood  picture  alone  dif- 
ferentiates from  pseudoleuksemia,  typhoid,  purpura,  anaemia,  sepsis, 
or  malaria.  Not  only  can  the  disease,  but  also  its  type,  be  recognized 
from  findings  in  the  blood. 

Special  caution  should  be  exercised  in  making  a  diagnosis  (a)  during 
remissions,  when  the  blood  is  rarely  morphologically  normal,  no  matter 
what  the  number  of  leukocytes.  In  one  of  the  author's  cases,  the  leu- 
kocyte count  dropped  from  1,250,000  to  9,000  in  a  week,  though  the 
myelocytes  still  constituted  33  per  cent,  of  the  white  cells.  (6)  Care  is 
also  necessary  during  acute  infections  when  the  leukaemic  character- 
istics may  disappear  (but  not  always),  as  during  typhoid,  acute  miliary 
tuberculosis,  influenza,  or  sepsis,  (c)  The  blood  findings  may  become 
atypical  just  before  death. 

Similar  Conditions. — 1.  Chloroma  is  considered  a  malignant  type 
of  leukaemia,  or  a  "neoplastic  hyperplasia  of  the  red  bone  marrow," 
by  Dock  and  Warthin,  who  in  1904,  collated  39  cases.  It  is  closely 
related  to  acute  lymphaemia.  Lymphomata  form,  causing  orbital  pain, 
tinnitus,  deafness,  temporal  and  orbital  swellings,  and  such  ocular 
symptoms  as  exophthalmos,  strabismus  and  disturbed  vision.  The 
lymphomata  are  greenish,  whence  the  name  chloroma.  It  usually 
develops  before  the  twentieth  year.  Retinal  infiltration  occurs  with 
hemorrhages.  Other  findings  are  ataxia,  pallor,  sternal  tenderness, 
hemorrhages,  severe  anaemia,  often  but  not  always  changing  to  leu- 
kaemic characteristics,  greenish  urine,  and  greenish  lymphomatous 
infiltration  of  the  bone  marrow,  periosteum  (sometimes  with  Charcot- 
Leyden  crystals),  the  liver,  or  lungs,  and  greenish  lymphadenoid 
changes.  The  haemoglobin  and  red  cells  are  reduced,  even  to  15  per 
cent,  and  500,000  respectively.  The  leukocytes  number  about  50,000, 
but  have  been  as  numerous  as  half  a  million ;  they  are  chiefly  lymph- 
ocytes.   The  affection  is  always  fatal. 

2.  Leukancemia  is  described  by  Leube  as  a  severe  blood  disease,  in 
which  the  myelogenous  formation  of  both  the  red  and  white  cells  is 
disordered,  i.e.,  it  combines  some  features  of  both  leukaemia  and  per- 


MYELOID   LEUKEMIA  859 

nicious  ansemia.  Its  features  are  (a)  a  progressive  anaemia,  waxy 
color,  and  asthenia;  (6)  numbers  of  normoblasts,  but  especially  of 
megaloblastS ;  (c)  no  abnormal  pigments  in  the  urine,  no  enlargement 
of  the  lymph  glands  (though  since  reported  by  Mattirolo),  and  no  sider- 
osis  of  the  tissues;  id)  no  true  leuksemic  blood  findings,  but  consider- 
able myelocytosis  and  lymphocytosis;  (e)  firm  connective  tissue  in  the 
bone  marrow,  and  (/)  enlargement  of  the  spleen,  and  prevertebral 
hsemolymph  glands. 

3.  Secondary  Cancer  in  Bone. — There  are  13  cases  in  the  literature, 
in  which  cancerous  bone  metastases  have  produced  blood  findings 
rather  like  those  of  pernicious  anaemia  and  increase  of  the  leukocytes 
(of  which  the  myelocytes  constituted  4  to  17  per  cent.). 

Prognosis. — The  prognosis  of  leukaemia  is  bad.  The  former  reports 
of  recoveries  are  not  wholly  reliable.  It  may  last  5  to  8  or  even  10  years 
after  a  diagnosis  has  been  made.  One-half  to  3  years  is  the  usual  length, 
and  a  little  over  1  year  is  the  average  course.  The  beginning  is  insidi- 
ous, and  enlargement  of  the  abdomen,  dyspnoea,  anaemia,  and  enlarged 
glands  are  the  cause  for  seeking  medical  treatment.  The  nutrition  is 
usually  good.  Sudden  death  may  occur,  either  without  discernible 
cause  or  from  hemorrhage  of  the  brain,  haematemesis,  marasmus,  ana- 
sarca, diarrhoea,  pleuritis,  peritonitis,  deep  coma,  pneumonia,  or  diar- 
rhoea. Remissions  (as  in  pernicious  anaemia)  occur,  but  the  blood 
findings  persist.  Ewing  observed  3  acute  cases,  and  Billings  and  Capps 
published  2  and  collated  7  others  from  the  literature  (which  resembled 
an  infection  with  hemorrhages,  moderate  splenic  and  lymphatic  hyper- 
plasia, severe  anaemia,  often  necrosis  of  the  throat  and  jaw,  with  16,000 
to  540,000  leukocytes,  and  often  with  low  fever).  A  permanent  cure 
after  erysipelas  has  been  reported  by  Richter. 

Treatment. — Hygienic  measures,  rest  and  a  careful  diet,  are  of  some 
benefit.  Fats  and  carbohydrates  cause  dyspepsia,  whence  Litten  gives 
animal  foods,  eggs,  milk,  raw  chopped  meat,  koumyss,  peptones, 
oysters,  beer,  wine,  zwieback,  spinach,  Valentine's  meat  juice,  and 
Brand's  meat  extract;  an  ice-bag  to  the  spleen  may  mitigate  pain  over 
it.  Splenectomy  is  most  irrational,  for  leukaemia  is  a  primary  disease 
of  the  bone  marrow.  All  of  Collier's  series  of  16,  and  94  per  cent,  of 
Bissel-Hagen  's  group  of  35,  died.  The  great  danger  is  that  of  hemor- 
rhage. Great  caution  must  be  observed  in  using  purges,  which,  as  in 
Addison 's  disease,  may  cause  sudden  collapse  and  death.  Inhalations 
of  oxygen,  blood  infusions,  spleno-  or  organotherapy  and  iron  are 
inferior  to  arsenic,  which  decreases  the  number  of  white  blood  cells, 
and  the  size  of  the  spleen.  Hemorrhages  may  disappear,  and  the  num- 
ber of  red  cells  increase.  Ebert  gives  arsenic  with  quinine.  It  is  injected 
locally  (by  Mosler)  into  the  glands  and  spleen,  but  in  the  author's  ex- 
perience, without  success.  Phosphorus  may  soften  the  glands.  Special 
care  should  be  employed  in  tapping  an  ascites,  for  peritonitis  is  prone 
to  develop.  The  x-rays  may  prove  decidedly  beneficial.  In  1  case 
already  alluded  to,  the  patient  lived  19  months  after  the  day  he  seemed 
to  be  dying.     The  way  it  helps  is  still  a  mystery.     Schirmer  says  that 


860  DISEASES  OF  THE  BLOOD 

72  cases  are  reported  (1905),  and  Wendell  thinks  over  90  per  cent,  were 
benefited.  In  some  cases,  the  glandular  and  splenic  enlargements, 
and  the  blood  findings  have  wholly  disappeared,  as  in  1  case  observed 
by  the  writer.  The  x-rays  seem  to  produce  a  leukotoxic  substance 
(Capps  and  Smith). 

(E).  PSEUDOLEUK-ffiMIA. 

Definition. — A  disease  resulting  in  chronic  anaemia,  or  cachexia, 
of  which  the  chief  symptoms  or  signs  are  enlargement  of  the  spleen,  or 
lymph  structures,  or  both.  The  definition  of  the  disease  as  "  leukaemic 
appearance  without  leuksemic  blood  findings,"  no  longer  holds.  Such 
conceptions  would  include  glandular  tuberculosis,  Kundrat  's  lympho- 
sarcomatosis,  etc.  It  is  also  called  Hodgkin  's  (1832)  disease,  pseudo- 
leuksemia  (Cohnheim),adenia  (Trousseau), lymphosarcoma  (Virchow), 
malignant  lymphoma  (Billroth),  and  ansemia  (cachexia),  lienalis  or 
lymphatica  (Wilkes). 

Etiology. — The  etiology  is  not  clear.  The  disease  occurs  after  local 
lymphatic  disturbances  in  the  neck,  following  otorrhoea,  coryza,  extir- 
pation of  the  glands  of  the  neck,  and  tonsillitis.  Like  chloroma  and 
leukaemia,  it  is  observed  chiefly  (75  per  cent,  of  cases)  in  males  between 
twenty  and  thirty  years  of  age.  The  disease  is  not  uncommon  in  chil- 
dren, and  often  occurs  in  the  lower  animals.  It  also  sometimes  runs 
through  several  members  of  the  same  family.  Malaria,  syphilis,  scrof- 
ulosis,  alcoholism,  rhachitis,  diarrhoea,  typhoid,  measles,  and  scarlatina 
are  often  noted  in  the  patient's  history,  but  their  relation,  if  any,  is 
obscure.  Suspected  to  be  mycotic,  many  negative  and  variant  exami- 
nations have  been  made.  Though  the  disease  has  no  well-established 
relation  to  leukaemia,  as  Cohnheim  held,  yet  Fleischer,  Penzoldt, 
Mosler  and  Senator  have  observed  transitions  from  pseudoleuksemia 
to  leukaemia.  Neumann  held  that  the  leukaemic  blood  changes  de- 
pended solely  on  the  hyperplastic  marrow  changes,  and  that  as  long 
as  the  hyperplasia  involves  only  the  spleen  and  glands,  pseudoleukaemia 
results.  Sternberg  and  others  have  maintained  that  it  is  tuberculosis, 
a  theory  disproven  by  Dorothy  Reed  and  Simmons. 

Symptoms. — Its  types  are  (a)  lymphatic ;  (6)  lienal,  pseudoleukaemia 
splenica,  splenomegalia ;  (c)  mixed  (a  and  h),  and  (d)  myelogenic. 

1.  Lymph  Glands. — Swelling  of  the  lymph  glands  is  generally  the 
earliest  symptom;  the  cervical  glands  first  become  enlarged,  perhaps 
after  an  otitis  or  tonsillitis.  The  axillary  glands  become  enlarged 
after  a  variable  period,  then  the  inguinal  and  other  groups.  They  are 
soft  and  elastic;  at  first,  the  individual  glands  are  round,  or  oval,  dis- 
crete, smooth,  and  clearly  palpable;  later,  with  increasing  size,  they 
fuse  into  harder,  irregular  masses  as  large  as  the  fist,  or  a  child 's  head, 
particularly  those  in  the  neck.  They  may  sometimes  be  painful  from 
periadenitis,  but  never  transcend  the  gland  capsule,  and  seldom  caseate 
or  suppurate.  From  the  neck,  where  the  jugular  veins  may  be  com- 
pressed, the  glandular  enlargement  often  passes  to  the  intrathoracic 


PSEUDOLEUKEMIA  861 

glands,  which  are  more  often  enlarged  than  the  other  internal  nodes; 
this  often  occasions  dyspnoea,  compression  of  the  superior  cava, 
(whence  the  development  of  a  large  collateral  circulation  on  the  chest- 
wall),  dysphagia,  bronchial  compression,  and  recurrent,  or  vagus  par- 
alysis. From  the  axillse,  the  glands  under  the  scapulae  and  pectoral 
muscles  enlarge.  The  veins  of  the  arm  may  be  compressed,  causing 
cedema.  In  the  abdomen  the  retroperitoneal,  mesenteric,  periportal, 
iliac,  and  other  lymphadenoid  groups,  may  enlarge  greatly;  according 
to  their  location,  abdominal  pain,  oedema  of  the  legs,  paraplegia,  hydro- 
nephrosis, ascites,  and  jaundice  may  ensue.  Histologically,  the  lymph- 
adenoid  changes  are  (i)  increase  in  the  endothelial  and  reticular  cells ; 
(ii)  hyperplasia  of  the  lymphoid  cells;  (iii)  formation  of  peculiar  giant 
cells;  (iv)  fibrosis  and  chronic  inflammation,  and  (v)  great  increase  of 
the  eosinophile  cells  (Dorothy  Reed). 

2.  Spleen. — The  spleen  is  enlarged  in  75  per  cent,  of  cases  (Gowers). 
When  enlarged,  it  reaches  dimensions  rarely  attained  in  leukaemia,  but 
maintains  its  form,  is  hard  and  tender,  and  presents  the  same  histo- 
logical appearance  as  in  leukaemia,  viz.,  nodes  of  lymphoid  cells  in  a 
fibrous  reticulum.  The  greatest  swelling  of  the  spleen  is  usually 
observed  when  the  lymphatic  glands  are  large  and  hard,  yet  spleno- 
megaly may  be  the  sole  symptom.  Some  physicians  doubt  the  correct- 
ness of  the  diagnosis  when  the  spleen  only  is  involved,  but  splenic 
hypertrophy  alone,  with  relative  increase  in  the  lymphocytes,  may  be 
classed  as  Hodgkin  's  disease  according  to  Pinkus. 

3.  Bone-marrow. — The  bone-marrow  is  less  frequently  involved  than 
in  leukaemia.  A  myelogenous  pseudoleukaemia  has  been  recorded, 
but  its  exact  status  is  still  doubtful.  The  eosinophiles  are  abundant  in 
the  lymph  nodes  and  bone-marrow. 

4.  The  Blood. — The  ratio  between  the  red  and  white  cells  is  normal. 
The  haemoglobin  is  decreased  and  the  blood  index  is  usually  1;  the 
haemoglobin  may  be  rapidly  decreased  as  in  Litten  's  case,  from  85  to 
40  per  cent,  within  a  week.  There  is  usually  moderate  anaemia,  espe- 
cially in  advanced  cases.  Poikilocytes  and  microcytes  often  occur; 
megalocytes  rarely,  and  normoblasts  sometimes  are  found,  but  the 
eosinophiles  are  not  increased.  The  blood  plates  are  increased,  but  the 
Charcot-Leyden  crystals  are  never  found.  Concerning  the  white  cells, 
there  is  a  relative  increase  of  lymphocytes,  the  chief  criterion  of  the 
disease,  according  to  Pinkus  and  Ehrlich.  The  polymorphonuclear 
neutrophiles  are  decreased.  These  changes  may  not  be  observed  in 
the  earliest  stage  of  the  disease.  The  total  of  white  cells  is  not  essen- 
tially increased;  in  the  case  of  Askanazy,  the  disease  was  pseudoleu- 
kaemia for  two  and  a  half  years;  when  it  became  leukaemia,  and  lasted 
another  one  and  one-half  years.  Limbeck  found  an  increase  in  the 
polymorphonuclears  in  inflammation  of  the  glands  with  fever,  and  the 
lymphocytes  increased  when  the  change  was  like  that  of  lymphosar- 
coma. Leukocytosis  may  be  explained  in  some  instances  as  a  leu- 
kocytosis of  the  death  agony,  or  a  terminal  infection.    Reinert  found 


862  DISEASES  OF  THE  BLOOD 

cases  T^dth  decrease  in  the  lympliocytes,  which  was  caused  by  their 
decreased  formation  in  the  lymph  glands. 

5.  Other  Organs. — (a)  The  urticarious  eruptions  and  lymphatic 
growths  in  the  skin  occur  rather  more  frequently  than  in  leukaemia; 
the  lymphoderma  perniciosa  of  Kaposi  {erythrodermie  mycosique  of 
French  T\Titers)  may  be  considered  a  type  of  pseudoleuksemia  in  cases 
with  an  absolute  lymphoc}i;osis.  Er}i;hema,  purpura,  furuncles, 
pemphigus,  prurigo  from  irritation  of  the  lymphatic  deposits  around 
the  sweat  glands,  and  pigmentation,  have  been  observed.  According 
to  Dubreuilh  (1905),  18  cases  of  prurigo  are  reported.  Severe  sweats 
are  frequent,  (b)  Symptoms  of  ancemia  occur,  as  a  feeling  of  cold, 
vertigo,  spicope,  dyspnoea,  oedema,  hemorrhage,  palpitation,  ano- 
rexia, dyspepsia,  and  severe  diarrhoea,  (c)  Local  pain  over  the  liver 
and  spleen  may  indicate  perihepatitis,  or  perisplenitis.  Swelling  of  the 
liver  may  be  marked,  and  is  due  to  lymphoid  deposits.  Severe  mus- 
cular pain  has,  in  some  instances,  suggested  trichinosis,  {d)  Gangre- 
nous stomatitis,  or  pharyngitis,  may  occur  in  degenerated  lymph  nodes 
in  the  mouth,  tonsils,  and  throat.  Gastric  and  intestinal  ulcerations 
and  sometimes  perforation  are  noted,  though  they  are  less  frequent 
than  in  lymphosarcoma.  Xeusser  noticed  gastric  crises  like  those  of 
tabes,  (e)  Ross  and  Osier  described  lancinating  pains  in  the  feet,  and 
oedema  from  involvement  of  the  spine  and  cava  by  the  lymph  nodes. 
(/)  Amyloidosis,  bronchial  catarrh,  and  pulmonary  phthisis  have  been 
noted,  ig)  The  uric  acid  in  the  urine  is  not  increased.  Qi)  The  lym- 
phatic hyperplasia  may  also  involve  the  lymphatic  structures  in  the 
tonsils,  circumvallate  glands  of  the  tongue,  the  muscles,  mammae,  eye- 
lids, tibia,  thyroid,  or  thymus;  secondary  deposits  may  be  noted  in 
the  lungs,  liver,  heart,  pleura,  and  more  rarely  in  the  brain,  genitalia, 
and  peMs. 

6.  Fever. — Fever  is  common.  Gowers  and  Murchison  observed  a 
chronic  recurrent  type,  which  was  later  described  by  Pel  and  Ebstein ; 
the  term  is  a  misnomer,  and  classification  of  this  febrile  variety,  as  a 
separate  form,  is  incorrect,  for  it  has  been  observed  in  chronic  malaria, 
lymphosarcoma,  other  malignant  diseases,  and  in  glandular  and  splenic 
tuberculosis  which  simulates  Hodgkin's  disease.  The  urine  may  show 
the  diazo  reaction  with  the  fever.  When  the  disease  involves  the  inter- 
nal glands  only,  the  fever  may  simulate  t}^hoid.  Winnewarter  stated 
that  fever  occurred  when  the  glands  decreased  in  size  under  the 
administration  of  arsenic.  Fever  is  rather  indicative  of  glandular 
tuberculosis,  or  of  intercurrent  (terminal)  infections. 

Course. — The  clinical  course  is  long.  The  glandular  swelling  some- 
times decreases  T\^th,  or  without,  therapeutic  measures.  The  exten- 
sion from  the  cervical  to  other  lymphatic  glands  is  generally  gradual, 
but  may  occur  ^vdth  great  suddenness,  as  in  Trousseau's  case.  An 
acute  form  of  Hodgkin's  disease  is  not  well  established,  although 
cases  have  been  reported;  many  are  sepsis,  tuberculosis,  or  acute  sar- 
comatosis.  Death  may  occur  from  intercurrent  diseases,  but  it  most 
frequently  results  from  chronic  cachexia.    Obstruction  of  the  air  pas- 


PSEUDOLEUKEMIA  863 

sages  occurs  more  frequently  than  in  leukaemia.  Death  may  also  occur 
from  twisting  of  the  pedicle  of  the  spleen,  or  from  hemorrhages  from 
the  nose,  uterus,  stomach,  intestines,  or  larynx,  which  sometimes 
resemble  purpura  hemorrhagica  of  Werlhof.  Very  exceptionally, 
transition  into  leukaemia  is  observed.  It  is  a  question  whether  patients 
with  well-developed  cases  ever  recover,  though  the  disease  is  not  so 
fatal  as  is  leukaemia.  Pleural  effusions,  diarrhoea,  dysentery,  and 
vomiting  from  pressure  of  the  splenic  tumor,  are  unfavorable  compli- 
cations. 

Diagnosis,  Allied  Affections  and  Differentiation. — For  pseudo- 
leukaemia  there  are  two  criteria;  these  are  (a)  the  lymphadenoid 
hyperplasia  and  chronic  inflammation  observed  when  an  excised  node 
is  examined  histologically;  other  kinds  of  cells,  or  other  degenerations, 
excite  suspicion  that  the  disease  is  other  than  pseudoleukaemia;  and 
(&)  according  to  Pinkus,  an  absolute  lymphocytosis,  with  a  practically 
normal  number  of  white  blood  cells.  Differentiation  from  similar 
affections  is  as  follows: 

1.  Glandular  Tuberculosis  (Sternberg,  Noothaft,  Goldman,  Kanter, 
Delafield,  Crowder,  Askanazy,  Waetzoldt). — Hodgkin's  disease  may 
be  complicated  by,  or  confused  with,  tuberculosis;  in  pseudoleukaemia 
the  typical  structure  of  the  tubercle  is  lacking,  but  in  tuberculous  aden- 
itis, there  may  rarely  be  a  diffuse  accumulation  of  large  endothelioid 
cells  between  which  lie  tubercle  bacilli  (Ziegler);  after  a  long  course, 
caseation  and  giant  cell  formation  may  result;  the  forms  of  glandular 
tuberculosis  are  (a)  Ziegler's  large  cell  infiltration,  (6)  purely  hyper- 
plastic lymphoid  proliferation,  or  (c)  anatomical  tubercles.  Of  late,  the 
number  of  reported  instances  of  glandular  tuberculosis  simulating 
Hodgkin  's  disease  has  been  increasing  enormously.  The  author  exam- 
ined 2  cases  of  supposed  pseudoleukaemia  in  which  tubercle  bacilli 
(without  anatomical  tubercles)  were  found  in  numbers  in  the  spleen 
and  lymph  nodes.  In  the  neck,  tuberculous  adenitis  is  more  often  in 
the  submaxillary  than  in  anterior  and  posterior  glands,  in  the  latter 
of  which  pseudoleukaemia  is  more  common.  Tuberculosis  is  more 
frequently  a  local  than  a  general  adenitis,  and  is  more  often  attended 
by  secondary  suppuration.  Tiirck  believes  that  fever  and  glandular 
tenderness  indicate  tuberculosis,  and  that  node-Hke  swellings  of  the 
lymph  vessels  in  the  mouth  are  symptomatic  of  pseudoleukaemia. 
Excision  of  a  node  or  operation  determines  the  question. 

2.  Anaemia  Infantum  Pseudoleukaemica. — This  disease  was  first  fully 
described  by  von  Jaksch,  though  earlier  observed  by  Senator;  it  is 
known  in  Italy  as  ancemia  splenica  infettiva  del  bambini;  it  is  called 
"anaemia  splenica,"  or  "pseudopernicious  anaemia  of  children,"  by 
Ehrlich.  It  is  a  profound  anaemia  in  which  the  blood  findings  suggest 
pernicious  anaemia;  that  is,  there  are  normoblasts,  megaloblasts, 
decrease  of  the  red  blood  cells  (1^  to  3  million),  and  sometimes  poiki- 
locytes,  or  polychromatophilia;  there  is  often  increase  of  the  leukocytes, 
but  they  rarely  number  more  than  50,000.  It  occurs  in  young  children 
from  nine  to  eighteen  months  of  age;  the  convalescence  is  usually  very 


864  DISEASES  OF  THE  BLOOD 

slow,  or  death  may  result.  Its  symptoms  are  hardness  and  enlarge- 
ment of  the  spleen,  swelling  of  the  liver  (less  than  in  leukaemia  and  less 
than  the  swelling  of  the  spleen),  signs  of  profound  anaemia  and  hemor- 
rhages into  the  skin  or  from  the  nose,  mouth,  stomach,  or  intestines. 
The  status  of  the  disease  is  not  yet  determined,  because  the  lymphocytes 
are  frequently  increased  in  children,  and  leukocytosis,  in  general,  has 
less  significance  than  in  adults.  The  diagnosis  is  especially  difficult 
when  it  occurs  in  syphilitic  children;  syphilis,  rickets,  and  dyspepsia, 
are  common  antecedents. 

3.  Anaemia  Splenica. — Doubt  has  been  expressed  whether  it  should 
be  classed  as  an  essential  anaemia,  liver  cirrhosis,  chronic  splenitis,  or 
as  a  splenic  form  of  Hodgkin  's  disease,  (a)  The  spleen  is  enlarged,  its 
capsule  thick,  its  stroma  increased,  and  the  endothelium  of  the  lymph 
sinuses  sometimes  proliferated.  The  cause  is  unknown ;  possibly  it  is 
toxic.  (6)  There  is  an  ancemia  of  the  secondary,  or  chlorotic,  type; 
the  red  cells  average  3,500,000,  the  haemoglobin  is  even  more  reduced 
and  the  whites  are  decreased  to  3  or  4  thousand,  (c)  Hemorrhages, 
particularly  from  the  stomach,  are  frequent,  (d)  In  many  cases  there 
is  a  terminal  liver  cirrhosis  (Banti's  disease),  with  icterus  and  ascites, 
(e)  Its  course  is  very  chronic,  covering  years.  In  some  cases  there  are 
profound  alterations  of  nutrition,  as  stunted  growth,  clubbed  fingers, 
or  pigmentation  of  the  skin  (in  8  of  Osier's  18  cases).  In  several  cases 
Dock  and  Warthin  found  portal  thrombophlebitis  and  hyperplasia 
of  the  haemolymph  glands.  Of  Lichty's  cases  5  recovered,  12  showed 
improvement,  and  7  died. 

4.  Lymphosarcomatosis. — This  is  sometimes  most  difficult  to  dif- 
ferentiate, and  some  clinicians,  as  Hoffmann,  class  the  two  diseases 
together.  According  to  Kundrat,  lymphosarcoma  is  largely  a  local 
disease,  with  local  glandular  involvement,  especially  of  the  cervical 
glands,  leading  to  infiltration  of  the  throat  by  contiguity;  the  disease 
may  begin  in  the  tonsils,  the  air-passages,  the  portal  glands,  etc.  Lym- 
phosarcoma ulcerates  and  transgresses  the  gland  capsule;  this  never 
occurs  in  leukaemia  or  in  pseudoleukaemia.  The  glands  in  leukaemia 
and  pseudoleukaemia  may  compress  neighboring  structures  but  never 
actually  invade  them.  Unless  lymphosarcoma  extends  beyond  the 
capsule  of  the  glands,  it  cannot  be  distinguished  by  physical  examina- 
tion unless  it  lies  in  parts  which  can  be  easily  inspected,  as  the  mouth. 
The  spleen  may  be  enormously  enlarged.  According  to  Pinkus,  the 
leukocytes  are  increased  in  pseudoleukaemia  while  in  lymphosarcoma 
they  are  decreased. 

5.  Other  Splenic  Enlargements. — ^The  most  common  of  these  are: 
Cirrhosis  of  the  liver,  malarial  spleen,  sometimes  carcinoma,  chlorosis 
with  enlarged  spleen  (Chvostek),  chronic  polycythaemic  cyanosis 
(characterized  by  (a)  enlarged  spleen,  (6)  cyanosis,  and  (c)  increase  in 
the  red  cells)  and  finally  miliary  tuberculosis  of  the  spleen,  actino- 
mycosis, syphilis,  rhachitis  or  echinococcus  which  are  rarer  forms 
(see  Diseases  of  Spleen). 


PSEUDOLEUKEMIA  865 

6.  Multiple  Myeloma. — ^This  is  characterized  pathologically  by 
lymphoid  hyperplasia  of  the  bone  marrow,  occurring  in  the  ribs  and 
body-ends  of  the  long  bones  chiefly,  and  more  often  in  the  proximal 
than  in  the  distal  bones;  no  metastases  occur.  The  bones  soften  or 
sometimes  sclerose.  Clinically,  it  occurs  in  males  over  forty-five  years 
and  is  characterized  by  severe,  deep-seated  pain  in  the  body,  chest, 
spine,  neck^  and  more  rarely  in  the  extremities.  Prominences  in  the 
bones,  spontaneous  fractures,  especially  of  the  sternum  and  ribs,  and 
kyphosis,  from  softening  of  the  vertebrae,  may  result.  The  growths 
may  rupture  externally.  The  x-rays  may  clearly  define  them.  They 
sometimes  pulsate.  Severe  anaemia,  marked  nervous  disturbances, 
as  neuralgia,  motor  and  sensory  paralyses,  which  usually  develop  late 
and  involve  the  opticus,  hypoglossus,  facialis,  cord  (paraplegia  dolo- 
rosa), and  sciatic  nerve;  fever  and  the  Bence-J ones'  albumosuria  are 
observed.  The  anaemic  blood  findings  show  no  increase  of  the  white 
cells.  To  call  this  disease  a  myelogenic  form  of  pseudoleuksemia,  or 
myelogadenia,  there  must,  according  to  Pinkus,  be  a  lymphocytosis. 

7.  Other  Affections. — Syphilis  of  the  lymphatic  glands  (lymphoma 
gummosa);  symmetrical  lymphoma  of  the  lachrymal  and  salivary 
glands  of  Mikulicz,  which  are  simple  lymphoma  reacting  to  arsenic, 
and  resembling  pseudoleuksemia;  and  secondary  carcinoma,  or  sar- 
coma must  be  differentiated.  Difficulties  of  diagnosis  are  met  when 
the  enlarged  glands  in  internal  parts  produce  topical  symptoms,  thus 
simulating  hypertrophic  cirrhosis,  when  it  begins  in  the  spleen. 

Treatment. — 1.  Local  Applications. — These  are  useless,  excepting 
the  x-rays;  William  A.  Pusey  states  that  two  of  his  cases,  seen  by  the 
author  five  years  ago,  wholly  recovered.  In  some  cases  the  rays  have 
no  influence  on  the  spleen  and  glands,  and  in  others  the  cachexia 
increases,  though  there  may  be  improvement  in  the  local  findings. 
Inunctions  of  green  soap,  given  once  or  twice  daily,  are  sometimes 
beneficial,  and  in  one  instance  the  author  saw  marked  temporary 
benefit. 

2.  Drugs. — Arsenic  is  most  efficacious  {v.  Pernicious  An.emia 
for  details);  it  acts  on  the  glands  more  than  on  the  spleen.  Some 
clinicians  believe  that  the  fever  which  it  sometimes  produces,  reduces 
the  adenopathy.  Winnewarter  and  Billroth  recommended  its  paren- 
chymatous injection  into  the  glands,  but  the  results  are  not  very  encour- 
aging. Iodides  are  seemingly  injurious.  Berberin  hydrochlorate  gr. 
XV  increases  the  appetite  and  contracts  the  spleen  (Litten).  For 
hemorrhages  Litten  uses  a  decoction  of  quercus  cortex,  which  rather 
disturbs  digestion;  equal  parts  of  formalin  and  rectified  spirits  locally 
(which  may  irritate  a  delicate  skin),  and  guacamphol  gr.  iij  to  iv  once 
or  twice  daily  may  be  given. 

3.  Surgical  Treatment. — Extirpation  of  the  glands  is  seldom  bene- 
ficial. The  removal  of  the  spleen  is  attended  by  constantly  decreasing 
mortality.  In  1900,  Bessel-Hagen  collected  300  operations  for  various 
indications;  the  average  mortality  was  38  per  cent,  (for  splenomegaly, 
61  per  cent,  before  1891,  and  since  then,  13  per  cent.).    In  1901,  Harris 

55 


866  DISEASES  OF  THE  BLOOD  ' 

and  Herzog  reported  2  operated  cases,  and  collected  17  others,  the 
mortahty  being  20  per  cent.  In  Lichty's  25  cases,  8  were  operated  on 
with  a  37  per  cent.  mortaKty.  Scott  has  added  6  cases,  of  which  33 
per  cent.  died. 

Carstens,  in  November,  1905,  collected  739  cases  of  splenectomy 
for  various  diseases  of  the  spleen ;  72  per  cent,  recovered. 


THE  HEMOREHAGIC  DISEASES. 


The  hemorrhagic  diseases  may  be  classified  roughly  as  follows : 

(A).  Acquired  types.  |  1;  ^^3^^^^' 

(B).  Congenital  (hereditary)  type,    3.  Hsemophilia. 


(F).  PURPURA. 

Purpura  includes  a  number  of  affections,  more  or  less  similar  in 
kind  and  differing  chiefly  in  degree,  some  of  which  are  symptomatic, 
though  others  are  independent  but  obscure  affections. 

Symptomatic  purpura  is  observed  as  a  symptom  in: — (a)  Various 
infections,  as  endocarditis,  scarlatina,  measles,  smallpox,  rheumatism, 
typhus,  sepsis  (strepto-,  pneumo-  and  staphylococcus,  and  bac.  pyo- 
cyaneus  and  coli),  anthrax,  cholera,  yellow  fever,  plague,  syphilis,  or 
tuberculosis,  (b)  Toxic  conditions,  as  nephritis,  cholsemia,  snake- 
bites, and  drug-poisoning  (from  copaiba,  ergot,  belladonna,  quinine, 
mercury,  iodides,  bromides,  or  arsenic),  (c)  Cachexies;  old  age,  mal- 
nutrition, carcinoma,  sarcoma,  leukaemia,  pseudoleuksemia,  or  per- 
nicious anaemia,  (d)  Nervous  states;  cerebrospinal  lesions,  as  tabes, 
myelitis;  neuroses  (bloody  stigmata  of  hysteria);  neuralgias,  or  vaso- 
motor fluxions,  (e)  Mechanical  conditions,  as  trauma,  embolism, 
or  stasis. 

Purpura  simplex  (Zeller,  1684),^  is  purpura  in  which  the  cutaneous 
hemorrhages  are  the  chief  symptom.  Its  etiology  is  obscure.  It 
develops  most  often  in  middle-aged  males.  As  in  the  other  forms, 
whose  description  follows,  there  is  no  constant  nor  characteristic 
'pathology,  though  vessel  alteration  (thickening,  hyaline,  and  fatty 
degeneration),  thrombosis,  hemorrhage,  and  pigmentation  sometimes 
occur.  In  the  blood  itself  no  change  is  observed  other  than  its  tardy 
coagulation;  this  requires  10  to  30  minutes,  instead  of  3  to  5,  which 
is  the  normal  time.  The  eruption  begins  as  small  red  spots,  which 
gradually  become  green  and  black;  they  occur  largely  on  the  extensor 
surfaces  of  the  limbs,  and  more  often  on  the  legs  than  on  the  arms  or 


PURPURA  867 

trunk.  They  do  not  fade  upon  pressure.  The  initial  eruption  may 
be  macular,  papular,  or  urticarious  (purpura  maculosa,  papulosa, 
or  urticans),  but  soon  becomes  blood-tinged.  Constitutional  symptoms 
are  usually  absent;  there  may  be  slight  fever,  gastric  disorder,  or 
diarrhoea  (Graves).  The  usual  duration  is  1  to  2  weeks,  the  ^prognosis 
is  good,  and  the  treatment  hygienic  rather  than  medicinal.  Relapses 
are  common. 

Purpura  (or  peliosis)  rheumatica  is  a  form  described  by  Schoenlein, 
and  still  generally  listed  by  itself  because  of  the  articular  symptoms. 
As]  joint  symptoms  also  occur  in  Werlhof's  disease  {v.i.),  scurvy  and 
hgemophilia,  its  separate  classification  is  somewhat  arbitrary.  Most 
cases  develop  in  males  between  fifteen  and  thirty  years  of  age.  It  has 
no  relation  to  rheumatism  proper,  being  a  pseudorheumatism.  Its 
pathology  is  obscure. 

Symptoms. — (a)  As  frodromes,  indisposition,  low  fever,  muscular 
pains,  colic,  and  particularly  sore  throat,  may  be  noted.  The  developed 
disease  is  manifested  chiefly  by  various  forms  of  purpura,  and  by  symp- 
toms in  the  joints;  (6)  the  purpura  may  occur  before,  with,  or  after 
the  joint-symptoms.  It  occurs  as  simple  hemorrhages  of  the  skin, 
which  vary  from  red  to  green-black  according  to  their  age,  or  as  urti- 
caria, erythema,  pemphigus,  or  oedema,  which  become  stained  with 
blood;  the  legs  are  most  often  involved,  largely  on  the  extensor  sur- 
faces, (c)  Articular  symptoms  are  most  common  in  the  knees  and 
ankles,  being  less  frequent  in  the  elbows,  and  rare  in  other  joints; 
there  may  be  only  stiffness  and  pain,  or  there  may  be  actual  swelling; 
if  the  joints  are  first  involved,  their  symptoms  frequently  abate  with 
the  appearance  of  the  purpura,  and  may  last  but  5  to  10  days,  (d) 
Other  symptoms  are  inconstant,  as  fever,  which  may  rise  to  102°  or  103°, 
splenic  tumor,  albuminuria,  or  nephritis.  The  author  once  had  3  cases 
at  one  time  in  the  Cook  County  Hospital,  in  which  there  was  severe 
sloughing  of  the  tonsils.  Osier  (1904)  described  29  cases  in  which 
visceral  lesions  occurred  with  purpuric,  urticarious,  and  erythematous 
symptoms;  they  occurred  chiefly  in  children,  and  relapses  were  fre- 
quent; (i)  digestive  complications  occurred  in  25  cases;  vomiting  in 
15;  colic  in  8  (resembling  renal  stone  or  appendicitis);  blood  in  the 
stools  in  8,  and  diarrhoea  in  15;  (ii)  acute  nephritis  occurred  14  times, 
and  5  cases  died  of  uraemia;  (iii)  arthritis  occurred  in  17  cases;  (iv) 
swelling  of  the  fauces,  oedema  of  the  larynx,  aphasia,  transient  hemi- 
plegia and  least  often  endocarditis,  may  occur. 

The  diagnosis  chiefly  concerns  affections  characterized  by  hemor- 
rhages of  the  skin,  articular  symptoms  and  perhaps  temperature. 
Acute  leukffimia,  septicopyeemia  and  endocarditis  must  be  excluded. 
Genuine  rheumatic  polyarthritis  is  usually  differentiated  with  ease  by 
the  earlier  migrating,  inflammatory  joint  involvement,  the  tempera- 
ture, sweating,  characteristic  cardiac  complications,  and  the  later, 
rather  accidental  and  wholly  secondary  occurrence  of  the  purpura. 

The  prognosis  is  generally  good,  though  relapses  are  common  and 
sometimes  periodical.    Its  course  is  rarely  longer  than  a  week  or  two. 


868  DISEASES  OF  THE  BLOOD 

Treatment  is  hygienic  and  symptomatic.  The  joint-symptoms  yield 
somewhat  to  acetanilide  and  salicylates,  though  the  latter  exert  no 
specific  influence. 

Purpura  hemorrhagica  {Morbus  maculosus  Werlhofii,  "Werlhof,  1775) 
closely  resembles  the  sub-types  already  described,  but  differs  from 
them  in  that  not  only  are  the  skin  and  joints  the  seat  of  hemorrhage, 
but  also  the  mucous  membranes,  serous  membranes,  and  perhaps  the 
viscera. 

Etiology. — Of  this  little  is  known;  staphylo-,  strepto-  and  pneumo- 
cocci,  Bacillus  pyocyaneus  and  coli,and  one  like  Friedlander's  pneumo- 
bacillus  have  been  found.  It  occurs  oftener  in  young  weakly  women 
than  in  robust  adults.  Exposure  to  cold  or  dampness,  and  malnu- 
trition seem  to  be  predisposing  causes.  It  usually  develops  as  an 
apparently  primary  affection,  but  it  may  occur  in  some  of  the  conditions 
listed  under  symptomatic  purpura. 

Symptoms. — Perhaps  after  inconstant  and  variable  prodromes,  as 
fever,  vomiting,  or  vertigo  (a)  hemorrhages  appear  on  the  extremities; 
the  face  is  not  often  involved;  they  occur  as  spontaneous  petechise, 
blood-stained  bullae,  or  \abices,  or  may  result  from  slight  trauma,  as 
by  pinching  the  skin,  (b)  The  mucous  membranes  bleed  to  a  varying 
degree;  the  nose  and  mouth  bleed  most  often;  less  frequently  there 
is  haemoptysis,  hpematemesis,  enterorrhagia,  hsematuria,  and  metror- 
rhagia, in  various  combinations,  sequences,  and  degrees.  The  con- 
junctivae may  be  blood-stained.  The  writer  saw  one  rapidly  fatal  case 
in  which  there  was  hemorrhage  from  the  middle  ear.  (c)  The  serous 
membranes,  and  the  joints,  particularly  the  knees,  ankles,  and  elbows, 
are  often  implicated.  Ecchymoses  in  the  endo-  and  pericardium, 
pleura,  peritoneum,  and  meninges  are  common  findings  at  autopsy 
id)  Other  hemorrhages  are  much  less  common,  as  retinal  hemorrhages 
hemorrhage  into  the  brain,  cord,  or  testis.  The  connective  tissues, 
fasciae  and  bones  are  practically  exempt. 

There  may  be  general  symptoms  and  complications.  As  to  the  blood, 
there  is  delayed  coagulation  and  some  anaemia,  but  the  red  cells  and 
haemoglobin  are  rarely  much  reduced;  some  nucleated  red  cells  may 
be  found,  as  well  as  leukocytosis,  reduction  in  the  blood  plates,  and 
some  methaemoglobinaemia.  Fever  is  inconstant  and  atj'pical.  The 
pulse  rate  may  be  raised;  palpitation,  delirium,  vertigo,  albuminuria, 
hepatic  enlargement,  splenic  tumor,  subicterus,  and  nephritis  are 
occasional  symptoms.  In  J.  S.  Cutler's  case,  there  was  extensive  intes- 
tinal ulceration;  perforation  has  been  also  reported. 

Diagnosis. — Most  errors  in  diagnosis  result  from  confusion  with 
those  purpura  cases  which  are  symptomatic  of  sepsis,  hemorrhagic 
exanthemata,  or  blood  affections.  The  difficulties  in  diagnosis  are 
often  great;  in  an  anaemic  old  man,  who  suddenly  vomited  blood  and 
passed  bloody  urine,  the  diagnosis  of  purpura  was  made;  the  autopsy 
revealed  a  round  ulcer  of  the  stomach,  and  a  papilloma  of  the  bladder. 
Scurvy  is  distinguished  by  its  gingivitis  and  muscular  hemorrhages, 
and  hcemophilia  by  reason  of  its  hereditary  facts.    Henoch's  purpura 


HEMORRHAGIC  DISEASES  OF  THE  NEW-BORN  869 

is  a  type  which  occurs  chiefly  in  children,  and  is  characterized  (a)  by 
cutaneous^  lesions,  which  resemble  erythema  nodosum  rather  than 
purpura;  (6)  by  hemorrhages  of  the  mucous  membranes;  (c)  by 
gastro-intestinal  crises  of  vomiting,  diarrhoea,  and  abdominal  pain; 
(d)  by  pains  in  the  joints,  and  (e)  by  frequent  relapses,  often  over  a 
number  of  years  (v.  s.  Osier's  group). 

Prognosis. — ^The  prognosis  is  uncertain.  According  to  Gross,  50 
per  cent.  die.  Unfavorable  symptoms  are  sudden  onset,  high  tempera- 
ture, and  extensive  hemorrhages.  Purpura  fulminans,  of  which  Styler 
(1906)  collected  only  14  cases,  may  be  fatal  in  24  to  48  hours.  Recur- 
rence is  not  uncommon. 

Treatment. — This  has  advanced  but  little  beyond  Werlhof 's  therapy 
of  giving  dilute  sulphuric  acid  tijjx,  and  quinine  gr.  v  after  meals. 
Everything  of  a  supportive  nature,  as  sufficient  nourishment,  rest  in 
bed,  iron  and  arsenic,  are  helpful.  The  hemorrhages  are  arrested 
with  difficulty,  and  the  author  doubts  the  value  of  drugs  in  their  control. 
Turpentine  and  ergot  may  be  given  (as  in  haemoptysis  q.v.).  Adren- 
alin solution  to  the  nose  and  mouth,  gelatin  by  mouth  (see  Next 
Section),  and  especially  calcium  chloride  gr.  v,  t.  i.  d.,  to  increase  the 
coagulability  of  the  blood,  are  indicated. 


(g).  hemorrhagic  diseases  of  the  new-born. 

Syphilis  hemorrhagica  neonatorum  appears  soon  after  birth.  In 
some  instances  the  syphilitic  child  may  be  born  with  hemorrhages  in 
the  skin,  mucosae,  internal  organs,  and  from  the  navel.  Occasionally 
deep  jaundice  develops.  The  cause  is  probably  vascular  disease; 
Mracek  found  endarteritis,  especially  of  the  capillaries,  in  14  per  cent, 
of  19  cases.    In  other  cases  an  added  sepsis  is  apparently  causative. 

Winckel's  disease,  epidemic  hsemoglobinuria,  is  (a)  an  affection  of 
the  new-born  of  unknown  causation;  (6)  it  appears  epidemically  in 
hospitals;  (c)  it  develops  in  the  first  four  days  of  life;  (d)  it  is  char- 
acterized clinically  by  fever,  gastro-intestinal  symptoms,  icterus, 
dyspnoea,  cyanosis,  albuminuria,  methsemoglobinuria  and  large  mor- 
tality, and  (e)  pathologically  by  internal  hemorrhages,  fatty  degenera- 
tion, and  splenic  tumor. 

Morbus  maculosus  neonatorum  is  no  clearer  etiologically  than 
Werlhof 's  disease  in  adults ;  some  cases  come  under  congenital  syphilis ; 
others  with  fever,  jaundice,  and  epidemic  occurrence  under  infection 
(pyogenic  cocci,  pneumococci,  a  bacillus  like  Friedlander's,  pyocyaneus, 
and  colon  bacillus),  and  still  others  seem  embolic,  thrombi  forming  in 
the  auricles  when  the  heart  is  weak  (Landau).  Injuries  to  the  head, 
causing  hemorrhages  in  the  fourth  ventricle  and  cerebral  peduncles, 
and  other  vasomotor  disturbances  (von  Preuschen,  and  Pomarski) 
are  questionable  causes.    It  occurs  once  in  500  to  700  births. 

Symptoms. — In  the  first  week  of  life,  hemorrhages  occur  from  the 
navel  and  mucous  membranes;  in  Townsend's  50  cases  thev  occurred 


870  DISEASES  OF  THE  BLOOD 

in  the  following  frequency:  from  the  bowel  (melsena),  40  per  cent.; 

navel,  36  per  cent.;  mouth,  28  per  cent.;  stomach,  28  per  cent.,  and 
nose,  24  per  cent.  Death  occurs  Tv-ithin  a  week  in  62  per  cent.  Dusser, 
in  78  cases,  found  the  mortality  was  55  per  cent. 

Treatment. — Iron,  ergot,  and  adrenalin  are  useless.  Diffuse  stimu- 
lants should  be  given  when  there  is  a  weak,  rapid  pulse.  Injections  of 
gelatin  are  dangerous,  for  it  possibly  contains  some  ptomaine,  and  its 
local  use  and  administration  by  mouth  are  safer. 


(H).  SCURVY. 

Definition. — A  general  disease,  more  often  endemic  than  sporadic, 
caused  by  neglect  of  hygienic  conditions,  and  characterized  by  gingi- 
^^tis,  hemorrhages,  inflammations,  cachexia  and  chronicity  of  course. 

Etiology. — It  was  first  observed  in  the  Crusades,  and  was  described 
most  fully  by  Yasco  de  Gama;  in  his  voyage  around  the  Cape  in  1498, 
33  per  cent,  of  his  sailors  were  stricken  ^dth  scurvy.  It  has  developed, 
not  only  among  sailors,  but  among  prisoners,  Canadian  lumbermen, 
Pennsylvania  miners,  and  among  the  workers  on  the  Chicago  Drainage 
Canal,  where  in  1893-95,  the  author  saw  100  cases.  Insufficient,  monot- 
onous, possibly  spoiled,  food  causes  the  majority  of  cases,  sometimes, 
in  conjunction  with  lack  of  fresh  air,  impure  water,  damp  quarters, 
and  over-exertion;  a  lack  of  fresh  meat,  vegetables  (potassium  salts, 
malic  and  citric  acids),  and  fats  predispose  to  scorbutus,  though  the 
lack  of  no  single  group  is  solely  responsible.  The  Chicago  Drainage 
Canal  cases  were  all  Poles,  and  lived  on  coffee,  bread,  and  preserved 
and  fresh  meat.  It  develops  principally  in  middle-aged  males  of  the 
poorer  classes.  The  disease  is  becoming  less  frequent.  In  1780, 
Admiral  Gleary  had  2,400  cases  in  the  English  fleet,  and  in  1849,  there 
were  260,444  cases  in  Russia,  and  60,958  deaths.  It  is  still  -^N^dely 
endemic  in  Prussia,  where  it  is  regarded  as  an  infection. 

Sjrmptoms. — Scorbutus  begins  slowly,  and  progresses  insidiously; 
its  earliest  symptom  is  (1)  ancsmia  (cachexia  scorbutica).  The  skin  is 
scaly,  pale,  lustreless,  and  may  become  pigmented.  The  mucous  mem- 
branes are  rather  li^dd,  and  the  expression  is  apathetic.  The  blood 
findings  are  not  characteristic;  coagulation  is  slow,  the  red  cells  and 
haemoglobin  are  proportionately  reduced,  and  leukocytosis  is  absent, 
except  with  intercurrent  inflammation  or  severe  hemorrhage.  Emacia- 
tion, mental  depression,  muscular  weakness,  fatigue,  anorexia,  reduc- 
tion of  HCl  in  the  gastric  juice,  intestinal  fermentation,  constipation, 
palpitation,  weakness  with  irregularity  of  the  heart's  action,  a  systolic 
functional  murmur,  and  oedema  about  the  ankles  accompany  the 
anaemia.  Splenic  enlargement,  albuminuria,  peptonuria  and  ohguria 
are  common. 

2.  Gingivitis  begins  with  turgescence  of  the  gums,  which  is  due  to  a 
serohemorrhagic  infiltration,  usually  noticed  first  about  the  canine 
teeth;    the  gums  are  spongy,  painful,  particularly  on  eating,  bleed 


SCURVY  871 

readily,  and  may  become  so  swollen  as  to  hide  the  teeth.  Gingivitis 
is  absent  when  there  are  no  teeth  or  roots.  The  breath  is  extremely 
foetid.  In  severe  cases  the  gums  necrose,  and  bleed  profusely;  deep 
ulcers,  on  healing,  leave  cicatrices;  the  teeth  may  loosen  and  fall  out, 
the  salivary  and  cervical  lymph  glands  and  tongue  may  swell.  Necro- 
sis of  the  jaw  is  uncommon. 

3.  Hemorrhages  may  occur  (a)  in  the  shin,  especially  on  the  extensor 
surfaces  of  the  legs;  small  hemorrhages  often  occur,  first  about  the 
hair  follicles;  they  are  at  first  small  petechise,  but  later  become  larger 
and  stretch  the  skin.  In  less  frequent  instances,  the  first  eruption  may 
resemble  acne,  herpes,  or  pemphigus,  hemorrhages  appearing  later  in 
these  exanthems.  The  trunk  is  less  frequently  involved,  and  the  face 
is  usually  exempt.  As  the  hemorrhages  increase,  the  legs  are  diffusely 
mottled  with  red,  green,  and  black,  and  are  swollen,  tense  and  somewhat 
warmer  than  normal.  Similar  stains  may  be  noted  running  upward 
in  streaks  along  the  lymph  vessels.  Some  of  these  changes  are  due  to 
(6)  muscular  hemorrhages  {scorbutic  sclerosis).  They  occur  mostly  in 
the  calf  and  thigh,  less  in  the  buttocks,  or  abdominal  wall.  The  legs 
are  large,  extremely  hard,  blood-stained,  and  later  pigmented.  As  the 
disease  regresses  the  muscles  usually  recover  their  function,  but  in 
some  instances  ulceration  (scorbutic  ulcers),  suppuration,  muscular 
cicatrization,  or  pressure  atrophy  and  shortening  of  the  tendons  may 
leave  permanent  deformity  and  contractures,  (c)  Mucous  membrane 
hemorrhages  are  less  common  than  in  purpura  or  haemophilia,  though 
epistaxis  is  fairly  frequent.  In  some  cases  hemorrhages  occur  in  the 
conjunctiva,  air  passages,  and  stomach,  but  in  more  cases  in  the  bowels, 
perhaps  with  intestinal  ulceration,  {d)  Of  serous  membrane  hemor- 
rhages, articular  hemorrhage  (hsemarthrosis)  is  the  most  frequent. 
Next  in  order  of  frequency  are  those  in  the  pleura,  pericardium, 
peritoneum  and  meninges.  They  are  usually  sudden  in  onset,  extreme 
in  degree,  and  unfavorable  in  outcome,  (e)  Parenchymatous  hemor- 
rhages are  least  common,  as  in  the  eye-tissues,  brain,  and  other  viscera. 
Subperiosteal  and  epiphyseal  hemorrhages  are  rare,  unless  Barlow's 
disease  is  included  (see  Next  Section).  Scorbutic  ulcers  in  soft  tissues 
may  reach  the  bone,  causing  necrosis. 

4.  Scorbutics  are  subject  to  various  inflammations,  (a)  Painful 
joint  swellings  are  the  most  frequent,  and  occurred  in  35  per  cent,  of 
the  author's  cases,  and  chiefly  in  the  knees;  they  may  be  serous  or 
hemorrhagic,  or  in  severe  cases  the  cartilages  or  bones  may  become 
eroded  and  ulcerated;  sometimes  suppuration  intervenes;  deformity 
and  ankylosis  are  possible  sequences.  (6)  Hemorrhagic  pericarditis 
and  pleuritis  are  very  dangerous,  (c)  Onychia,  paronychia,  choroid- 
itis, and  panophthalmitis  are  occasional  incidents.  Fever  is  uncom- 
mon, except  from  extreme  inanition  or  terminal  infection. 

Course  and  Prognosis. — The  onset  is  insidious,  the  course  chronic, 
and  convalescence  protracted.  Most  cases  recover,  after  which  recur- 
rence is  not  frequent.  Death  may  occur  (a)  from  cachexia,  and  the 
autopsy  then  shows  fatty  degeneration  of  the  heart,  liver,  and  blood- 


S72  DISEASES  OF  THE  BLOOD 

vessels;  (6)  from  profuse  hemorrhages,  into  the  pleura,  pericardium, 
gastro-intestinal  tract,  or  rarely  into  the  brain,  or  meninges;  (c)  from 
infections,  as  dysentery,  pleurisy,  pneumonia,  or  septicopysemia,  prob- 
ably of  the  terminal  type,  and  promoted  by  the  reduced  physiological 
resistance.  ' 

Diagnosis. — The  diagnosis  is  usually  made  without  difficulty  from 
(a)  the  anaemia  or  cachexia,  (6)  gingivitis,  (c)  tendency  to  hemorrhage, 
and  id)  inflammation,  (e)  the  chronic  course,  and  (/)  the  temporary 
nature  of  the  condition  (as  contrasted  with  the  most  permanent  ten- 
dency to  hemorrhage  in  haemophilia). 

Treatment. — (a)  Hygienic;  avoidance  of  "cured"  or  smoked  foods 
is  both  prophylactic  and  curative.  In  Nansen  's  polar  expedition,  which 
lasted  three  years,  not  one  case  of  scurvy  developed.  His  meats  were 
cooked,  and  plenty  of  cooked  and  raw  fruits  and  vegetables  were  used. 
Berries,  sauerkraut,  potatoes,  radishes,  cress,  apples,  oranges,  and 
lemons  are  especially  valuable.  A  monotonous  dietary  is  particularly 
to  be  avoided,  (b)  The  anoemia  (q.v.)  should  be  treated  by  strychnine, 
quinine,  iron,  and  arsenic.  Yeast  §ij  two  or  three  times  daily,  is 
recommended,  (c)  The  gingivitis  is  treated  by  occasional  local  applica- 
tions of  silver  nitrate  (10  per  cent.).  Cocaine  may  be  painted  on  the 
gums  before  meals,  so  that  the  patient  may  be  able  to  eat,  but  great 
care  in  its  use  must  be  taken,  lest  the  habit  be  contracted,  or  toxic 
symptoms  develop,  (d)  Symptomatic  treatment;  hemorrhage  is  bene- 
fited by  rest  only.  Stimulation  is  required  in  intercurrent  pericarditis, 
and  pleuritis.  Drastic  cathartics  are  to  be  avoided.  CompHcating 
arthritis  necessitates  rest  and  the  application  of  cold,  but  rarely  aspira- 
tion or  drainage. 


(I).  INFANTILE  SCURVY— BARLOW'S  DISEASE. 

Moller  (1852-62)  described  the  affection  as  acute  rhachitis,  and 
Ingerslev  (1871),  Jalland  (1873),  Cheadle  and  Gee  (1878),  but  par- 
ticularly Barlow  (1883),  described  a  cachexia  with  hemorrhages, 
which  occurred  in' the  very  young.  De  Bruin  observed  61  cases  in 
Holland  in  1893.  In  1898,  379  cases  were  collected  in  the  United 
States. 

Etiology. — Unlike  scurvy  in  adults,  the  hygienic  conditions  are  good 
in  80  per  cent,  of  cases,  and  it  occurs  largely  in  the  better  classes, 
(a)  The  obvious  cause  is  feeding  with  malted,  condensed  or  cooked 
milk  or  baby  foods;  these  foods  lack  some  unknown  substance  which 
is  essential  to  health.  The  malady  is  very  rare  in  breast-fed  infants. 
In  713  cases  (S.  Weiss,  1905)  only  20  or  2.5  per  cent,  occurred  in  infants 
at  the  breast.  (6)  Ninety  per  cent,  of  cases  occur  between  the  sixth 
and  twelfth  month  (Heubner's  and  Neumann's  94  cases). 

Sjnnptoms. — These  are  not  always  typical;  there  may  be  anaemia 
("cachexia")  without  hemorrhages,  or  hemorrhages  without  anaemia, 
though  in  typical  cases  they  occur  together. 


HEMOPHILIA  873 

1.  Subperiosteal  hemorrhage  is  the  leading  symptom.  There  may 
be  at  first  some  vague  symmetrical  swelling  over  the  epiphyses,  which 
later  becomes  more  obvious,  though  no  real  oedema  is  noted.  There 
is  pain  and  tenderness  usually  in  the  thighs  or  legs,  which  are  drawn 
up,  flexed  or  everted,  immobile  and  semiparalytic  (pseudoparalysis). 
At  autopsy,  the  anatomical  findings  are  subperiosteal  hemorrhages; 
a  colloid  and  fibrillar  alteration  in  the  marrow  of  the  diaphyses; 
arrest  of  ossification;  decrease  of  the  osteoblasts;  rarefaction  of  the 
bone,  sometimes  leading  to  fractures  (spontaneous  or  after  slight 
trauma),  or  to  epiphyseolysis  (usually  at  either  end  of  the  femur  or 
the  upper  end  of  the  tibia);  the  joints  are  normal.  Seventy  per  cent, 
of  the  lesions  is  in  the  thigh,  24  per  cent,  in  the  leg,  and  6  per  cent, 
in  the  orbit;  the  arms,  ribs,  spine,  skull,  sternum,  and  scapula,  are  not 
often  involved.    Rib  involvement  results  in  depression  of  the  sternum. 

2.  The  cachexia  is  evidenced  by  the  anaemia  (usually  moderate  and 
sometimes  attended  by  slight  lymphocytosis),  sallow  skin,  asthenia, 
anorexia,  constipation,  irregular  temperature  (in  66  per  cent.)  or  sub- 
normal registration  and  the  almost  invariable  severe  sweats. 

3.  Gingivitis  is  noticed  when  the  teeth  have  already  erupted  or 
are  about  to  erupt.  In  73  cases  (Heubner  and  Neumann),  the  gums 
were  normal  in  but  15  per  cent. 

4.  Other  symptoms  embrace  hemorrhages  in  the  skin  in  15  per 
cent.,  from  the  kidneys  in  9  per  cent,  (hemorrhagic  nephritis),  and 
rarely  in  the  conjunctivae,  muscles,  stomach,  bowels  or  meninges.  The 
spleen  is  rarely  swollen. 

Diagnosis. — Diagnosis  is  not  difficult,  after  one  typical  case  has 
been  seen;  it  is  based  upon  the  etiology,  subperiosteal  hemorrhages, 
gingivitis  and  anaemia  (cachexia).  Confusion  with  genuine  paralysis 
is  unnecessary,  for  the  immobility  is  voluntary  to  escape  the  pain  of 
movement.  Syphilitic  bone  disease  (syphilitic  pseudoparalysis  or 
Parrot's  disease)  is  rather  similar  as  to  the  crepitus,  epiphyseolysis 
and  pain,  but  other  syphilitic  stigmata  or  scorbutic  symptoms  are 
generally  present. 

Prognosis  and  Treatment. — Proper  treatment  secures  marked  and 
immediate  improvement  in  the  great  majority  of  cases.  Death  is 
uncommon;  in  unfavorable  cases,  it  occurs  in  the  third  or  fourth 
month  of  the  disease. 

The  diet  consists  of  raw  cow's  milk,  potato  puree,  and  beef  juice 
(not  broth  or  extracts);  orange  juice,  apple  sauce,  pears,  cooked 
berries  and  spinach  are  most  beneficial.  Treatment  by  drugs  is  gen- 
erally superfluous. 

(J).  HEMOPHILIA. 

Definition. — A  congenital  and  hereditary  affection,  characterized  by 
deficient  coagulability  of  the  blood,  and  a  consequent  tendency  to 
various  profuse  hemorrhages,  which  are  spontaneous  or  traumatic, 
and  are  most  difficult  to  arrest. 


874  DISEASES  OF  THE  BLOOD 

Etiology. — Its  real  cause  is  unknown,  and  the  few  pathological 
changes  described  in  the  blood  and  the  bloodvessels  are  insufficient 
factors.  Sahli  believes  that  there  is  an  hereditary  deficiency  in  the 
fibrin-forming  substances  (thrombokinase).  (a)  Heredity  is  the  only 
clear  etiological  fact,  which  Fordyce  noted  in  1784;  as  Grandidier 
remarks,  hsemophilia  is  "the  most  hereditary  of  all  hereditary  diseases." 
Osier  quotes  Brown  as  observing  haemophilia  through  seven  generations. 
Sometimes  a  generation  may  be  exempt.  (6)  Broadly  speaking,  the 
males  of  the  "bleeder  families"  are  the  "bleeders,"  and  the  females 
transmit  the  disease  to  their  male  offspring  without  manifesting  the 
disease  themselves.  In  200  families  of  "bleeders,"  Grandidier  found 
609  cases  in  males,  and  48  in  females  (8  per  cent.);  Stahel  in  1,880 
families  found  only  24  cases  in  males.  In  the  Mampel  family,  first 
reported  by  von  Chelius  in  1827,  Lossen  (1905)  found  212  members 
of  which  111  were  males;  of  these  exactly  one-third  were  bleeders, 
and  48.7  per  cent,  of  the  male  bleeders  died  of  hemorrhage;  none  of 
the  females  were  bleeders  and  all  transmission  of  the  disease  occurred 
through  the  women,  (c)  The  disease  occurs  most  frequently  in  Ger- 
many, England,  North  America  and  France.  Consanguinity  and  family 
tendencies  (gout,  rheumatism,  or  tuberculosis),  have  been  suggested 
as  causes.  "Bleeders"  are  generally  healthy  individuals  with  soft, 
delicate  skins. 

Symptoms. — In  75  per  cent,  of  cases,  hemorrhages  develop  in  the  first 
two  years  of  life;  rarely  do  they  first  appear  after  puberty  or  in  the 
third  decade,  though  isolated  observations  are  recorded  of  persons 
having  their  first  hemorrhages  after  the  seventieth  year.  The  hemor- 
rhages are  spontaneous  or  traumatic;  they  most  often  occur  as  capil- 
lary oozing  from  a  mucous  surface;  deep  interstitial  bleeding  is  most 
unusual.  They  are  copious  and  hard  to  still.  Epistaxis  is  the  most 
common  (50  per  cent.);  hemorrhages  from  the  gums  (12  percent.), 
intestine  (12  per  cent.),  lungs,  kidneys  and  stomach  (each  6  per  cent.) 
are^next  in  frequency.  Uterine  hemorrhage  and  arthropathies  are 
not  infrequent.  According  to  Konig,  the  joint  findings  are  (a)  an 
hsemarthros,  with  pain,  swelling  and  fluctuation ;  (6)  then  panarthritis, 
whose  gross  pathology  resembles  tuberculous  arthritis,  with  flexion  of 
the  joint;  (c)  regression,  or  ankylosis  and  deformity,  which  rather 
resembles  arthritis  deformans.  The  knees  and  elbows  are  most  often 
affected.  Subcutaneous  hemorrhages  may  occur.  The  first  bleed- 
ing may  occur  from  the  navel,  or  may  result  from  vaccination, 
extraction  of  teeth,  circumcision,  from  a  trifling  prick  or  cut,  from 
delivery,  or  from  rupture  of  the  hymen  on  the  wedding  night.  In 
various  attacks,  one  part  after  another  may  bleed  or  the  hsemophilic 
disposition  may  be  confined  to  one  part,  as  a  kidney  (renal  haemophilia). 
Haemophilia  differs  from  purpura,  in  that  the  bleeding  seldom  occurs 
into  a  serous  membrane  (excepting  the  joints),  or  into  the  viscera. 
The  amount  of  blood  lost  may  be  enormous,  and  in  one  case  amounted 
to  24  pounds  in  eleven  days.    The  coagulation  test  of  the  blood  may 


HEMOPHILIA  875 

show  that  coagulation  is  delayed  to  thirty  or  forty-five  minutes  (Wright) ; 
the  clot,  when  formed,  is  porous. 

Of  general  symptoms,  there  are  few  except  changes  in  the  joints 
(like  those  in  subacute  rheumatism),  a  neuropathic  tendency  (neuroses 
and  neuralgia,  particularly  of  the  fifth  nerve),  and  anaemia  (though 
hsemophilics  tolerate  loss  of  blood  better  than  other  individuals,  show 
it  less,  and  recover  from  it  more  readily). 

Diagnosis. — The  diagnosis  may  be  for  a  time  uncertain,  when 
hemorrhage  develops  after  an  operation,  or  occurs  from  one  organ  only, 
as  the  kidney.  The  family  history  clearly  stamps  the  affection,  and 
readily  differentiates  it  from  scurvy,  purpura  and  hemorrhages  in  the 
new-born. 

Prognosis. — The  prognosis  is  grave.  Any  hemorrhage  may  prove 
fatal.  Sixty  per  cent,  of  cases  die  before  the  eighth  year,  and  only  11 
per  cent,  reach  the  twenty-second  year;  if  middle  life  is  reached,  the 
danger  gradually  lessens.  It  is  more  favorable  in  girls,  despite  the 
apparent  menstrual  dangers.  De  Bons  (1905)  found  69  excessive 
hemorrhages  among  150  deliveries  in  hsemophilic  women;  he  believes 
pregnancy  has  a  rather  favorable  effect  on  the  disease.  De  Lee  has 
reported  premature  detachment  of  the  placenta  in  haemophilia.  The 
rudimentary  or  local  forms  are  more  favorable  than  general  haemophilia. 

Treatment. — 1.  Prophylaxis. — Grandidier  lays  down  the  following 
rules :  (a)  women,  with  an  haemophilic  family  tendency,  whether  they 
are  "bleeders"  or  not,  should  not  marry,  (b)  Men,  if  not  "bleeders" 
themselves,  may  marry,  (c)  Men  should  not  marry  when  their  family 
history  indicates  that  male  "bleeders"  have  begotten  haemophilic 
children.  It  is  obvious  that  in  haemophilic  families,  general  measures 
to  elevate  the  physiological  resistance,  and  avoidance  of  trauma  or 
any  but  life-saving  operations,  are  indicated.  Vaccination  is  rarely 
contra-indicated. 

2.  Control  of  Actual  Hemorrhage. — This  is  almost  impossible,  (a) 
Wounds  should  be  cauterized  or  enlarged,  as  Fordyce  discovered  that 
in  haemophilics  large  bleed  less  than  small  wounds.  Other  surgical 
haemostatic  measures  need  not  be  further  considered.  The  Esmarch 
constrictor  controls  some  hemorrhages  of  the  extremities,  (b)  Styptics, 
as  Monsell's  solution,  or  tannic  preparations,  are  useless,  (c)  Adren- 
alin, locally  and  internally,  has  no  apparent  affect,  (d)  Calcium 
chloride  is  somewhat  more  beneficial,  grs.  iij  to  v  t.i.d.  should  be 
given;  it  should  be  given  intermittently,  because  protracted  adminis- 
tration decreases  the  coagulability  of  the  blood,  (e)  Gelatin  may  be 
given  by  mouth  or  in  unusually  severe  hemorrhages  by  sub-cutaneous 
infusion  (v.  Hemorrhages  of  the  New-born).  (/)  Saline  cathartics 
are  sometimes  apparently  efficacious,  possibly  by  diverting  blood  from 
the  seat  of  hemorrhage,  (g)  Very  acute  anaemia  necessitates  injection 
of  salines  under  the  skin ;  when  the  hemorrhage  is  over,  regeneration 
of  the  blood  is  remarkably  rapid,  (h)  Joint  involvement  is  treated 
by  rest,  immobilization,  and  rarely  aspiration. 


SECTION  VII. 


DISEASES  OF  THE  DUCTLESS  GLANDS. 


(A).  DISEASES  OF  THE  SUPEARENAL  GLANDS. 

ADDISON'S  DISEASE;  OTHER  AFFECTIONS  OF  THE  SUPRA- 
RENAL GLANDS. 

Definition. — A  disease  characterized  (a)  pathologically  by  lesions 
(usually  tuberculous)  in  the  adrenal  glands  or  by  degenerative  changes 
in  the  adjacent  abdominal  sympathetic  ganglia,  and  (&)  clinically  by 
langor,  muscular  and  mental  adynamia,  digestive  disorders,  pigmen- 
tation of  the  skin  and  a  fatal  issue. 

Etiology. — 1.  Suprarenal  disease  was  first  associated  pathologically 
with  melanoderma  by  Addison,  in  1855.  By  far  the  most  common 
lesion  is  (a)  chronic  fibrocaseous  tuberculosis  of  the  adrenal  glands; 
the  tubercles  of  the  adrenal  glands  are  usually  bilateral,  destroy  most 
of  the  suprarenal  structure,  and  frequently  involve  the  semilunar  ganglia 
and  solar  plexus  by  their  attendant  formation  of  connective  tissue;  in 
rare  cases  only  is  the  adrenal  tuberculosis  primary,  though  cases  were 
recorded  by  Symes  and  Fisher;  there  is  usually  a  primary  focus  in  the 
lungs  (in  over  50  per  cent.),  in  the  genito-urinary,  alimentary  or  glandu- 
lar system,  (b)  Less  common  are  tumors,  simple  atrophy,  fibrous 
induration  (usually  tuberculous),  cirrhosis  (26  cases  recorded),  gumma, 
amyloid  degeneration,  acute  inflammation  (as  by  contiguity  from  peri- 
nephric abscess),  acute  hemorrhage,  embolism,  echinococcus,  traumatic 
adenoma,  or  other  very  rare  lesions.  In  what  way  suprarenal  lesions 
produce  Addison's  melasma  suprarenale  is  still  a  disputed  question,  for 
our  knowledge  of  adrenal  physiology  is  incomplete.  It  seems  (i)  that  the 
glands  contain  a  substance  (sphygmogenin)  which  maintains  vascular 

S77 


878  DISEASES  OF  THE  DUCTLESS  GLANDS 

tonus,  and  stimulates  the  vasomotor  centres  and  nerves,  the  vagus, 
and  respiration;  when  secreted  in  excess,  as  in  hypernephroma,  the 
blood  tension  may  be  much  elevated  (Fraenkel,  Neusser,  Kolisko) 
and  this  may  induce  cerebral  hemorrhage;  (ii)  the  glands  apparently 
elaborate  a  substance  which  is  necessary  to  life ;  this  internal  secretion 
probably  renders  less  toxic  some  substances  produced  by  other  tissues, 
e.g.,  the  "fatigue  stuffs"  of  muscle  metabolism.  Chemically,  sphyg- 
mogenin,  pyrokatechin,  neurin  and  lecithin  have  been  found.  Able 
holds  that  the  active  glandular  substance  is  epinephrin. 

There  are,  however,  cases  of  Addison's  disease,  in  which  the  adrenals 
are  normal.  Lewin's  statistics  from  500  cases  are  as  follows:  in 
typical  cases,  the  adrenals  are  diseased  in  88  per  cent,  and  apparently 
sound  in  12  per  cent.;  on  the  other  hand,  disease  of  the  adrenals  is 
attended  by  pigmentation  of  the  skin  in  72  per  cent.,  and  unattended 
by  it  in  28  per  cent.  There  is  no  wholly  satisfactory  explanation  for 
such  cases.  Perhaps  compensatory  hypertrophy  or  accessory  glands 
may  prevent  symptoms  in  some  cases  of  adrenal  disease. 

2.  The  adjacent  sympathetic  structures — the  solar  plexus  and  semi- 
lunar ganglia, — may  be  involved  directly,  or  indirectly  as  by  fibrous 
changes  in  the  adrenals,  and  pressure  from  contiguous  aneurysm  or 
lymphomata.  Pigmentary  atrophy,  hyaline  degeneration  and  round 
cell  infiltration  of  their  vessels,  and  degeneration  extending  upward 
to  the  cord,  or  downward  along  the  nerve  fibers  have  been  described. 
Some  writers  explain  Addison's  disease  as  a  disease  of  the  sympathetic 
system,  though  others  endeavor  to  reconcile  conflicting  facts  by  assum- 
ing that  there  is  decreased  adrenal  activity  and  also  sympathetic 
disturbance. 

3.  Minor  etiological  factors  are  (a)  age;  most  cases  occur  between 
the  fifteenth  and  fortieth  years;  the  youngest  patient  recorded  was  a 
congenital  case,  and  the  oldest  one  was  eighty  years;  (6)  sex;  66  per 
cent,  occurs  in  males;  (c)  social  status;  90  per  cent,  is  found  in  the 
laboring  classes. 

Symptoms. — 1.  Marked  physical  and  mental  adynamia  is  usually 
the  initial  symptom  and  persists,  with  increase  after  possible  remis- 
sions, from  onset  to  death.  The  insidious  langor,  weakness,  apathy, 
lack  of  initiative  and  muscular  relaxation  contrast  sharply  with  the 
healthy  appearance  of  the  patient,  at  least  in  the  early  stages.  These 
symptoms  are  probably  toxsemic,  partly  from  reduced  internal  secre- 
tion and  partly  from  the  tuberculous  lesion.  Obstinate  early  in- 
somnia and  headache,  and  somewhat  later  attacks  of  vertigo,  tinnitus, 
spots  before  the  eyes  and  syncope  are  frequent.  The  intellectual 
functions  are  somewhat  weakened,  neuralgias  occur  in  the  epigastrium, 
intercostal  spaces,  back  and  extremities,  periodic  attacks  of  irritability 
are  frequent,  and  the  deep  reflexes  are  usually  somewhat  reduced. 

2.  Digestive  symptoms  generally  appear  next.  The  tongue  is  some- 
what coated  and  moist;  there  are  anorexia,  thirst,  a  sense  of  abdominal 
fulness  or  pressure,  eructations,  and  sensitiveness  over  the  abdomen. 
Paroxysmal  pains  in  the  epigastrium  or  back  radiate  widely,  especially 


ADDISON'S  DISEASE  879 

into  the  chest;  they  resemble  tabetic  crises  and  are  most  severe. 
Vomiting  is  the  most  distressing,  ominous,  and  intractable  alimentary 
symptom;  It  may  follow  eating  or  occur  independently  of  it.  Though 
at  first  intermittent,  it  later  hastens  the  fatal  issue.  Early  constipation 
gives  way  to  terminal  diarrhoea. 

3.  Pigmentation  (melanoderma,  bronzed  skin,  melasma  suprarenale) 
develops  after  the  adynamia  and  alimentary  disturbance.  Its  cause  is 
obscure;  Neusser  refers  it  to  involvement  of  the  sympathetic  nerves 
or  ganglia.  It  is  found  in  the  deep  layers  of  the  rete  Malpighii,  to 
which  it  is  apparently  brought  from  the  blood  by  leukocytes.  At  first 
the  skin  has  a  dirty,  yellow-gray  color,  and  small  areas  appear  which 
gradually  fuse,  and  then  slowly  become  darker  and  more  diffuse; 
extended  pigmentation  may  occur  with  focal  areas  of  deeper  dis- 
coloration. Pigmentation  develops  particularly  (a)  where  it  is  nor- 
mally deepest,  as  about  the  nipples,  anus  and  genitalia;  (6)  where 
pressure  or  friction  is  greatest,  as  over  folds  of  the  skin,  over  the 
clavicle,  spine,  ischia,  scapulse  or  waist  (from  belts  or  corsets);  (c) 
where  there  is  exposure  to  the  sun,  as  in  the  face,  neck  or  arms;  (d) 
where  accidental  irritation  occurs,  as  by  blistering,  eczema  or  parasitic 
affections.  The  soles  of  the  feet,  palms  of  the  hands,  nail-beds  and 
hair  are  seldom  stained.  Previous  scars  may  or  may  not  be  stained; 
sometimes  they  are  surrounded  by  a  zone  of  deeper  discoloration. 
The  skin  is  dry,  is  sometimes  bathed  with  profuse  perspiration  and 
may  have  a  fish-like  odor.  Scattered  spots  of  pigment  may  atrophy 
(vitiligo)  and  impart  to  it  a  strange  appearance.  The  mucous  mem- 
brane of  the  lips,  gums,  cheek  and  palate  also  show  pigmentation,  but 
usually  later  than  the  skin.  The  spots  and  horizontal  ink-like  stains 
on  the  cheek  where  the  teeth  touch  it  are  particularly  of  diagnostic 
value.  The  conjunctivae  are  pearly  white,  and  are  usually  said  to 
be  exempt,  though  frequently  small  aggregations  of  pigment  can  be 
seen  on  careful  examination  (Leva).  Staining  of  the  larynx,  nymphse, 
vagina,  glans  penis,  serous  membranes  and  internal  organs  is  infre- 
quent. 

4.  Other  findings  embrace  the  following:  (a)  The  heart  shares  in  the 
general  adynamia;  it  frequently  shows  brown  atrophy  at  autopsy;  its 
tones  and  apex  are  weak.  Pain  over  the  heart  is  frequently  reflected 
from  the  abdomen;  palpitation  and  dyspnoea  are  common,  but  func- 
tional murmurs  are  rare.  The  pulse  is  compressible  and  somewhat 
accelerated,  seldom  slow  or  arrhythmic.  The  peripheral  vessels  and 
abdominal  aorta  pulsate  actively.  Atheroma  is  common,  even  in  young 
subjects  (Kolisko).  (b)  Ancemia  was  considered  characteristic  by 
Addison,  though  Nothnagel  and  others  have  demonstrated  its  infre- 
quency;  in  a  recent  case,  the  writer  observed  a  red-cell  count  of  2 
million.  Increase  in  the  red  cells  (polycythsemia  rubra),  and  in  the 
hsemoglobin  results  from  concentration  of  the  blood,  which  is  due  to 
vomiting  and  diarrhoea.  The  lymphocytes  are  somewhat  increased,  (c) 
The  lymph  nodes  and  Peyer's  patches  are  sometimes  hyperplastic. 
The  spleen,  thyroid,  thymus  and  pineal  glands  are  often  enlarged, 


880  DISEASES  OF  THE  DUCTLESS  GLANDS 

probably  vicariously.  (d)  Emaciation  and  cachexia  are  terminal 
rather  than  initial  conditions.  QEdema  of  the  ankles  is  infrequent 
even  toward  the  end.  Characteristic  metabolic  changes  are  not  found; 
pigment  in  the  urine  is  rare,  acetonuria  is  occasional,  the  urea  is  often 
decreased  and  terminal  albuminuria  may  develop,  (e)  The  tempera- 
ture is  most  often  normal  or  subnormal  and  a  subjective  chilliness  is 
experienced.  (/)  The  genital  functions  may  decline  as  in  any  cachexia. 
(g)  Tuberculosis  of  the  lung  or  bowel  may  somewhat  modify  the 
symptoms. 

Diagnosis. — Diagnosis  is  based  on  (a)  the  prostration,  psychical 
and  physical;  (b)  digestive  disorders,  vomiting,  diarrhoea  and  neural- 
gia; (c)  pigmentation  of  the  skin  and  oral  mucosa;  (d)  cardiac  weak- 
ness and  (e)  the  chronic  lethal  course. 

As  Addison's  disease  usually  indicates  the  presence  of  tuberculosis, 
the  advisability  of  injecting  tuberculin  may  be  considered;  a  reaction, 
however,  may  easily  occur  from  tuberculosis  in  other  tissues.  Adrenal 
tumors  may  cause  metastases  in  the  brain  or  (like  tumors  of  the  thyroid, 
prostate  and  mammae),  in  the  long  bones,  skull  and  spine. 

Clinical  Course. — The  cardinal  symptoms  described  progress  slowly, 
with  occasional  intermissions,  and  in  nearly  all  cases,  death  results 
after  a  year  or  two;  the  terminal  symptoms  are  often  violent;  there 
may  be  delirium,  hallucinations,  convulsions,  incoercible  vomiting  and 
diarrhoea,  irregular  respiration,  small  pupils,  occasional  pseudomen- 
ingitic  symptoms  and  finally  collapse  and  coma.  The  course  may 
vary:  (a)  acute  cases  may  resemble  typhoid,  digestive  disease  or  acute 
poisoning;  (b)  chronic  cases  sometimes  last  ten  or  thirteen  years; 
(c)  sudden  death  may  occur  before  pigmentation  develops,  the  supra- 
renal lesion  at  autopsy  disclosing  an  anomalous  type  (forme  jrvste)  of 
Addison's  disease;  {d)  the  course  may  be  modified  by  'pulmonary  or 
intestinal  tuberculosis. 

Differentiation. — Pigmentation  occurs  in  numerous  other  conditions: 
(a)  poisonings  by  silver  {argyria),  in  which  the  reduced  metal  forms 
a  gray  deposit  in  the  extracellular  tissue  of  the  skin,  sweat-glands,  con- 
junctiva and  nail-beds;  by  arsenic,  which  seldom  stains  the  mucosae; 
in  pellagra,  which  is  endemic  and  intermittent  in  occurrence,  with 
exacerbations  in  the  spring  and  fall,  is  preceded  by  erythema,  is  rarely 
associated  with  tuberculosis,  but  with  eosinophilia,  diarrhoea,  and 
voracious  appetite  and  is  exempt  from  mucous  membrane  pigmen- 
tation (Neusser).  (6)  Chronic  icterus  (which,  however,  stains  the 
sclerse  and  urine),  cyanosis  (arteriosclerosis  and  heart  disease,  also 
sometimes  pigmenting  the  oral  mucosa),  various  physiological  pig- 
mentations, and  dirt  and  parasites  as  in  tramps  (vagabondism),  (c) 
Abdominal  diseases,  dyspepsia,  gastric  ulcer,  tumor  (cancer,  lym- 
phomata,  and  Hodgkin's  disease),  hypertrophic  cirrhosis  and  hsemo- 
chromatosis  (hepatic  and  pancreatic  cirrhosis,  diabetes  and  skin 
pigmentation,  diabete  bronze).  (d)  Pelvic  conditions;  pregnancy, 
uterine  and  ovarian  tumors  (after  the  removal  of  which  pigmentation 
may   regress),      (e)  Phthisis,   malaria,   melanosarcoma   of  the   skin. 


OTHER  AFFECTIONS  OF  THE  SUPRARENAL  GLANDS         881 

exophthalmic  goitre  or  rarely  scleroderma.     In  these  conditions,  pig- 
mentation of  the  oral  mucosa  is  rare. 

Treatment.— 1.  Supporting  and  Tonic— Absolute  rest  is  imperative 
because  of  exhaustion  and  proneness  to  lethal  syncope.  Alcoholic 
stimulation  is  poorly  tolerated.  Careful  feeding  is  necessary  because 
of  the  sensitiveness  of  the  stomach  and  bowels.  Strychnine,  arsenic, 
nitroglycerine,  faradization  and  galvanization  may  be  given. 

2.  Symptomatic. — Narcotics  for  pain,  gastric  sedatives  for  vomiting 
(v.  Gastritis),  astringents  and  opiates  for  diarrhoea  (v.  Enteritis) 
should  be  administered;  strong  cathartics  are  always  contra-indicated, 
for  they  may  precipitate  fatal  collapse;  one  case  in  the  Cook  County 
Hospital  died  suddenly  after  taking  a  dram  of  compound  jalap  powder. 

3.  Organotherapy. — Adrenal  extract  by  mouth  has  surely  helped 
some  cases  and  apparently  arrested  the  development  of  others  (Oliver, 
Sansom,  Lloyd,  Jones,  Osier,  Ringer,  Langlois,  Dupaigne).  In 
Adam's  review  of  97  cases,  one-third  were  benefited,  and  one-sixth 
recovered.  The  medullary  portion  of  the  gland  is  best.  It  may  in- 
crease the  vascular  and  muscular  vigor  or  even  lessen  pigmentation. 
Some  practitioners  advocate  the  hypodermatic  administration  of 
adrenalin  chloride,  3j  of  1  to  1,000  in  salt  solution,  on  alternate  days. 
Some  advanced  cases  are  unfavorably  aflfected  by  organotherapy. 


Other  affections  of  the  suprarenal  glands  are  of  slight  cHnical  inter- 
est, (a)  In  developmental  anomalies,  the  glands  are  sometimes  absent 
or  hypoplastic,  chiefly  with  other  defects,  as  encephalocele,  etc.  (6) 
Hypertrophy  in  one  gland  may  compensate  for  hypoplasia  in  the  other. 
Supernumerary  glands  are  not  uncommon,  (c)  Atrophy  is  usual  in 
advanced  age.  (d)  Degenerations  embrace  the  parenchymatous,  fatty, 
hyaline  and  amyloid  types,  (e)  Circulatory  disorders  are  hypersemia, 
embolism,  thrombosis  and  hemorrhage,  which  latter  may  occur  in 
trauma  in  the  new-born,  tumors,  inflammation  and  the  hemorrhagic 
diathesis.  (/)  Inflammation,  acute  and  chronic,  is  uncommon,  (g) 
Granulomata,  chiefly  syphilitic  and  tuberculous,  are  rarely  primary. 
(A)  Tumors,  carcinoma,  sarcoma  (20  recorded,  Affleck  and  Leith), 
and  hypernephroma  {v.  Kedney  Tumors)  are  chiefly  of  anatomical 
importance.  In  23  published  operations,  the  mortality  was  50  per 
cent.,  recurrence  developed  in  21  per  cent.,  and  29  per  cent,  recovered 
(in  nine  months  to  six  years).  At  the  Johns  Hopkins  Hospital,  three 
tumors  of  the  suprarenal  glands  were  successfully  operated  on  (Osier). 
{i)  Parasitic  disease  (echinococcus)  is  extremely  infrequent. 


56 


882  DISEASES  OF  THE  DUCTLESS  GLANDS 

(B).  DISEASES  OF  THE  SPLEEN. 

Lesions  of  the  spleen  are  usually  secondary. 

ACUTE  SPLENIC  TUMOR. 

This  occurs  (a)  in  acute  infections,  due  either  to  the  local  action  of 
microorganisms  and  their  toxins,  or  to  toxsemic  paralysis  of  the 
splanchnic  nerve,  which  normally  controls  the  vascular  supply  of 
the  organ;  it  is  most  common  in  typhoid,  malaria,  recurrent  fever 
and  septic  conditions;  (b)  in  acute  stasis,  usually  from  portal  obstruc- 
tion ;  and  (c)  in  embolism  {v.  i.)  and  trauma.  Symptoms  are  infrequent; 
much  pain  usually  indicates  involvement  of  the  capsule  (perisplenitis). 
On  objective  examination:  (a)  The  spleen  may  sometimes  be  seen, 
during  deep  inspiration,  (b)  Palpation  alone  is  wholly  reliable.  By 
the  bimanual  method  and  with  the  examiner  sitting  at  the  right  side 
of  the  patient,  the  edge  of  the  spleen  comes  in  contact  with  the  fingers 
and  slips  sharply  down  below  them;  splenic  crenations  are  seldom 
palpable.  A  palpable  spleen  always  indicates  enlargement,  or  much 
less  often,  downward  dislocation  by  pleurisy,  emphysema,  pneumo- 
thorax or  thoracic  tumor,  (c)  Percussion,  which  is  valuable  in  outlin- 
ing the  upper  splenic  level,  is  unreliable  in  determining  enlargement, 
for  confusion  with  fsecal  accumulations  is  frequent. 

CHRONIC  SPLENIC  TUMOR. 

Chronic  enlargement  is  symptomatic  of  (a)  chronic  infections,  as 
malaria,  tuberculosis  and  syphilis,  (b)  continued  portal  stasis,  (c) 
repeated  embolism,  (d)  blood  affections,  as  leukaemia,  pseudoleuksemia 
or  splenic  anaemia,  and  (e)  rickets,  amyloidosis,  neoplasms,  cysts,  poly- 
cythsemia  (v.i.),  arthritis  deformans  and  chronic  acetanilide  poisoning. 

EMBOLISM. 

Embolism  occurs  frequently  in  the  spleen,  because  of  the  wide  arteries 
and  slow  current;  it  ranks  second  in  frequency  to  kidney  embolism. 
It  usually  develops  in  the  course  of  acute  endocarditis,  chronic  valvular 
lesions  or  arteriosclerosis  and  seldom  follows  local  lesions  as  sinus 
thrombosis  or  splenic  vein  thrombosis.  The  symptoms  vary  some- 
what as  the  embolus  is  simple  or  infective;  sudden  chill,  fever,  pain 
in  the  side,  acute  splenic  tumor  and  perisplenitic  friction  may  develop, 
which  with  a  cause  or  embolic  symptoms  in  other  organs  justify  a 
diagnosis  of  embolism.     Frequently  no  distinctive  symptoms  occur. 


0  TUMORS  AND  CYSTS  883 

If  septic,  symptoms  of  abscess  may  be  present  (v.i.).     Treatment  is 
wholly  symptomatic. 


ABSCESS   (SPLENITIS  APOSTEMATOSA). 

Abscess  of  the  spleen  may  result  from  embolism,  trauma  or  invasion  by 
contiguity.  Swelling,  pain,  perisplenitic  friction  or  possibly  unevenness 
of  surface  or  fluctuation  may  mark  its  development.  It  is  more  often 
hidden  by  the  symptoms  of  the  causal  focus.  It  may  rupture  into 
the  pleura,  kidney  or  peritoneum.  Aspiration  may  determine  the 
diagnosis,  and  surgical  evacuation  is  then  indicated. 


PERISPLENITIS. 

This  affection  may  be  primary  or  secondary,  simple  or  suppurative, 
an  isolated  lesion,  or  part  of  a  chronic  peritonitis  (see  "Icing  Liver," 
Chronic  Perihepatitis).  It  usually  accompanies  the  various  splenic 
affections  already  enumerated.  Without  local  peritonitic  friction  its 
diagnosis  is  impossible.    There  is  no  efficient  therapy. 


AMYLOID  SPLEEN. 

Its  etiology  is  considered  under  amyloid  liver  and  kidney.  Patho- 
logically its  two  types  are  (a)  the  sago  spleen,  in  which  there  are  amy- 
loid deposits  in  the  vessels  of  the  Malpighian  tufts  and  (b)  the  more 
important,  diffuse  amyloid  infiltration.  It  is  diagnosticated  by  (i) 
the  etiological  factors,  (ii)  its  usually  large  size,  hardness,  smoothness 
and  thick  edge,  and  (iii)  coincident  amyloidosis  of  the  liver  and  kidneys. 

SPLENIC  ANEMIA. 

Splenic  anaemia  (v.  Diagnosis  of  Pseudoleukemia).  Springthorpe 
observed  six  cases  in  one  family.  Umber  advises  operation  in  every 
case,  because  he  believes  that  the  spleen  destroys  the  red  cells.  The 
x-rays  h&,ve  been  of  therapeutic  value. 

TUMORS  AND  CYSTS. 

New  growths  are  very  infrequent.  They  are  more  often  secondary 
than  primary.  They  include  carcinoma,  sarcoma  (of  which  19  pri- 
mary cases  were  reported  by  Adolph,  1905),  enchondroma,  and  lymphan- 
gioma. They  are  rarely  differentiated  from  splenic  anaemia  and  like 
affections.    The  chronic  endothelioma  of  Gaucher  clinically  resembles 


884  DISEASES  OF  THE  DUCTLESS  GLANDS 

splenic  anaemia;    pathologically,  large  endothelial  cells  replace  the 
splenic  tissue;  this  can  be  seen  under  the  microscope  or  macroscopically 

as  in  Stengel's  case. 

Echinococcus  cysts  are  found  in  but  0.2  to  3  per  cent,  of  echinococcus 
disease,  and  usually  with  concomitant  cysts  in  the  liver.  Dermoid 
cysts  are  exceedingly  uncommon.  Only  13  non-parasitic  cysts  are 
found  in  the  literature. 

Granulomaia  (see  Tuberculosis  and  Syphilis). 


RUPTURE  OF  THE   SPLEEN. 

Rupture  may  be  traumatic  or  spontaneous;  the  latter  variety  has 
been  observed  in  embolism,  malaria,  typhoid,  acute  leukaemia,  and 
pregnancy.  It  is  more  common  in  India,  and  tropical  climates  than 
in  temperate  zones.  Aspiration  and  even  palpation  have  occasioned 
rupture.  The  treatment  is  surgical.  Up  to  1905,  46  splenectomies  for 
rupture  were  reported  (Faltin). 


MOVABLE  OR  FLOATING  SPLEEN. 

Permanent  mobility  {lien  mobile)  and  dislocation  are  due  to  the 
same  factors  observed  in  enteroptosis,  with  which  it  may  be  associated : 
(i)  lax,  elongated  or  ruptured  ligaments  (ligamentum  gastrolienale, 
phrenicolienale,  and  most  important,  ligamentum  phrenicocolicum) ; 
(ii)  relaxed  abdominal  walls;  and  (iii)  enlargement  and  increased 
weight  of  the  spleen  operating  with  the  above  factors. 

Symptoms. — Symptoms  are  often  absent.  Pain  or  a  dragging  sen* 
sation  is  frequent,  which  is  either  local  or  radiates  to  the  thorax,  left 
shoulder  or  legs,  similar  to  that  observed  in  neurotics  or  women  wdth 
uterine  or  ovarian  disease.  There  may  be  headache,  insomnia,  psy- 
chical alteration,  dyspepsia,  constipation,  menstrual  anomalies,  vesical 
tenesmus,  and  parsesthesia  in  the  legs;  most  of  these  are  neurotic. 
Objectively:  (a)  The  most  important  sign  is  palpatory  detection  of  the 
spleen  in  an  abnormal  location,  (i)  It  is  located  most  often  in  the 
left  ilio-inguinal  region,  near  the  ilium,  but  may  lie  just  below  the 
left  costal  arch,  near  the  navel,  in  a  hernial  sac,  in  the  pelvis,  or  above 
the  pubes.  (ii)  Its  hilum  usually  points  upward,  either  directly,  if  it 
lies  across  the  vertebrae  or  in  the  pelvis,  or  with  slight  inclination  to 
the  right  or  left  if  it  lies  to  one  side,  (iii)  The  form,  notches  and  pos- 
sibly the  pulsating  vessels  are  those  of  the  spleen,  (iv)  In  size  it  is 
usually  enlarged,  either  from  some  causal  hypertrophy  or  some  later 
congestion;  torsion  of  its  pedicle  may  lead  to  softening,  atrophy, 
gangrene  or  even  liberation  of  the  spleen  as  a  free  body,  (v)  As  a 
rule  it  can  be  replaced,  and  its  position  changes  with  posture;  peri- 
splenitis, causing  a  friction  rub,  may  result  in  firm  adhesions  to  the 
colon,  bladder,  rectum,  or  uterus,  thereby  causing  great  or  insuperable 


SPLENOMEGALY,  WITH  CHRONIC  POLYCYTHEMIA,  CYANOSIS     885 

diagnostic  difficulty;  in  such  cases  the  spleen  is  dislocated,  but  ceases 
to  "wander."  (6)  The  spleen  is  absent  from  its  normal  location,  the 
splenic  area"  being  replaced  by  tympany  from  the  colon  (which  changes 
to  dulness  when  water  is  introduced  into  the  colon),  (c)  Pressure 
symptoms,  intestinal  obstruction,  gastric  dilatation,  vesical  and  rectal 
compression  may  be  noted. 

Diagnosis. — Diagnostic  confusion  with  floating  kidney,  and  pedun- 
culated ovarian  tumors  is  rather  infrequent,  when  the  abdomen  and 
pelvis  are  carefully  examined.  The  author  knows  of  three  laparotomies 
performed  for  supposed  uterine  or  renal  disease,  in  which  abundant 
adhesions  rendered  differentiation  impossible.  On  the  other  hand, 
a  hard,  immovable  suprapubic  tumor  was  correctly  diagnosticated 
as  leuksemic  spleen  from  the  glands  and  blood  findings. 

Treatment. — (a)  Bandages  are  more  difficult  to  apply  than  for 
movable  kidneys,  though  some  cases  can  be  benefited  by  them.  (6) 
The  spleen  may  be  replaced  by  operation,  and  its  vicinity  well  packed 
with  gauze;  the  resulting  adhesions  often  retain  the  viscus.  (c) 
Splenopexis  (Rydygier)  may  be  performed,  the  spleen  being  sewed 
in  place  or  deposited  in  a  peritoneal  pocket.  Stierlin  (1897)  collected 
32  operated  cases,  in  which  the  mortality  was  6  per  cent,  (d)  Splenec- 
tomy (see  Pseudoleukemia)  may  be  performed  as  a  last  resort,  the 
mortality  being  about  27  per  cent. 


SPLENOMEGALY,  WITH  CHRONIC  POLYCYTH.ffiMIA,  AND 

CYANOSIS. 

This  condition  has  been  described  particularly  by  Osier,  Weintraud 
and  Tiirck.  About  34  cases  are  reported  up  to  1905.  (a)  The  red 
cells  are  increased,  even  to  9  or  13  million  (polycythsemia  rubra  or 
polyglobulism) ;  the  haemoglobin  may  reach  150;  the  white  cells  number 
from  4,000  to  31,000.  The  viscosity,  specific  gravity  and  volume  of 
the  blood  are  increased.  (6)  There  is  chronic  cyanosis,  without  adequate 
cause  and  (c)  splenomegaly.  There  may  be  headache,  constipation, 
vomiting,  and  an  hemorrhagic  diathesis.  The  arterial  tension  may  be 
increased  and  the  heart  may  hypertrophy.  De  Lee  sent  the  author 
what  appeared  to  be  a  forme  fruste,  a  case  with  splenomegaly  and 
cyanosis  but  without  polyglobuly.  The  etiology  is  obscure;  in  about 
one-third  of  the  cases  it  was  tuberculosis  of  the  spleen  and  8  of  the  11 
operated  cases  recovered;  stasis  may  be  the  cause,  e.g.,  a  malignant 
growth  compressing  the  superior  vena  cava;  it  seems  probable  that 
in  most  cases  the  cause  is  an  undue  activity  of  the  bone-marrow.  The 
treatment  is  aj-rays,  venesection,  iodide  of  potash  or  splenectomy. 


886  DISEASES  OF  THE  DUCTLESS  GLANDS 


(C).  LYMPH ATISM  (STATUS  LYMPH ATIOUS). 

Lymphatism  is  a  condition  in  which  there  is  hyperplasia  of  the 
various  lymphoid  and  kindred  tissues,  and  a  tendency  to  sudden 
death.  It  is  also  known  as  the  constitutio  lymphatica,  status  thymicus 
and  statiLs  lymphaticus. 

Its  etiology  is  most  obscure.  The  affection  is  rare  and  occurs  most 
often  in  women  and  children.  Hedinger  observed  it  as  a  familial 
affection. 

Sjnnptoms. — 1.  There  is  lymphoid  hyperplasia,  (a)  The  lymph 
glands  of  the  chest  and  abdomen  are  more  often  involved  than  the 
external,  cervical,  axillary  or  inguinal  glands,  (b)  The  tonsils,  naso- 
pharyngeal, lingual  and  intestinal  lymphadenoid  tissues  are  fre- 
quently  hyperplastic,      (c)  Moderate   splenic   enlargement  is   usual. 

(d)  The  thymus  is  swollen,  sometimes  giving  retrosternal  dulness. 

(e)  The  bone-marrow  often  changes  to  a  reddish  color. 

2.  Associated  findings  may  include  hypoplasia  of  the  heart  aiid 
aorta,  thyroid  enlargement,  poor  development,  infantiUsm,  rickets, 
tetany,  and  laryngismus. 

3.  Sudden  death  is  often  the  first  evidence  of  the  condition  and  may 
occur  without  seemingly  adequate  cause,  (a)  It  has  occurred  during 
or  after  ancesthesia,  especially  with  chloroform.  In  one  case,  a  patient 
with  enlarged  glands  died  suddenly  after  receiving  but  20  drops  of 
chloroform.  (6)  Operations  with  local  ancesthesia  have  also  been  fatal, 
(c)  Administration  of  antitoxin  has  caused  death,  as  in  the  well- 
known  case  in  Prof.  Langerhans'  family,  (d)  It  may  occur  while 
bathing  or  after  falling  in  the  water,  (e)  Sudden  deaths  during  con- 
valescence from  acute  infections,  or  some  collapses  during  hydro- 
therapeutic  treatment  (Escherich)  may  be  attributed  to  the  lymphatic 
constitution.  (/)  Children  with  eczema  may  die  suddenly;  lymphatism 
causes  75  per  cent,  of  these  deaths.  It  is  said  to  be  due  to  cardiac 
excitability  (Kundrat),to  lessened  physiological  resistance  with  a  ten- 
dency to  heart  paralysis  (Paltauf),  and  to  a  toxic  condition  (Blumer, 
who  suggests  the  term  lymphotoxism.) 


(D).  DISEASES  OF  THE  THYEOID  GLAND. 

GOITRE. 

Definition. — Hypertrophy  of  the  thyroid  gland.  Sporadic  cases  are 
common  in  Europe  and  America.  Goitre  occurs  endemically  in 
Switzerland  and  Italy,  though  we  have  no  knowledge  of  its  cause; 
the  drinking-water  has  been  thought  causal.  It  is  usually  acquired, 
and  is  seldom  congenital. 


GOITRE  887 

There  are  three  main  forms:  (a)  the  'parenchymatous  or  folKcular 
type,  with  more  or  less  symmetrical  enlargement,  and  formation  of 
colloid  material  in  the  hyperplastic  folhcles;  (6)  the  cystic;  and  (c) 
vascular  or  congestive  type,  with  dilatation  of  the  bloodvessels.  The 
last  form  borders  closely  on  those  almost  physiological  variations 
in  the  organ,  which  are  observed  at  puberty,  in  defloration,  pregnancy, 
chlorosis  and  psychical  trauma. 

Sjnnptoms. — 1.  The  thyroid  enlargement  may  be  diffuse,  as  in  the 
soft,  symmetrical  and  moderately  vascular  form,  or  partial  or  nodose, 
implicating  but  one  lobe  or  the  isthmus.  In  most  cases  there  are  only 
local  findings. 

2.  Compression  symptoms  are  not  common.  The  carotid  artery 
and  jugular  vein  are  pushed  to  one  side,  and  the  sternomastoids 
become  thin.  The  trachea  may  be  compressed,  its  lumen  becoming 
shaped  like  a  sword  scabbard;  asthma,  dyspnoea,  bronchiectasis  and 
dilatation  of  the  right  ventricle  follow  stenosis  of  the  air-passages. 
Laryngeal  paralysis  occurs  in  over  10  per  cent.  Fraenkel  states  that 
in  25  per  cent,  of  cases  in  which  there  is  tracheal  stenosis,  there  is 
also  laryngeal  paralysis.  From  the  isthmus  or  lower  horns  of  the 
thyroid,  goitres  may  grow  in  a  retrosternal  or  retroclavicular  direction 
(5  to  10  per  cent.)  causing  compression  of  the  vagus,  sympathetic 
nerves  and  vena  cava.  A  goitre  may  disappear  into  the  chest  with 
each  inspiration  and  appear  on  expiration  {goitre  en  dedans).  It  may 
become  incarcerated  in  the  chest. 

3.  An  aberrant  or  accessory  thyroid  may  occasionally  form  a  tumor, 
anywhere  from  the  tongue  to  the  aorta,  and  from  the  spine  to  the 
anterior  chest  wall,  in  the  retropharyngeal  or  retrooesophageal  tissues 
(causing  dysphagia  or  dysarthria),  in  the  trachea,  larynx,  root  of  the 
tongue,  pleura  or  mediastinum;  it  may  compress  an  entire  lung. 
Storrs  (1904)  collected  32  lingual  goitres;  there  are  three  cases  in 
the  literature  of  retrosternal  accessory  thyroids,  which  became  cystic 
and  calcarious  (Collins,  1905),  and  fourteen  which  were  intratracheal 
(PfeifFer,  1905). 

4.  Sudden  death  may  occur  in  large  goitres;  it  may  be  due  to  pres- 
sure on  the  vagus,  spasm  or  oedema  of  the  glottis,  sudden  hypersemia 
of  the  gland  and  pressure  on  the  trachea,  hemorrhage  dissecting 
into  the  chest,  or  status  lymphaticus. 

Diagnosis. — Confusion  is  possible  with  tumors  as  sarcoma,  carci- 
noma or  adenoma,  for  whose  differentiation  and  symptoms  reference 
to  surgical  treatises  should  be  made.  There  are  23  cases  in  the 
literature  of  echinococcv^  cysts.  In  83  per  cent,  of  cases,  cancer  de- 
velops from  a  preexisting  goitre;  early  metastases  are  specially  com- 
mon and  characteristic;  only  10  per  cent,  recovered  among  110 
operations  (Madelung).  There  are  20  cases  recorded  in  which  metas- 
tases throughout  the  body  occurred  from  benign  tumors  of  the  thyroid 
(chondroma  or  myxoma).  Thyroid  inflammation  (strumitis)  is  usually 
secondary  (metastatic)  or  traumatic,  rarely  primary;  it  may  occur  in 
sound  or  goitrous  glands;    it  is  most  often  due  to  the  streptococcus 


888  DISEASES  OF  THE  DUCTLESS  GLANDS 

but  may  be  caused  by  the  colon,  typhoid,  pneumonia,  diphtheria  or 
other  organisms. 

Treatment. — In  regions  where  goitre  is  prevalent,  the  drinking 
water  should  be  boiled.  Medical  treatTnent  is  of  uncertain  value. 
Iodine  may  be  used  externally  or  by  injection  (Maunoir,  1825). 
Potassium  iodide  (Coindet,  1820)  is  beneficial  in  some  subacute  cases, 
according  to  Bruns,  in  75  per  cent.;  Kraus  found  it  particularly 
beneficial  in  the  vascular  type,  with  cardiovascular  symptoms,  as 
moderate  tachycardia  and  full  arteries.  The  x-rays  are  valuable  in 
some  cases.  Thyroid  extract  is  occasionally  beneficial.  Surgical 
treatment  is  indicated  in  large  or  growing  goitres.  Reverdin's  collec- 
tion of  6,103  operations  shows  a  mortality  of  2.8  per  cent.,  and  in 
Kocher's  series,  now  several  thousand,  but  one  death  occurred  in 
each  600   operations.     See   Cachexia   Thyreopriva,  under  Myx- 

CEDEMA. 

EXOPHTHALMIC  GOITRE. 

Definition. — A  malady  probably  due  to  excessive  activity  of  the 
thyroid  gland,  and  characterized  by  three  cardinal  symptoms,  exoph- 
thalmos, enlarged  thyroid  and  tachycardia,  and  by  other  accessory 
symptoms,  as  tremor,  increased  metabolism,  and  ocular,  vascular, 
digestive  and  other  symptoms.  It  was  first  described  in  England  by 
Parry  (1786),  and  Graves  (1835),  and  later  in  Germany  by  Basedow 
(1840).  The  claims  of  the  Italians,  that  Flajani  (1800)  first  described 
the  affection,  are  ill-founded. 

Etiology. — ^Its  etiology  is  obscure,  but  (1)  the  most  probable  cause 
is  over-activity  or  perversion  of  thyroid  secretion  (Moebius,  Johnston 
and  Greenfield).  Exophthalmic  goitre  contrasts  sharply  with  myx- 
oedema  (v.i.)  of  which  the  anatomical  basis  is  thyroid  atrophy.  The 
outlines  of  this  theory  can  be  best  presented  by  comparing  these 
antithetic  conditions; 

Exophthalmic  Goitre.  vs.  Myxcedeima.. 

(a)  Hypertrophy  of  gland;    excessive  Atrophy;  deficient  (hypothyrea)  or  ab- 

internal  secretion  (hyperthyrea  sent  secretion    (athyrea). 

or  thyroidism). 

(b)  Increased    nervous    excitability.  Dulness,  apathy,  cretinism. 

(c)  Vascular  erythrism;  flushed,  moist,  Skin  dry,  thick  and  cool,  and  pulse  slow. 

warm  skin;  rapid  pulse. 

(d)  Increased  diuresis  and  active  metab-         Decreased. 

olism. 

(e)  Thyroid    extract    increases    symp-         Thyroid  extract  improves  or  cures 

toms ;  it  may  produce  in  normal 
individuals  symptoms  like  those 
of  exophthalmic  goitre,  tachy- 
cardia, tremor,  even  exophthal- 
mos. 


EXOPHTHALMIC  GOITRE  889 

(/)    Surgical  (partial)  excision  relieves,  Some  cases  result  from  removal  of  thy- 

and  often  cures.  roid.    Transplantation  of  new  gland 

improves  or  cures. 

(g)  Exophthalmic  goitre  (glandular  hypertrophy  with  excessive  function)  may 
occasionally  become  myxoedema  (insufhcient  function  from  glandular 
atrophy) . 

2.  Other  etiological  explanations  are  less  probable,  as  (a)  vasomotor 
neurosis  (Charcot) ;  (6)  lesions  in  the  corpus  restiforme  of  the  medulla, 
based  on  experiments  by  Filehne;  (c)  lymphatic  disease  and  (d)  dis- 
ease of  the  parathyroid  glands. 

3.  Disposing  or  exciting  factors  are:  (a)  Sex;  in  Eschner's  series 
of  200  cases  80  per  cent,  were  women  (95  per  cent,  in  other  series). 
Fibroids,  pregnancy,  and  puberty  are  sometimes  promoting  factors. 
(6)  Age;  most  cases  occur  between  the  twentieth  and  thirtieth  years. 
Barrett  (1904)  could  collect  only  42  cases  in  persons  under  fifteen 
years,  (c)  Psychical  trauma,  as  fear,  excitement  or  concussion,  are 
sometimes  apparent  causes,  {d)  Anaemia,  debility,  excesses,  neuro- 
pathic family  tendencies  and  occasionally  chorea,  hysteria,  epilepsy 
or  psychoses  favor  its  development,  (e)  After  thyroidectomy,  symp- 
toms resembling  those  of  exophthalmic  goitre  may  develop;  this 
postoperative  thyroidism  is  rare. 

Symptoms. — Cardinal  Symptoms. — 1.  Tachycardia  is  usually  the 
earliest  cardinal  symptom,  and  is  almost  always  present.  The  pulse 
ranges  from  100  to  120,  and  in  severe  cases  to  140  (160  or  even  200). 
It  is  associated  with  other  cardiovascular  symptoms,  as  (a)  increased 
cardiac  action,  manifested  by  a  diffuse  apex  and  cardiac  impulse, 
sharp  tones  sometimes  heard  at  a  distance  of  several  feet  (Graves), 
and  hypertrophy  chiefly  of  the  left  ventricle  which  is  ultimately  com- 
plicated by  dilatation;  (6)  a  functional  (systolic)  murmur  over  the 
apex;  (c)  palpitation,  which  usually  antedates  tachycardia  and  is  an 
evidence  of  intoxication  (thyroidism);  {d)  vascular  symptoms;  a  pulse 
rather  weaker  than  the  apex  beat;  active  arterial  pulsation  in  the 
carotids,  and  abdominal  aorta;  systolic  capillary  pulsation  in  the 
fingers,  forehead  or  even  in  the  retina,  palate,  liver  and  spleen;  even 
the  peripheral  veins  may  pulsate;  (e)  irregular  and  failing  heart  action 
occurs  late  and  only  in  severe  cases.  Hemorrhages,  notably  epistaxis, 
are  not  uncommon. 

2.  Exophthalmos  is  usually  a  later  symptom  than  tachycardia  or 
sometimes  than  the  goitre.  It  is  present  in  about  90  per  cent,  of  cases 
and  results  from  dilatation  of  the  orbital  vessels.  In  developed  cases 
the  protrusion  of  the  eyeballs,  and  the  staring,  fixed  expression  are  very 
characteristic  (exophthalmos  may  also  occur  in  extreme  myopia,  tumors 
of  the  orbit,  and  sympathetic  irritation).  The  condition  is  generally 
bilateral,  though  often  unequal;  in  one  instance,  the  author  saw  uni- 
lateral exophthalmos  with  homolateral  goitre.  The  eyelids  are  unable 
to  cover  the  eyeball  entirely,  and  a  rim  of  the  white  sclera  shows 
about  the  iris.    The  protrusion  may  be  very  extreme,  even  amounting 


890  DISEASES  OF  THE  DUCTLESS  GLANDS 

to  dislocation  of  the  bulb;  in  these  cases  it  may  be  necessary  to  sew 
together  the  lids  to  prevent  corneal  ulceration  and  loss  of  the  eye  by 
panophthalmitis.  Under  this  topic  may  be  mentioned  the  associated 
eye-symptoms;  they  are  (a)  von  Graefe's  sign,  which  is  the  failure  of 
the  upper  lid  to  follow  the  eye-ball  when  it  is  rolled  downward;  it  is 
present  in  at  least  33  per  cent.,  and  is  of  considerable  diagnostic  value, 
though  present  also  in  Thomsen's  disease.  (6)  Stellwag's  sign,  which 
is  rarely  absent,  is  widening  of  the  interpalpebral  fissure  with  infre- 
quent winking;  it  also  occurs  in  mania,  and  in  old  age.  (c)  Moebius' 
sign  consists  of  weakness  of  the  internal  recti,  whereby  convergence 
is  less  complete,  or  unsustained,  when  a  finger  on  which  the  eyes  are 
focused  is  brought  close  to  the  nose;  it  occurs  also  in  other  conditions, 
as  paretic  dementia,  (d)  Becker's  sign  consists  of  pulsation  of  the 
retinal  vessels,  (e)  In  Joffroy's  sign,  the  patient's  forehead  remains 
smooth  (instead  of  becoming  wrinkled)  when  he  glances  upward 
with  the  head  bent  somewhat  downward.  Eye  paralyses  and  retinal 
or  pupillary  changes  are  infrequent. 

3.  The  goitre  is  rarely  an  initial  symptom,  and  usually  develops 
later  and  in  a  remittent  fashion,  i.e.,  swelling,  recession  and  renewed 
swelling.  It  is  present  in  92  per  cent,  (a)  Its  typical  form  is  vascular, 
though  it  may  develop  upon  any  of  the  ordinary  forms  of  goitre,  as 
in  an  acute  fatal  case,  seen  in  1905,  with  Dr.  Dorsey  of  Streator,  in 
which  exophthalmos,  tachycardia,  and  thyroid  thrills  and  murmurs 
developed  in  a  chronic  cystic  goitre.  Acute  thyroidism  may  develop  in 
thyroid  malignancy.  The  goitre  is  smaller  than  the  ordinary  bron- 
chocele;  it  is  diffuse  or  oftener  more  developed  on  the  right  side  (an 
accentuation  of  physiological  proportions) ;  and  microscopically  shows 
the  dilated  vessels  alluded  to  above,  and  hyperplasia  of  the  parenchym- 
atous tissue,  in  which  the  colloid  matter  is  scanty  or  resembles  the 
embryonal  form  (not  staining  with  eosin);  in  the  later  stages  some 
fibrous  tissue  may  develop.  (6)  It  is  usually  soft,  elastic,  variable  in 
size  from  time  to  time,  pulsating  on  inspection,  thrilling  on  palpation, 
and  revealing  on  auscultation  a  loud  systolic  bruit,  or  a  double  mur- 
mur which,  according  to  Guttmann,  is  pathognomonic. 

Accessory  Symptoms. — (a)  Tremor,  described  first  by  Basedow,  is 
classified  as  a  cardinal  symptom  by  some  writers,  as  Charcot  and 
Marie.  It  is  present  to  some  degree  in  most  cases,  and  is  conspicuous 
in  50  per  cent.  It  is  characteristically  fine,  regular  and  rapid,  number- 
ing 8  or  9  vibrations  to  the  second.  It  affects  the  wrist  more  than 
the  fingers;  sometimes  it  affects  the  trunk,  (b)  There  maj  he  nervous 
symptoms.  Some  cerebral  symptoms  are  usual,  as  headache,  vertigo, 
impaired  memory,  insomnia,  irritability,  depression  or  change  in  dis- 
position. Psychoses  are  infrequent,  as  the  mania  which  is  sometimes 
observed  in  fatal  cases.  Choreiform  movements  were  described  by 
Kahler.  Muscular  weakness  is  usual,  as  "giving  way  of  the  legs" 
(Charcot),  and  wealoiess  of  the  respiratory  muscles  (scant  inspiratory 
increase  in  the  chest  measurement,  Bry son's  sign).  The  reflexes  are 
often  increased.     Rheumatic  pains  may  be  noted.     Vasomotor  symp- 


EXOPHTHALMIC  GOITRE  891 

toms  are  common,  as  violent  reddening  of  the  face,  subjective  warmth, 
dry  mouth,  sweats  of  a  peculiar,  penetrating  odor,  or  intermittent 
swelling  of  the  joints.  Rarer  complications  are  cerebral  paralyses, 
tabes,  syringomyelia  or  other  neuroses,  (c)  Respiratory  symptoms 
include  dyspnoea  and  dry  cough.  The  author  has  seen  two  incipient 
cases  diagnosticated  as  phthisis,  (d)  There  may  be  digestive  symp- 
toms. Severe  (nervous)  vomiting  and  diarrhoea  may  simulate  organic 
disease;  their  persistence  is  ominous,  (e)  Cutaneous  symptoms  may 
be  marked.  Pigmentation  may  be  extreme  (Drummond,  Chvo- 
stek).  Pigmentation  of  the  eyelids,  vasomotor  oedema,  urticaria 
(particularly  in  acute  cases),  vertigo,  itching,  and  falling  of  the  hair 
may  also  occur,  A  peculiar  fulness  above  the  clavicles  may  develop, 
sometimes  with  pain  in  the  neck.  The  electrical  resistance  of  the 
skin  is  decreased,  perhaps  to  one-fifth  of  the  normal  (Charcot,  Chvo- 
stek,  Vigouroux);  it  is  probably  occasioned  by  profuse  sweating  and 
has  no  pathognomonic  importance.  (/)  There  may  be  constitutional 
symptoms.  Emaciation  and  ansemia  are  common,  especially  in  blondes. 
Metabolism  is  almost  always  increased ;  this  is  evidenced  by  the  nitrog- 
enous excretion,  increased  diuresis  and  the  frequent,  slight,  but  wholly 
atypical,  elevation  of  temperature;  these  symptoms  may  be  inter- 
mittent (Huchard).  Amenorrhoea,  albuminuria,  glycosuria,  persist- 
ence of  the  thymus  gland,  and  the  occasional  hyperplasia  of  the  spleen 
are  difl&cult  to  explain. 

Diagnosis. — The  diagnosis  is  unequivocal  when  the  cardinal  triad 
of  symptoms  is  present,  reinforced  by  the  secondary  symptoms. 
Atypical  forms  (formes  jrustes)  may  cause  confusion,  but  careful 
watching  of  the  clinical  course  usually  settles  all  doubt.  The  affec- 
tion is  often  incorrectly  diagnosticated  in  young  girls  at  puberty,  in 
whom  thyroid  turgescence,  moderate  tachycardia  and  vascular  excit- 
ability occur  without  particular  significance.  Incipient  tuberculosis 
and  neurasthenia  may  be  simulated.  ->    - 

Course  and  Prognosis. — (a)  The  onset  is  usually  insidious  and  the 
course  chronic.  Remissions  are  very  common.  Chronic  cases  some- 
times begin  rather  acutely.  Acute  cases  are  unusual;  they  occur 
chiefly  in  men;  Lloyd  records  a  case  which  was  fatal  in  three  days, 
and  Trousseau  one  which  was  fatal  in  eight  days.  The  author  has 
seen  three  cases  in  which  death  occurred  in  from  two  to  five  weeks. 
The  acute  type  is  usually  fatal,  though  Solbrig  mentions  a  recovery 
after  ten  days.  (6)  Death  occurs  in  12  per  cent,  of  cases;  it  is  almost 
always  due  to  cardiac  failure,  from  hypertrophy  passing  into  dilata- 
tion, (c)  The  outlook  is  best  in  the  less  typical  (rudimentary)  forms. 
{d)  Complete  recovery  is  rare,  though  20  to  50  per  cent,  of  cases 
improve  (relative  recovery).  (e)  Unfavorable  prognostics  are  its 
occurrence  in  the  very  young  and  in  men,  emaciation,  extreme  tachy- 
cardia, persistent  vomiting  or  diarrhoea,  fever,  corneal  disease,  lymph- 
atism  and  intercurrence  of  myxoedema  (v.i.). 

Treatment. — 1.  General. — Rest  is  the  first  indication.  Travel,  so- 
journ at  the  various  springs  and  resorts,  gymnastics  and  excitement 


892  DISEASES  OF  THE  DUCTLESS  GLANDS 

are  always  injurious.  A  simple  diet  and  interdiction  of  all  stimulants 
(alcohol,  coflPee,  tea,  tobacco)  are  essential.  A  quiet  life  at  a  very 
moderate  elevation  or  at  the  sea-side  is  very  beneficial. 

2.  Drugs. — Except  for  symptomatic  indications,  drugs  have  a  very 
limited  use.  The  heart  tonics  are  disappointing;  digitalis  usually 
fails  to  slow  the  heart,  and  strophanthus  and  spartein  sulphate  are 
rather  more  efficient  but  do  not  adequately  control  tachycardia.  Bella- 
donna, in  the  largest  physiological  doses  (until  it  produces  mydriasis 
and  dry  mouth),  is  recommended  by  Gowers;  some  cases  are  dis- 
tinctly benefited,  and  in  personal  experience,  the  annoying  palpitation 
and  abdominal  throbbing  are  most  relieved.  Ergotin,  quinine, 
arsenic,  iron  and  strychnine  are  of  uncertain  value,  but  the  latter 
seems  rather  more  beneficial ;  iron  is  apparently  useful  only  in  chlorotic 
girls  (]Moebius)  and  is  directly  injurious  in  men,  for  it  aggravates 
digestive  and  vasomotor  disturbance.  Constant  application  of  an  ice- 
bag  to  the  heart  is  very  helpful;  it  relieves  palpitation  and  somewhat 
slows  the  heart  rate. 

3.  Electricity. — This  is  chiefly  valuable  as  a  suggestive  remedy, 
according  to  some  writers ;  galvanization  is  particularly  recommended 
by  Erb,  who  uses  the  anode  over  the  cer^dcal  spine  and  the  kathode 
over  various  peripheral  areas.  Electrotherapy  effects  only  transient 
results. 

4.  Organotherapy. — Thyroid  extract  aggravates  the  symptoms  in 
all  save  a  very  few  cases.  Thymus  extract  has  apparently  helped  some 
cases,  but  most  recent  reports  concur  T\ath  the  rather  negative  results 
obtained  by  ^Mackenzie  and  Kinnicutt.  The  use  of  serum  or  milk 
from  dethyroidated  animals  is  still  in  the  experimental  stage;  Baumann 
(1895)  demonstrated  that  the  thyroid  gland  contained  an  iodine  body 
which  Ross  proved  was  the  main  functional  constituent  of  the  organ. 
The  active  element  of  the  gland  presents  two  clinical  phases:  (a)  it 
neutralizes  toxins  (failing  in  which,  myx oedema  results),  and  (h)  if  not 
itself  neutralized,  Basedow's  disease  results;  to  neutralize  the  hyper- 
thyrea  of  this  disease,  it  was  suggested  that  the  serum  of  thyroidec- 
tomized  animals  be  used  (Ballet,  Enriquez,  Lanz,  Burghart  and 
Blumenthal) ;  some  good  results  have  recently  been  obtained  (Rogers). 

5.  Thyroidectomy. — The  earlier  objections  to  partial  thyroidectomy 
on  the  grounds  that  many  operated  cases  were  ordinary  goitres,  or 
that  improvement  often  occurs  spontaneously  or  medicinally,  are  now 
weakening  because  of  convincing  surgical  statistics.  The  average 
mortality  is  about  15  per  cent.  (Mayo,  Oppenheim).  In  Kocher's 
large  experience  of  167  operations  (1906),  naturally  on  severe  types, 
only  5  per  cent.  died.  The  ]Mayos'  last  series  shows  8  per  cent,  mor- 
tality; they  consider  general  preferable  to  local  anaesthesia.  Death 
may  also  occur  under  local  anaesthesia  which  latter  is  a  very  unpleasant 
procedure.  Removal  under  nitrous  monoxide  gas  gave  excellent  results 
in  two  of  the  author's  cases.  The  results  of  operations  by  Kocher, 
Kiimmell,  Friedheim  and  others  show  approximately  the  following 
results;    mortality  5  per  cent,  (as  against  12  per  cent,  under  medical 


CRETINISM  \  893 

treatment) ,  complete  recovery  (which  is  rare  under  expectant  therapy) 
in  70  per  cent,  and  partial  recovery  in  25  per  cent.  Kocher  prefers 
trying  the  a;-rays  first  and  then  proceeding  by  stages,  first  ligating  the 
thyroid  arteries  (after  which  tetany  may  occur  and  once  within  half 
an  hour),  and  later  performing  partial  thyroidectomy;  the  danger  of 
a  "heart"  death  is  avoided  by  relatively  early  operation.  Hirst  states 
that  the  mortality  of  operation,  for  any  indication,  in  an  exophthalmic 
subject,  is  increased  15  per  cent. 

Division  of  the  cervical  sympathetic  is  inadvisable. 


MYXCEDEMA. 

Definition. — Myxoedema  is  a  chronic  constitutional  disease,  char- 
acterized (i)  by  loss  of  thyroid  function  (athyrea),  (ii)  by  myoedema 
(an  elastic  oedematous  change  in  the  subcutaneous  tissue),  (iii)  by 
cachexia  or  (iv)  by  cretinism  (mental  failure).  It  was  described  by 
Gull  (1873)  as  a  cretinoid  manifestation,  and  later  by  Ord  (1877), 
in  England,  and  in  France  by  Charcot,  Bourn eville,  d'Olier  and  others. 

The  symptoms  vary  as  to  cause  and  combination,  whence  (a) 
cretinism,  (b)  adult  myxoedema,  and  (c)  operative  myxoedema  will  be 
considered  separately. 

Etiology. — The  thyroid  may  be  aplastic,  hypoplastic,  cirrhotic 
from  an  infective  sclerosing  thyroiditis  (syphilis,  tuberculosis,  rheu- 
matism, or  erysipelas),  or  hypertrophied  (goitre)  or  it  may  be  removed 
by  operation,  but  in  all  cases  the  thyroid  function  (internal  secretion  or 
antitoxic  action),  is  suspended  or  lost. 


CRETINISM. 

Cretinism  may  be  congenital,  in  which  instance  life  is  not  long 
protracted;  it  usually  develops  in  the  first  year,  and  is  noticed  near 
the  time  of  weaning  (infantile  form);  it  may  develop  between  the 
fourth  year  and  puberty  (juvenile  form).  The  endemic  form  occurs 
in  regions  where  goitre  is  prevalent,  in  Switzerland,  Italy,  France, 
Great  Britain,  Spain  and  Sweden;  according  to  Kocher,  when  both 
parents  are  goitrous,  the  child  is  invariably  a  cretin,  is  myxoedematous 
and  may  also  have  goitre.  The  sporadic  form  may  develop  from 
thyroid  aplasia,  sclerosing  thyroiditis  or  from  goitre.  In  1901,  100 
cases  were  collected  in  America. 

Symptoms. — In  the  last  part  of  the  first,  or  in  the  second  year  of 
life,  retardation  of  mental  and  physical  development  is  apparent. 
The  head  is  disproportionately  large,  the  fontanelles  persist,  the  fore- 
head is  narrow,  and  the  base  of  the  skull  is  shortened.  The  face  is 
turgid,  pale,  and  imbecile,  the  lids  are  swollen,  as  are  the  nose,  the 
protruding  tongue,  and  pouting  lips.  Dentition  is  retarded  and  caries 
is  frequent.    The  skin  loses  its  tone  and  is  dry,  and  the  hair  is  thin. 


894  DISEASES  OF  THE  DUCTLESS  GLAXDS 

The  neck  is  short,  which  condition  is  accentuated  by  supraclavicular 
deposits  of  fat.  The  abdomen  is  large  and  pendulous;  umbilical 
hernia  is  very  frequent.  The  body  is  dwarfed  and  the  extremities 
are  short,  stumpy,  and  weak  or  helpless.  ^Metabolism  is  slow,  the 
gaseous  interchange  being  reduced  to  50  or  60  per  cent,  of  the  normal. 
Diagnosis. — (a)  The  mental  alteration  is  marked,  though  mild  com- 
pared -^^ith  the  grimaces,  grinding  of  the  teeth,  and  compulsory  move- 
ments caused  by  gross  lesions  of  the  brain,  (b)  In  hyperplasia  of  the 
bone  cartilages  {chondrodystrophia  jcetalis),  there  is  great  enlargement 
of  the  head  and  joints,  dwarfing  of  the  body,  and  shortness  of  the 
extremities  (micromelia),  but  no  essential  mental  change;  court  fools 
were  probably  of  this  type,  (c)  Infantilism  concerns  only  the  infantile 
appearance  of  the  genitaha,  and  the  absence  of  the  primary  and  second- 
ary evidences  of  sex;  general  malnutrition,  aplasia,  and  cretinism  are 
absent,  though  some  cases  of  infantiHsm  are  due  to  thyroid  h}^o- 
plasia. 

MYXEDEMA  OF  ADULTS. 

Sjnnptoms. — Myxoedema  spontaneum  adultorum,  or  cachexie  pachy- 
dermique  (Charcot)  is  characterized  by  (1)  thyroid  atrophy,  (2)  myx- 
oedema (pachydermia),  (3)  intellectual  and  physical  weakness,  and 
(4)  certain  accessory  symptoms.  It  is  most  frequent  in  England  and 
France.  ]Most  cases  occur  in  persons  between  thirty  and  fifty  years 
of  age. 

1.  Thyroid  Atrophy. — This  is  difficult  to  detect  clinically.  It  is 
less  a  clinical  than  a  histological  condition,  as  e\4denced  by  the  lack 
of  function  sometimes  observed  in  gross  enlargement  of  the  gland; 
Magnus  Levy,  in  34  cases  observed  by  him,  found  the  thyroid  hard 
and  large  in  5  cases.  Eighty-six  per  cent,  occurs  in  women,  and  it 
is  possibly  related  to  the  uterine  functions  or  to  the  physiological 
congestive,  thyroid  enlargement  observed  in  women.  It  may  be 
hereditary  or  familial.  It  sometimes  occurs  in  a  family  (or  in  indi^dd- 
uals)  in  which  there  are  cases  of  exophthalmic  goitre. 

2.  Myxoedema. — In  a  few  instances,  much  mucin  has  been  found 
in  the  skin  and  subcutaneous  tissues.  These  structures  are  inelastic, 
semigelatinous  and  semioedematous,  but  do  not  pit  upon  pressure; 
the  skin  is  pale,  waxy,  dry,  rough,  firm,  and  its  electrical  resistance 
is  increased;  the  hair  and  teeth  may  fall  out  and  the  nails  thicken 
and  break.  The  facies  is  somnolent,  coarse,  and  swollen,  and  the 
features  are  individually  changed,  rather  resembling  those  of  a  cretin; 
the  cheeks  are  patchy-red,  pendulous  and  tremble  like  jelly,  and  the 
tongue  is  big.  The  supraclavicular  tissue  is  enlarged  in  lumps  and 
rolls,  though  this  is  also  observed  in  healthy  persons  (Verneuil's 
pseudohpomata).  S.  Kuh  observed  a  painful  swelling  over  the  clavicle 
alone,  which  rather  resembled  keloid.  The  hands  and  feet  are  infil- 
trated.   The  swellings  may  change  rapidly.    The  oral  mucous  mem- 


CACHEXIA  STRUMIPRIVA   OR  OPERATIVE  MYXCEDEMA      895 

brane  is  dry  and  thick,  sometimes  also  the  pharynx,  larynx  and  even 
the  rectuni;   polypi  are  frequent  and  secretion  of  tears  is  scanty. 

3.  Mental  Weakness. — Intellectual  and  physical  weakness  is  ap- 
parent. Somnolence  is  more  frequent  than  insomnia.  Charcot  com- 
pares the  condition  to  hibernation.  Headache  is  common.  The 
patient  is  apathetic,  irritable,  weak  in  memory,  and  slow  in  thought, 
speech  and  movement;  sometimes  delirium  and  mania  precede  the 
ultimate  dementia.  The  gait  is  clumsy  ("hippopotamus  gait")  and 
muscular  fatigue  follows  moderate  exertion. 

4.  Other  Symptoms. — The  accessory  symptoms  are  variable,  as 
cardiac  hypertrophy,  arteriosclerosis,  palpitation;  small,  sluggish 
pupils,  tremor,  vertigo,  night  terrors,  sensitiveness  to  cold;  indiges- 
tion and  constipation;  anaemia;  amenorrhoea;  scanty  urine  with 
little  urea,  and  low  specific  gravity,  sometimes  albuminuria,  and  less 
often  glycosuria;  hemorrhages,  especially  from  the  uterus;  and  subnor- 
mal temperature.  The  thymus  is  usually  enlarged,  sometimes  the 
hypophysis;   Hunt  describes  it  with  adrenal  tuberculosis. 

Course. — The  course  is  chronically  progressive,  and  covers  ten  to 
twenty  years.  Remissions  may  occur  in  the  warm  weather,  from 
change  to  a  milder  climate  or  during  pregnancy.  In  the  last  stage, 
the  myxoedema  often  disappears.  Transient  cases  of  acute  myxoedema 
have  been  observed  by  Sollier,  Osier,  and  others.  Osier  in  1898, 
reported  an  acute  case  with  melsena,  mania,  glycosuria,  tachycardia, 
and  death  in  six  months.  Sudden  death  is  occasional  but  most 
patients  die  of  intercurrent  tuberculosis  or  acute  infections. 


CACHEXIA  STRUMIPRIVA  (THYREOPRIVA)  OR  OPERATIVE 

MYXEDEMA. 

Horsley  reported  that  myxoedema,  tetany  contractures,  apathy,  and 
coma  occurred  in  the  monkey  after  complete  thyroidectomy;  when 
kept  warm,  the  monkeys  did  not  manifest  myxoedema,  but  a  species 
of  cretinism.  Cachexia  follows  extirpation  in  man  and  herbivora; 
convulsions  develop  in  carnivora,  resulting  from  the  fact  that  the 
antitoxic  elements  of  the  thyroid  are  not  present  to  neutralize  the  nuclein 
of  ingested  meat.  The  toxaemia  strumipriva  is  manifested  by  anaemia 
(2  million  red  cells),  leukocytosis  (30,  to  38,000)  and  degeneration  in 
the  walls  of  the  bloodvessels.  Kocher  (1882)  observed  cachexia 
strumipriva  in  about  17  per  cent,  of  408  cases,  more  often  after  the 
complete  tha.n  after  the  partial  operation.  Reverdin  made  similar 
observations,  and  Eiselberg  reported  it  in  about  23  per  cent,  of  com- 
plete excisions  made  in  Billroth's  clinic.  Accessory  thyroids  (v.  Goitre) 
may  avert  this  operative  complication.  The  author  knows  of  two 
instances  in  which  removal  of  an  accessory  lingual  thyroid  (under 
a  mistaken  diagnosis),  caused  myxoedema.  Schiff  (1884),  and  later 
Eiselsberg  succeeded  in  curing  operative  myxoedema  by  transplanta- 
tion of  a  thyroid.     Bircher   (1889)  first  successfully  made  a  trans- 


896  DISEASES  OF  THE  DUCTLESS  GLANDS 

plantation  in  the  human  being.  Unfortunately,  the  function  of  the 
transplanted  gland  is  very  seldom  maintained,  though  recently  Cris- 
tiani  reports  excellent  results. 

In  some  cases,  ablation  of  the  thyroid  gland  produces  tetany  {tetania 
thyreopriva).  Vassali  and  Generali  maintained  that  absence  or  abla- 
tion of  the  thyroid  causes  cachexia,  and  trophic  disorder,  and  that 
absence  or  ablation  of  the  parathyroid  glands  causes  tetany  (without 
cachexia).  The  parathyroids  have  maintained  life  thirty-seven  years 
when -the  thyroid  was  congenitally  absent,  and  Kishi  believes  that 
after  thyroidectomy,  the  parathyroids  actually  become  thyroid  tissue. 
In  thyroidectomy  the  upper  parts  of  the  lateral  and  middle  lobes 
should  be  removed  in  order  to  spare  the  parathyroids  which  are  located 
alongside  the  lower  part  of  the  lateral  lobes. 

Treatment  of  Cretinism,  Myxoedema  and  Cachexia  Thyreopriva. — 
For  these  allied  conditions  we  possess  in  the  thyroid  extract  one  of 
the  few  actual  specifics  of  medicine,  and  most  cases  of  cretinism,  adult 
myxoedema  and  operative  myxoedema  can  be  cured — in  a  sense  we  can 
seldom  employ  this  term.  Horsley's  pupil,  Murray,  first  used  the 
thyroid  extract  hypodermatically;  this  method  soon  gave  way  to  its 
administration  by  mouth,  advocated  by  Horwitz  of  Copenhagen  (1892), 
and  Mackenzie  and  E.  L.  Fox  in  London.  The  powdered  extract 
should  be  prepared  from  the  glands  of  young  sheep,  for  the  thyroid 
soon  atrophies  in  older  animals.  Beginning  with  gr.  ij  t.i.d.,  the  dose 
may  be  increased  to  gr.  v  or  even  xv.  In  a  short  time  the  evidences 
of  increased  metabolism  appear,  as  loss  of  weight,  increased  diuresis, 
increased  urea  and  elevation  of  bodily  temperature;  normal  growth  is 
stimulated,  myxoedema  and  cretinism  disappear,  the  pulse  becomes 
full  and  lively,  the  skin  moistens  and  regains  its  lustre  and  in  every 
regard  the  results  are  magical.  In  some  instances  toxic  effects  (thyroid- 
ism),  are  apparent,  as  tachycardia,  nervousness,  delirium,  dyspnoea, 
palpitation,  flushing,  sweating,  tremor,  less  often  tonic  spasms  and 
rarely  exophthalmos,  softening  of  the  bones,  particularly  in  young 
rhachitic  subjects,  or  even  death;  these  symptoms  are  alhed  to  those 
of  exophthalmic  goitre  (hyperthyrea) ;  thyroidism  is  seemingly  more 
frequent  in  myocarditic  and  arteriosclerotic  subjects.  Ewald  thinks 
that  administration  of  arsenic  lessens  the  liability  of  thyroidism,  which 
after  all  is  an  infrequent  condition.  Larger  doses  may  be  given  in 
winter  than  in  summer.  At  first  large  doses  are  indicated,  and  later, 
after  relief  is  obtained,  smaller  doses  should  be  given,  averaging  gr.  j 
to  ij,  or  whatever  size  experience  in  the  individual  case  may  determine. 
Relapses  are  common  after  withdrawal  of  the  extract,  and  in  most 
cases  it  becomes  rather  a  food  than  medication.  Change  of  climate, 
warm  baths,  and  sometimes  pilocarpin  hydrochlorate  gr.  t'o,  hypoder- 
matically, are  of  decided  benefit.  A  milk  diet,  or  a  salt-free  diet,  is 
also  advocated. 


DISEASES  OF  THE  THYMUS  GLAND  897 


(E).  DISEASES  OF  THE  THYMUS  GLAND. 

The  thymic  functions  are  unknowTi.  Among  other  hypotheses,  it  is 
said  that  the  thymus  is  concerned  in  neutralizing  infection,  that  it 
concerns  certain  vegetative  functions  as  the  growth  of  bone,  and  that 
it  bears  some  relation  to  cerebral  function.  Its  secretion  in  the  first 
two  years  of  life  is  milky  and  contains  iodine,  cells,  and  a  molecular 
subtance.  It  weighs  two  to  four  drams  (7  to  13  gm.)  at  birth,  about 
an  ounce  (24  to  30  gm.)  in  the  second  year,  after  which  it  wastes, 
weighing  but  one  dram  (3  gm.)  at  twenty-five  to  thirty  years  of  age. 

There  is  an  intimate,  though  obscure,  relation  between  the  thymus, 
thyroid,  pituitary  body,  parathyroids,  testes,  ovaries  and  possibly  also 
the  bone-marrow.  The  thymus  wastes  as  the  testicles  and  ovaries 
develop.  Thymic  extract  causes  a  fall  in  blood  pressure,  cardiac 
acceleration  and,  in  large  doses,  fatal  collapse. 


(a)  Hemorrhages  into  the  thymus  may  be  found  in  cases  of  con- 
genital syphilis  and  in  asphyxia  of  the  new-born,  (b)  Thymic  cysts 
have  been  described.  Chiari  claims  that  50  per  cent,  of  them  are 
merely  accentuation  of  the  normal  findings,  in  which  the  lymphoid 
elements  overgrow  into  the  convolutions  of  the  gland,  (c)  Abscess 
of  the  thymus  has  been  described  by  Dubois  (1850),  but  is  often 
mistaken  for  softened  gummata,  cysts  and  postmortem  softening. 
(d)  The  most  frequent  tumors  are  sarcoma  and  lymphosarcoma. 
Less  frequent  are  dermoids  and  granulomata. 

(e)  Persistence  of  the  gland  after  puberty  is  an  infrequent  and  wholly 
obscure  condition;  sometimes  it  may  be  identified  by  an  area  of 
dulness  reaching  upward  from  the  third  rib  and  an  inch  or  so  to  either 
side  of  the  sternum. 

(/)  Some  cases  of  "persistent  thymus"  are  hypertrophy,  which  is  the 
most  common  thymic  lesion,  (i)  Plater  (1614)  associated  enlargement 
of  the  thymus  with  sudden  death.  Grawitz,  Jacobi,  and  others  have 
described  cases  of  thymic  hyperplasia  which  has  caused  sudden  dysp- 
noea, usually  in  infants,  followed  by  early  death;  the  idea  is  advanced 
that  the  gland  presses  on  the  vagus,  cava,  or  trachea.  The  cases  are 
thought  to  be  lymphatism,  as  are  the  cases  described  by  Nordmann, 
Recklinghausen,  Rolleston,  Paltauf  and  Keyer,  who  collected  eight  cases 
of  sudden  death  in  robust  young  men  while  bathing,  by  Kundrat,  who 
found  thymic  hyperplasia  in  10  cases  of  death  from  chloroform,  and 
by  Schlomicher's  similar  series,  (ii)  The  existence  of  thymic  asthma 
(Kopp,  1830),  also  known  as  Millar's  asthma,  was  denied  by  Fried- 
leben  (1848).  Though  asthma  thymicum  is  probably  a  nervous  affec- 
tion (laryngismus  stridulus)  in  most  cases,  still  in  some  rare  instances, 
the  enlarged  gland  may  actually  flatten  the  trachea  (Summa  and 
Benecke),  as  the  distance  between  the  sternum  and  spine  is  but 
little  more  than  an  inch;   Siegel,  in  a  case  of  thymic  asthma,  stitched 

57 


898  DISEASES  OF  THE  DUCTLESS  GLANDS 

the  gland  to  the  skin,  which  reheved  all  symptoms;  and  Konig  and 
Ehrhardt  each  cured  a  case  by  partial  excision  of  the  gland.  Hoch- 
singer  (1905)  found  20  cases  of  thymic  stridor  in  26  enlarged  thymi 
in  children;  enlargement  was  determined  by  the  a;-rays.  (iii)  Hyper- 
plasia has  been  frequently  or  constantly  found  in  Graves'  disease  by 
Ord,  Mackenzie,  F.  Kraus  and  Hektoen.  It  is  occasionally  hyper- 
plastic in  acromegaly  and  epilepsy. 


(F).  DISEASE  OF  THE  HYPOPHYSIS:     ACROMEGALY. 

Acromegaly  (large  extremities),  first  described  by  Marie  (1886),  is 
a  nutritional  affection,  probably  caused  by  disease  of  the  hypophysis, 
and  marked  clinically  by  unusual  overgrowth  of  the  bones,  tissues 
of  the  face,  hands  and  feet,  and  by  general  symptoms,  glycosuria,  and 
sexual  disturbance. 

Etiology. — The  hypophysis  is  almost  always  diseased.  In  1902, 
Woods-Hutchinson  collected  262  cases;  in  77  autopsies,  the  gland 
was  diseased  in  73.  The  process  may  be  hyperplasia,  adenoma  or  soft 
malignant  sarcoma,  less  commonly  colloid  degeneration,  fibrosis,  soft- 
ening or  hemorrhage.  Dean  Lewis  found  hyperplasia  of  the  chromo- 
phile  cells,  which  confirms  Benda's  theory  that  acromegaly  is  due  to 
excessive  activity  of  the  cells  in  the  anterior  lobe  of  the  hypophysis. 
From  its  association  with  acromegaly,  the  gland  has  been  thought  to 
be  the  "growth  centre."  The  growth  may  compress  the  cerebral  nerves, 
cavernous  sinus,  sympathetic  nerves,  bone,  dura  or  even  the  brain. 
According  to  Sternberg,  the  sexes  are  about  equally  affected,  and  in 
50  per  cent.,  the  affection  begins  between  twenty  and  thirty,  in  75 
per  cent,  between  twenty  and  forty,  and  in  14  per  cent,  under  twenty 
years  of  age. 

Symptoms. — 1.  Acromegaly. — Enlargement  of  the  extremities  is 
usually  the  first  clear  symptom,  but  is  preceded  by  parsesthesiee  and  pains 
in  the  extremities,  which  are  often  extreme,  and  are  due  to  expansion, 
(a)  A  remarkable  change  occurs  in  the  face;  the  supraciliary  ridges 
protrude,  the  maxillae  enlarge  and  the  nose,  ears,  lips,  tongue,  and 
chin  attain  massive  proportions.  The  general  contour  of  the  face  is 
hexagonal.  The  teeth  separate,  and  the  tongue  sometimes  protrudes 
beyond  them.  The  eyes  by  contrast  appear  small.  Pathologically, 
the  change  in  the  bone  is  hypertrophy  without  inflammation ;  there  is 
increase  in  the  vascular  furrows,  widening  of  some  of  the  foramina 
(with  narrowing  of  others),  and  some  roughening  of  the  bone  and 
localized  protuberances  which  are  not  osteophytes;  the  skull  is  thicker 
and  larger,  especially  the  sphenoid,  supraciliary  ridges,  mastoid  and 
occipital  protuberances;  the  orbit  may  be  narrowed  by  ethmoid 
bulging  and  the  sinuses  and  sella  turcica  are  increased.  (6)  The 
hands  and  feet  are  greatly  enlarged;  they  are  not  deformed  but  are 
symmetrically  hypertrophied.  The  fingers  and  toes  show  two  types 
(Marie),  the  long  and  the  thick  types;  they  are  square  at  their  ends — 


DISEASES  OF  THE  HYPOPHYSIS:    ACROMEGALY  899 

the  "spade-like  fingers."  The  palms  of  the  hands  and  soles  of  the 
feet  become  flattened.  The  rc-rays  show  simple  hypertrophy  of  the 
periosteal  and  subperiosteal  tissues,  and  also  of  the  soft  parts;  in 
some  cases  the  soft  parts  are  more  hyperplastic  than  the  bones.  A 
common  statement  in  the  history  is  that  the  patient  "must  each  year 
buy  a  larger-sized  hat,  gloves,  or  shoes."  The  nails  are  thin  and 
small.  The  antithesis  of  acromegaly  is  micromelia  (Hutchinson), 
(c)  The  changes  in  the  trunk  are  less  conspicuous.  The  sternum  is 
increased  anteroposteriorly,  and  the  ribs  and  clavicles  are  thickened. 
The  anteroposterior  dimension  of  the  thorax  is  increased,  the  head  is 
held  backward,  and  the  dorsal  kyphosis  is  rather  characteristic.  The 
muscular  weakness,  and  lean  arms  and  legs  contrast  sharply  with  the 
first  impression  of  strength  imparted  by  the  massive  face  and  ex- 
tremities. The  breathing  is  largely  abdominal,  (d)  The  skin  is 
hyperplastic,  and  also  the  mucous  membrane  of  the  nose,  tongue, 
pharynx  and  larynx.  The  larynx  is  enlarged  (Marie),  which  may 
explain  the  deep,  low,  rough,  monotonous  voice. 

2.  Nervous  Manifestations. — (a)  Symptoms  of  brain  tumor  (hypo- 
physis) are  common,  as  headache,  vertigo,  mental  alteration,  vomiting, 
periodic  loss  of  consciousness,  bitemporal  hemianopsia  (early  and 
frequent),  optic  atrophy  (40  per  cent.),  ocular  paralysis,  anosmia, 
auditory  disturbance,  and  exophthalmos.  Hertel  in  175  cases  found 
eye  symptoms  in  52.5  per  cent.  (6)  Changes  in  character,  anxiety, 
apathy,  and  insomnia  which  deepens  into  terminal  somnolence,  are 
common;  severe  pains,  paraesthesia,  acroparsesthesia,  and  subjective 
warmth  are  frequent. 

3.  Constitutional  Symptoms. — (a)  Glycosuria  is  more  frequent  than 
Hansemann's  figures  indicate  (12  per  cent.).  Its  relation  to  acro- 
megaly is  uncertain,  probably  being  a  coordinate  manifestation.  Some- 
times polyuria  occurs  without  glycosuria,  (b)  Profuse  sweats  are 
common,  even  with  glycosuria;  the  skin  is  sometimes  pigmented; 
obesity  is  common,  (c)  Sexual  disturbance  is  the  rule;  in  women 
amenorrhoea  is  practically  constant,  and  is  often  preceded  by  dys- 
menorrhoea;  in  men  impotence  is  not  unusual;  the  genitalia  are 
much  oftener  infantile  than  hypertrophied.  {d)  The  heart  is  often 
dilated,  and  hypertrophied  from  the  frequent  concomitant  arterio- 
sclerosis, deformed  chest,  and  rarely  from  actual  overgrowth  (cardio- 
megaly);  there  may  be  cyanosis  as  the  heart  weakens.  The  vessels 
are  wide  and  thick.  Splanchnomegaly  may  be  early  observed  (intes- 
tines and  other  viscera).  In  most  cases  the  lymph  nodes,  particularly 
the  cervical,  are  palpably  enlarged,  the  tonsils,  spleen,  thymus,  and 
sometimes  the  thyroid  are  hyperplastic.  Gigantism  (v.i.)  occurs  in 
over  20  per  cent,  of  cases. 

Course  and  Prognosis. — (a)  Acromegalic  subjects  seek  advice  for 
the  enlargement  of  the  extremities  or  tonsils,  sweats,  pain,  eye-symp- 
toms, or  polyuria;  (b)  remissions  are  common,  the  constitutional 
symptoms  and,  to  a  slight  extent,  the  enlargement  subside;  on  the 
other  hand,  a  fitful  advance  may  be  noted,     (c)  The  average  course 


900  DISEASES  OF  THE  DUCTLESS  GLANDS 

is  chronic,  covering  ten  to  twenty  years,  though  relatively  benign  cases 
occur,  lasting  thirty  or  even  fifty  years,  and  acute  malignant  cases  are 
known,  which  are  always  due  to  sarcoma;  they  may  develop  in  a  few 
weeks,  and  average  two  to  four  years  in  duration,  (d)  Death  is 
inevitable,  though  it  may  occur  from  various  causes;  it  may  result 
suddenly  as  in  brain  tumor  or  from  gradual  marasmus;  diabetic 
coma,  intercurrent  infection,  cardiac  insufficiency,  intestinal  catarrh, 
or  pyelonephritis  may  explain  the  fatal  issue. 

Diagnosis. — In  this  connection,  Striimpell  quotes  Charcot's  maxim 
that  physicians  in  general  see  and  diagnosticate  only  what  they  have 
seen  and  learned  to  diagnosticate;  the  diagnosis  is  made  at  a  glance 
by  one  who  has  seen  a  single  case ;  undue  regard  to  a  single  symptom, 
as  the  skin  changes,  amenorrhoea  or  glycosuria,  may  cause  error,  but 
the  grouping  of  acromegalic  findings  is  unmistakable. 

Differentiation. — 1.  In  the  cranium  progenium,  the  lower  jaw  pro- 
trudes and  its  teeth  are  directed  forward;  the  lower  jaw  is  hyperplastic, 
the  upper  jaw  is  hypoplastic.  Cranium  progenium  may  occur  in 
acromegaly,  cretinism,  healthy  individuals  after  variola,  in  degeneracy, 
and  in  idiocy. 

2.  Gigantism  occurs  in  over  20  per  cent,  of  acromegaly  (particularly 
when  acromegaly  develops  early  in  life).  Forty  per  cent,  of  giants 
are  acromegalic  (Sternberg).  The  interrelation  of  these  conditions  is 
incompletely  understood.  Gigantism  proper  implies  symmetry  of  over- 
growth; there  are  normal  "giants"  and  giants  with  acromegaly, 
leontiasis  (v.i.),  facial  hemihypertrophy,  and  hereditary  syphilis. 
Bassoe's  report  of  the  autopsy  of  the  giant  Wilkins  covers  the  entire 
subject  (Journal  of  Mental  and  Nervous  Diseases,  1903). 

3.  Diffuse  hyperostosis  (Starr,  Putnam,  Prince)  occurs  in  the  young, 
involves  all  the  skull  bones,  and  seldom  the  extremities  or  spine; 
exophthalmos,  blindness,  deafness,  bilateral  facial  palsy,  dysphagia, 
dyspnoea,  and  other  basilar  symptoms  are  noted,  which  culminate 
fatally  with  stupor,  idiocy,  epileptiform  convulsions,  and  paralysis  of 
the  extremities.  A  sub-type  (leontiasis  ossea,  Dana,  1893)  occurs  in 
the  form  of  tumor-like  protuberances  on  the  skull  and  other  bones. 
Prince  (1902)  collected  20  cases  from  the  literature.  He  maintains 
that  it  is  a  form  of  osteitis  deformans. 

4.  Osteitis  deformans  (Paget's  disease,  1887)  is  a  combined  rarefying 
and  hypertrophic  osteitis.  It  begins  slowly  in  subjects  over  forty 
years  old,  with  pains  and  deformity  of  the  thighs,  legs,  and  spine; 
the  legs  bow  widely  outward  a.nd  somewhat  forward,  the  curved  cer- 
vical and  upper  dorsal  spine  becomes  kyphotic,  the  thorax  narrows 
transversely  and  widens  anteroposteriorly,  the  abdomen  is  diamond- 
shaped  and  crossed  by  a  sulcus,  and  the  head  hangs  forward.  The 
soft  parts  do  not  hypertrophy  as  in  acromegaly,  the  face  is  rarely 
involved,  the  head  is  larger  above  than  below,  and  the  arms  are  little 
altered.     About  70  cases  are  on  record. 

5.  Hypertrophic  osteoarthropathy,  known  since  the  time  of  Hippoc- 
rates, was  especially  described  by  Bamberger  and  simultaneously  by 


DISEASES  OF  THE  HYPOPHYSIS;     ACROMEGALY  901 

Marie,  in  1889.  The  ends  of  the  fingers  and  perhaps  the  toes  become 
clubbed  or"  drumstick  "  in  appearance.  While  the  nails  are  thin  and 
small  in  acromegaly,  in  hypertrophic  osteoarthropathy,  they  are  large, 
thick,  wide  and  curved  downward.  The  alteration  typically  involves 
the  terminal  phalanges,  but  also  in  severe  cases  the  ends  of  the  ulna, 
radius,  tibia  and  fibula.  The  pathology  is  a  toxsemic,  chronic  peri- 
ostitis, with  hypertrophy  and  osteophytic  growth.  The  most  common 
cause  is  chronic  lung  disease  (chronic  phthisis,  bronchiectasis,  emphy- 
sema, or  fibrosis),  whence  Marie's  name  of  osteoarthropathie  hypertro- 
phiante  pneumonique;  it  may  develop  in  congenital  heart  disease  or 
aneurysm,  or,  much  less  frequently,  in  icterus,  gastric  dilatation, 
syphilis,  cystitis,  or  various  infections.  Adult  males  are  most  often 
affected. 

The  treatment  of  acromegaly  is  merely  symptomatic.    Extract  of  the 
hypophysis  has  been  given,  and  in  a  few  cases  with  temporary  success. 


SECTION  VIII. 


CONSTITUTIONAL  DISEASES 


(A).   DIABETES  MELLITUS. 

Definition. — An  independent  disease  of  metabolism  characterized 
(a)  by  a  permanent  lessened  capacity  of  the  organs  fixing,  storing  and 
consuming  grape  sugar;  (6)  by  excess  of  sugar  in  the  blood  {hyper- 
glyccBTYhia),  resulting  in  (c)  grape  sugar  in  the  urine  {glycosuria) ;  (d) 
caudal  changes  in  the  pancreas.  (The  term  mellituria  includes  the 
presence  of  all  kinds  of  sugar  in  the  urine.) 

Willis  (1622-75)  first  differentiated  between  diabetes  mellitus  and 
diabetes  insipidus,  and  Dobson  (1774),  of  Liverpool,  fully  described 
the  clinical  symptoms. 

The  liver,  the  reservoir  for  carbohydrates,  may  contain  even  14 
per  cent,  of  glycogen.  It  collects  carbohydrates  from  the  portal  vein, 
stores  them  as  glycogen,  and  again  imparts  them  to  the  blood  as 
grape  sugar,  for  use  in  the  tissues.  The  muscles  also  manufacture 
glycogen  from  the  grape  sugar  of  the  blood,  and  are  more  tenacious 
of  it  than  is  the  liver.  Glycogen  may  also  be  produced  from  the  album- 
inates. When  there  is  a  temporary  carbohydrate  shortage,  the  reserve 
store  of  glycogen  is  drawn  upon.  Fat  is  converted  in  the  liver  into 
sugar,  when  neither  the  carbohydrates  or  the  albuminates  suffice  to 
maintain  the  normal  proportion  of  sugar  in  the  blood.  The  fate  of 
carbohydrates  when  ingested  in  excess  is:  (a)  glycogen  storage  (up 
to  10  ounces — 300  grams);  (b)  conversion  into  fat;  (c)  alimentary 
glycosuria  from  hyperglycsemia,  when  the  sugar  in  the  arterial  blood 
exceeds  0.2  per  cent.;  this  is  known  as  "alimentary  glycosuria," 
which  is  physiological,  wholly  distinct  from  diabetes  mellitus,  and 
occurs  when  the  blood-sugar  exceeds  the   assimilation   limit.     The 

903 


904  CONSTITUTIONAL  DISEASES 

test  for  alimentary  glycosuria  consists  of  giving  3  ounces  (100  gms.)  of 
grape  sugar,  after  a  light  breakfast  of  bread  and  coffee.  If  more  than 
1  per  cent,  of  sugar  appears  in  the  urine,  or  if  2  or  3  per  cent,  of  the 
entire  amount  administered  is  found,  it  is  indicative  of  diabetes  rather 
than  of  glycosuria.  Most  sugar  absorbed  goes  to  the  liver,  but  some 
absorbed  by  the  lymphatics  appears  in  the  urine,  whence  its  presence 
is  not  necessarily  a  sign  of  diabetes;  in  liver  cirrhosis,  sugar  may 
reach  the  blood  with  the  collateral  circulation.  Traces  of  sugar 
(0.01  to  0.02  per  cent.)  are  normally  present  in  the  urine,  but  are  not 
detected  by  the  usual  tests,  whence  healthy  urine  is  regarded  as  free 
of  sugar.  ' 

Etiology. — 1.  The  pancreas  (q.v.)  has  long  been  considered  an  etio- 
logical factor  in  diabetes.  Recently  Opie  discovered  atrophic  changes 
in  the  cells  of  the  islands  of  Langerhans;  they  are  determined  only  by 
microscopic  examination.  These  cells  are  thought  to  produce  an 
internal  secretion,  concerned  in  breaking  up  sugar  in  the  tissues  and 
muscles.  This  internal  secretion  from  Langerhans'  islands,  is  wholly 
distinct  from  the  external  secretion  of  the  pancreatic  juice  voided 
into  the  intestine.  Lepine  some  years  ago  spoke  of  a  "glycolytic 
ferment,"  which  entered  the  blood  from  the  pancreas  and  broke  up 
the  sugar  molecules;  in  diabetes  resulting  from  the  absence  of  the 
ferment,  the  sugar  is  not  broken  down.  This  ingenious  argument  has 
received  much  experimental  corroboration,  since  (a)  total  pancreatic 
extirpation  in  animals  and  man  produces  glycosuria;  (b)  after  partial 
extirpation  and  suture  of  the  remaining  portion  to  the  abdominal 
wall,  diabetes  fails  to  appear,  but  develops  if  this  portion  is  later 
removed;  (c)  when  about  a  tenth  part  is  left,  a  mild  form  of  diabetes 
ensues,  and  glycosuria  occurs  only  after  the  ingestion  of  carbohydrates; 
(d)  subsequent  destruction  of  the  remaining  portion  of  the  gland 
produces  a  severe  form;  (e)  when  more  than  one-tenth  of  the  func- 
tionating gland  is  left  behind  no  diabetes  ordinarily  results;  (/)  diabetes 
does  not  occur  in  simple  Hgature  of  the  pancreatic  duct,  excluding  the 
juice  from  the  intestine,  nor  when  the  fluid  escapes  through  a  cutaneous 
fistula,  whence  the  argument  that  there  is  an  internal  secretion,  (g) 
Cohnheim's  experiments  (1903)  suggest  that  a  ferment  or  pro-enzyme 
secreted  by  the  pancreas,  joins  another  ferment  secreted  by  the  muscles, 
and  that  the  united  ferments  break  down  the  sugar  molecules  to  pro- 
duce heat  and  energy.  In  167  patients,  Thoinot  and  Delamare  found 
"Langerhans'  insufficiency"  in  80  per  cent.,  and  chiefly  in  "lean 
diabetics." 

2.  There  is  a  neurogenous  diabetes,  the  relations  of  which  (if  there  are 
any)  to  the  pancreas  are  wholly  obscure.  This  and  the  following  type 
might  be  considered  as  symptomatic  diabetes.  Nervous  diseases,  as 
Claude  Bernard's  well  known  puncture  of  the  fourth  ventricle,  may 
possibly  alter  the  circulation  in  the  hver.  Among  them  are  apoplexy, 
tabes,  brain  tumors  (particularly  those  located  near  the  base),  general 
paralysis,  multiple  sclerosis,  meningitis,  syphilis,  softening  of  the  brain, 
diseases  of  the  cord,  vagus  and  sympathetic  system,  trauma,  traumatic 


DIABETES  MELLITUS  905 

neurosis,  paralysis  agitans,  mental  diseases,  Basedow's  disease,  and 
acromegaly.  Hoffman  distinguishes  between  (a)  neurogenous  dia- 
betes, which  occurs  chiefly  in  men,  with  no  tendency  to  furuncles, 
carbuncles  or  cataract,  with  no  connection  with  gout,  and  which  passes 
away  if  the  brain  affection  is  curable,  and  then  always  in  a  compara- 
tively short  time,  though  in  some  cases  it  causes  death  within  two 
years;  and  (b)  diabetes  of  the  obese,  which  occurs  as  frequently  in 
women  as  in  men,  often  produces  carbuncles,  is  often  connected 
with  gout,  and  is  very  chronic,  often  lasting  ten  or  twenty  years. 

3.  Obesity  may  be  a  cause;  according  to  von  Noorden,  "There  are 
(a)  cases  in  which  the  consumption  of  sugar  and  its  conversion  into 
fat  are  simultaneously  restricted — glycosuria  which  varies  in  severity, 
and  in  degree  of  emaciation  (ordinary  diabetes);  (6)  cases  in  which 
only  the  consumption  of  sugar,  and  not  its  conversion  into  fat  is  inter- 
fered with — obesity  without  glycosuria  (masked  diabetes);  these  pass 
readily  at  a  later  period  into  (c)  cases  in  which  the  consumption  of 
sugar  is  restricted,  and  the  collecting  of  carbohydrates  in  the  fatty 
tissues  is  also  more  or  less  interfered  with — obesity  with  consecutive 
glycosuria  (ordinary  diabetes  of  the  adipose)." 

4.  Gout,  arteriosclerosis,  various  liver  lesions  (cirrhosis),  and  possibly 
acute  infections,  have  apparent  though  obscure  relations  with  diabetes. 
Adrenalin  may  produce  glycosuria  (Blum  and  Herter).  Renal  diabetes 
(glycosuria  without  an  excessive  amount  of  sugar  in  the  blood)  may 
occasionally  develop  in  nephritis,  renal  hemorrhage,  chyluria,  and  from 
administration  of  the  glucoside,  phloridzin.  Lactosuria  may  occur  in 
late  pregnancy,  the  puerperium  and  nurslings;  von  Noorden's  hypoth- 
esis is  that  in  the  "puerperal  state  the  capacity  of  the  tissues  for 
breaking  up  milk-sugar  is  diminished,  an  instance  of  adaptation  to 
an  end  in  that  the  cells  of  the  mother  refuse  a  material  which  is  pre- 
eminently suited  to  the  nutritive  wants  of  the  nursling." 

5.  Predisposing  factors  are  (a)  sex;  men  (3:2)  are  especially  subject 
to  diabetes;  (b)  age;  though  it  occurs  at  any  age,  its  frequency  is  as 
follows:  In  persons  from  thirty  to  forty  years,  18  per  cent.;  forty  to 
fifty  years,  25  per  cent.;  fifty  to  sixty  years,  26  to  30  per  cent.;  in 
Stern's  collection  of  117  infantile  cases,  one  was  apparently  congenital. 
(c)  Heredity.  A  family  history  of  obesity,  consanguinity,  neuropathic 
taint  (20  per  cent.),  or  gout  is  especially  significant;  cases  are  reported 
in  which  the  grandfather  was  diabetic,  the  son  gouty,  and  the  grandson 
again  diabetic  (hereditary  alternating  diabetes),  (d)  Race.  Diabetes 
is  comparatively  rare  in  the  colored  race,  and  is  especially  common  in 
Jews.  It  is  rather  less  common  in  America  than  in  Europe,  (e) 
Occupation.  Diabetes  is  more  often  seen  in  private  than  in  hospital 
practice.  Wealth  and  culture  increase  ten-fold  the  predisposition  to 
diabetes  (von  Noorden).  It  is  frequently  found  in  scientists,  lawyers, 
musicians,  poets,  teachers,  statesmen,  merchants,  speculators,  and  in 
those  leading  a  luxurious  or  self-indulgent  existence  with  sedentary 
habits ;  it  also  results  from  overwork,  excitement,  over-eating  and  over- 
drinking.    Diabetes  is  apparently  increasing  in  frequency. 


906  CONSTITUTIONAL  DISEASES 

Symptoms. — 1.  The  Urine. — Glycosuria. — Sugar  in  the  urine  is 
the  leading  symptom  of  diabetes.  A  daily  excretion  of  1  to  3  drams 
(5  to  12  grams),  is  not  uncommon;  the  maximum  amount  recorded  is 
1,500  gm.;  the  largest  quantity  of  sugar  is  voided  late  in  the  morning 
or  after  6  p.m.  A  percentage  of  from  1  to  4  is  not  uncommon,  8  or 
9  per  cent,  is  rare,  and  the  maximum  is  20  per  cent,  (personal  obser- 
vation). The  estimation  of  a  diabetic's  capacity  to  consume  sugar, 
suggested  simultaneously  by  Seegen  and  Traube  is  as  follows :  Accord- 
ingly as  the  urine,  after  a  diet  absolutely  free  from  carbohydrates,  is 
free  from  sugar  or  not,  a  distinction  is  made  between  (a)  mild  and  (6) 
severe  cases  of  glycosuria,  (a)  Mild  glycosuria  is  characterized  by 
the  urine  becoming  sugar-free  within  a  few  days  after  carbohydrates 
are  withdrawal,  and  by  sugar  reappearing  when  carbohydrates  are 
again  ingested.  The  test  diet  consists  of  ham,  eggs,  roast  beef,  cucum- 
ber with  vinegar,  olive-oil,  and  salt  and  pepper;  brandy  with  Appolin- 
aris" water;  coffee  without  milk  or  sugar;  clear  bouillon ;  butter,  green 
salad,  green  vegetables,  and  sardines;  this  diet  is  free  from  carbo- 
hydrates. With  increasing  additions  of  starch,  sugar  at  some  time 
is  again  voided,  i.e.,  the  limit  of  tolerance  or  of  assimilation  is  reached. 
(6)  Severe  glycosuria  is  characterized  by  continued  excretion  of  sugar, 
in  spite  of  the  withholding  for  days  of  all  carbohydrates  from  the  diet, 
and  signifies  (i)  that  even  those  carbohydrates  which  are  slowly  formed 
from  the  albumin  are  not  wholly  consumed;  (ii)  that  the  functions 
of  glycogen  storage,  and  (iii)  of  splitting  up  of  sugar  in  the  tissues  are 
seriously  affected;  of  this  type  there  are  many  degrees.  Fat  and 
alcohol  never  increase  the  severity  of  glycosuria.  Muscular  exercise 
and  massage  usually  decrease  it.  It  is  often  increased  by  psychic 
disturbances  and  may  be  suspended  or  lessened  during  an  acute 
intercurrent  infection,  especially  in  typhoid;  chronic  diseases  with 
fever,  especially  pulmonary  tuberculosis,  have  less  influence.  It  is 
reduced  or  absent  in  the  final  stages  of  diabetes,  and  may  be  absent 
in  diabetic  coma.  Glycosuria  very  often  disappears  when  granular 
atrophy  of  the  kidney  develops  (Frerichs,  Stokvis,  Furbringer);  the 
diabetes  is  then  cured  in  some  unknown  way.  Gouty  diabetics  as  a 
rule  pass  no  sugar  during  an  attack  of  gout  (diabetes  alternans). 

Tests  for  Sugar. — (a)  For  Fehling's  test,  two  solutions  are  kept 
separate;  one  contains  copper  sulphate,  34.64  gm.  in  500  c.c.  of  water, 
and  the  other,  sodium  and  potassium  tartrate  173  gm.,  and  sodium 
hydrate  125  gm,  in  500  c.c.  of  water.  Equal  parts  of  these  solutions 
are  heated,  but  not  boiled,  and  the  urine  is  added  drop  by  drop. 
The  volume  of  urine  should  never  exceed  that  of  the  solutions.  Re- 
duction of  the  blue  copper  solution  to  the  yellow-red  suboxide  of 
copper  occurs  when  sugar  (its  aldehyd  group)  is  present.  Chloral, 
phenacetin,  chloroform,  formalin,  morphine,  uroleukinic,  and  homo- 
gentisinic  acids  (the  probable  causes  of  alkaptonuria),  glycuronic  acid, 
cascara,  rhubarb,  and  saHcylates,  may  also  reduce  Fehling's  solution, 
particularly  after  boiling.  In  doubtful  cases,  or  as  corroborative  tests, 
(6)  the  fermentation  test  may  be  used;   yeast  is  shaken  thoroughly 


PLATE  XV= 


Crystals  of  Phenyl-glueosazone.     (Musser. 

(Oc.  4,  Ob.i.  D.)     Drawn  by  J.  D.  Z.  Chase. 


DIABETES  MELLITUS  907 

with  a  quantity  of  urine,  the  air  allowed  to  bubble  up,  and  the  mixture 
placed  in  a  saccharometer, — a  tube  closed  at  the  top,  and  graduated 
for  estimation  of  percentages.  The  sugar,  fermenting,  is  measured 
by  the  amount  of  carbon  dioxide  formed.  A  control  test  should  be 
made,  (c)  The  polarization  test,  showing  dextro-rotary  reaction,  may 
be  employed,  (d)  The  very  delicate  and  reliable  phenylhydrazin  test 
of  E.  Fischer  may  be  used.  Cipollina's  method  is  the  simplest:  5 
minims  of  pure  phenylhydrazin,  eight  drops  (0.5  c.c.)  of  glacial  acetic 
acid,  and  a  dram  (4  c.c.)  of  urine  in  a  test-tube  are  gently  boiled  for 
one  minute  with  frequent  agitation.  Four  or  five  drops  of  sodium 
hydrate  solution  are  added,  the  mixture  is  boiled  again,  and  allowed 
to  cool;  in  a  few  minutes  (to  a  half  an  hour)  yellow  rosettes  of 
phenylglucosazon  precipitate;  maltose  and  certain  pentoses,  the  crystals 
of  which  melt  at  different  degrees,  may  alone  cause  error.  Plate  XV. 
Quantity  of  Urine  and  Specific  Gravity. — The  urine  is  almost 
always  acid  even  after  fermentation  (lactic  acid),  and  has  a  sweet 
taste.  As  a  general  rule  the  quantity  of  urine  secreted  during  the 
night  is  less  than  that  secreted  in  the  day-time;  this  is  an  important 
point  because  in  other  polyurias  frequently  f  to  f  of  the  entire  amount 
of  urine  is  secreted  during  the  night  (Lecorchd  and  Quincke).  A 
secretion  of  ten  quarts  is  not  rare.  The  largest  amounts  recorded  are 
16,  17  or  28  quarts  in  a  day.  Higher  figures  suggest  simulation, 
patients  having  been  known  to  add  sugar  to  the  urine.  Pollakiuria 
(frequency  of  urination)  is  common.  The  urine  is  pale.  If  dark  and 
if  uratic  deposits  are  present,  the  prognosis  is  good  (Seegen  and  Pavy). 
Foam  often  remains  long  on  its  surface  and  the  sediment  is  very 
scarce  or  is  absent.  Prout  considered  that  the  onset  of  diabetes  began 
at  the  time  the  urine  ceased  having  a  turbid,  uratic  deposit.  An  in- 
crease in  the  amount  of  sugar  usually  brings  an  increase  in  the  amount 
of  urine,  but  ordinarily  the  amount  of  urine  rises  less  rapidly  than 
does  that  of  the  sugar.  The  specific  gravity  is  higher,  the  greater 
the  amount  of  urine  secreted. 

Amount  in 
liters  cfr  quarts.  Specific  gravity.  Sugar. 

1.5  to    2.5 1.025  to  1.030 2  to  3% 

2.5  to    4     1.030  to  1.036 3  to  5% 

4      to    6     1.032  to  1.046 4  to  7% 

6      to  10     1.036  to  1.046 6  to  9% 

Two  or  three  per  cent,  of  sugar  may  cause  no  change  in  specific 
gravity.  The  average  is  1,030-40,  it  is  rarely  more  than  1,050,  and 
the  highest  record  is  1,074;  very  high  specific  gravity  suggests  fraud; 
the  lowest  records  are  1,002  and  1,008.  If  under  the  influence  of 
meat  diet,  the  urine  becomes  entirely  or  nearly  free  from  sugar,  the 
quantity  approaches  normal.  The  specific  gravity  remains  high 
because  the  urine  is  rich  in  meat  end-products.  There  is  no  absolute 
parallelism  between  the  percentage  of  sugar  and  the  specific  gravity; 
(a)  glycosuria  is  often  preceded  by  premonitory  polyuria,    (b)  Though 


908  CONSTITUTIONAL  DISEASES 

diabetes  may  be  cured,  polyuria  may  persist  without  glycosuria;  this 
may  be  caused  by  the  habit  of  drinking  large  quantities  of  water,  (c) 
There  are  some  cases  in  which  though  there  is  a  large  percentage 
of  sugar,  only  a  pint  or  a  pint  and  a  half  (500  to  800  c.c.)  of  urine  is 
secreted;  this  was  first  described  by  Peter  Frank  a  century  ago  as 
"diabetes  decipiens."  Crystals  of  sugar  may  be  seen  on  the  shoes, 
clothing,  or  in  the  vessel. 

Nitrogenous  Constituents  of  the  Urine. — Diabetic  patients 
usually  excrete  considerable  urea;  2  ounces  (50  to  60  gm.)  are  not  in- 
frequent, and  over  5  ounces  (163  gm.)  have  been  noted;  larger  figures 
are  reached  in  no  other  disease;  it  is  occasioned  by  the  abundant 
ingestion  of  proteids,  and  possibly  by  fermentation  of  the  tissue 
albumins;  the  condition  is  pathological  when  the  amount  of  nitrogen 
in  the  urine  exceeds  that  in  the  food.  Naunyn  and  von  Mehring  deny 
that  there  is  an  increase  in  the  urea  save  in  severe  and  exceptional 
cases. 

Ammonium,  normally  8  to  15  grains  (0.5  to  1  gm.)  per  diem,  may 
increase  to  20  or  180  grains,  although  the  highest  figures  are  seen 
exclusively  in  diabetic  coma.  The  organism  excretes  increased  amounts 
of  ammonia  in  order  to  neutralize  pathological  acids  (acidosis).  The 
diabetic  diet  is  acid;  phosphoric  acid  forms  from  the  ingested  meat, 
and  much  sulphuric  acid  is  produced  by  oxydation  of  sulphur  in  the 
albumin  molecule.  The  quantity  of  creatinin  may  reach  20  to  30 
grains  (1.3  to  2  gm.)  per  diem,  because  of  the  diet,  and  tissue  waste. 
The  amount  of  uric  acid  is  nearly  normal. 

Albuminuria  is  found  in  from  30  to  40  per  cent,  of  cases;  it  is 
almost  always  slight,  and  is  due  (a)  to  cystitis,  pyelitis,  intercurrent 
diseases  as  gangrene  or  infection,  pulmonary  tuberculosis,  and  in  some 
cases  without  relation  to  diabetes  as  in  the  arteriosclerotic  and  gouty 
types  of  diabetes,  to  liver  cirrhosis,  etc.;  (&)  to  diabetes  in  nervous 
individuals,  and  (c)  to  circulatory  disturbances;  {d)  in  uncomplicated 
cases  of  diabetes  it  may  be  due  to  the  action  of  the  sugar,  /?-oxybutyric 
and  other  acids  and  toxins  on  the  kidneys.  Albuminuria  is  a  frequent 
forerunner  of  diabetic  coma,  either  as  a  coordinate  manifestation  or  a 
determining  factor  (decreased  renal  permeability  with  retention  in 
the  blood  of  toxins).  Diabetes  may  develop  into  chronic  interstitial 
nephritis,  and  the  sugar  then  disappears, 

N on-nitrogenous  organic  substances.  Lipuria  has  been  observed. 
Acetone,  aceto-acetic  acid  and  beta-oxybutyric  acid  are  most  frequent; 
they  may  be  derivatives  of  albumin  or  of  fat.  Beta-oxybutyric  acid 
is  absent  in  diabetics  who  are  in  good  physical  condition,  and  not  infre- 
quently also  in  those  who  are  suffering  from  marked  loss  of  albumin. 
The  urine  may  be  odorless,  or  may  smell  like  chloroform,  fruit  or 
wine.  Sometimes  the  daily  amount  excreted  is  only  a  few  grains; 
at  other  times  it  reaches  2  to  even  7  ounces  (50  or  226  grams).  Its 
abnormal  excretion  once  begun,  is  uninterrupted,  sometimes  lasts 
years,  and  shows  a  constant  tendency  to  increase.  It  is  of  the  gravest 
prognostic  significance  because  in  most  cases,  at  the  end  of  days. 


DIABETES  MELLITUS  909 

weeks  or  months,  fatal  diabetic  coma  develops.  An  excretion  of  more 
than  an  ounce  indicates  imminent  coma.  Acidosis  is  most  accurately 
estimated  'by  the  output  of  ammonium ;  according  to  Magnus  Levy, 
2  gm.  of  ammonium  correspond  to  6  gm.  of  |5-oxybutyric  acid,  5  gm.  to 
20  gm.,  and  8  gm.  to  36  or  40  gm.  /?-oxybutyric  acid  is  thought  by 
some  to  be  the  parent  substance  of  acetone  or  diacetic  acid.  Acetone 
and  diacetone  are  present  in  the  urine  in  diabetes,  fevers,  cancer,  in- 
anition or  auto-intoxications,  and  indicate  malnutrition.  When  the 
amount  of  acetone  progressively  rises  from  15  grains  upward,  the 
outlook  is  unfavorable.  It  is  not  proven  that  the  acetones  cause 
coma,  but  they  at  least  accompany  acidosis.  They  impart  a  fruity 
or  wine-like  odor  to  the  urine  and  breath.  Denniges'  test  for  acetone 
(quoted  from  Simon's  Clinical  Diagnosis)  is  as  follows:  20  grams 
of  concentrated  sulphuric  acid  are  poured  into  100  c.c.  of  distilled 
water,  when  5  grams  of  freshly  prepared  yellow  mercuric  oxide  are 
added.  The  mixture  is  allowed  to  stand  for  twenty-four  hours.  This 
reagent  is  added  to  3  c.c.  of  urine,  drop  by  drop,  until  the  precipitate 
thus  formed  no  longer  disappears  on  stirring.  When  this  point  is 
reached  a  few  more  drops  are  added.  After  two  to  three  minutes 
the  precipitate  is  filtered  off.  The  clear  filtrate  is  further  treated 
with  about  2  c.c.  of  the  reagent,  and  3  to  4  c.c.  of  a  30  per  cent,  solu- 
tion of  sulphuric  acid,  and  placed  in  a  vessel  with  boiling  water. 
In  the  presence  of  an  abundant  amount  of  acetone  a  copious  white 
precipitate  forms  immediately;  while  in  the  presence  of  traces  only  (less 
than  1 :  50,000),  a  slight  cloud  develops  on  standing  for  several  minutest 
The  precipitate  is  almost  entirely  soluble  in  an  excess  of  hydrochloric 
acid.  If  albumin  is  present,  the  urine  becomes  turbid  at  once  when 
the  reagent  is  added.  In  that  case  the  test  is  continued  as  described, 
attention  being  directed  to  the  coarser  precipitate  which  occurs  later. 
To  such  urines  large  amounts  of  the  reagent  must  be  added,  the  idea 
being  to  precipitate  everything  that  can  be  precipitated  with  the 
reagent,  before  heating.  Oppenheimer  claims  that  it  is  a  delicate 
test,  and  gives  well-pronounced  reaction  with  a  dilution  of  1 :  20,000. 

Gerhardt's  test  for  diacetone  is  as  follows:  a  dram  of  urine  is 
treated  with  a  strong  solution  of  ferric  chloride  added  drop  by  drop. 
A  precipitate  of  phosphates  is  filtered  off,  and  more  of  the  iron  solution 
is  added  to  the  filtrate.  If  a  bordeaux-red  color  now  appears,  another 
portion  of  the  urine  is  boiled,  and  similarly  treated.  If  in  the  second 
test  no  reaction  is  obtained,  a  third  portion  of  the  urine  is  treated 
with  sulphuric  acid  and  extracted  with  ether.  A  positive  reaction, 
when  the  ethereal  extract  is  tested  with  ferric  chloride,  the  color  dis- 
appearing upon  standing  for  twenty-four  to  forty-eight  hours,  indicates 
diacetic  acid,  particularly  if  the  urine  is  rich  in  acetone. 

Mineral  Constituents. — Sodium  chloride,  sulphuric  and  phosphoric 
acids,  and  the  ethereal  phosphates  are  abundant;  they  are  caused 
by  the  increased  amount  of  food  ingested.  The  oxalates  are  increased 
in  mild  cases.    Much  lime  is  excreted,  which  suggests  osseous  waste. 


910  CONSTITUTIONAL  DISEASES 

Pneumaturia. — The  butyric  acid  bacillus,  the  Bacillus  coli,  yeast 
fungus  and  other  bacteria  may  cause  fermentation  in  the  bladder, 
producing  carbon  dioxide,  hydrogen,  and  methane  gas, 

2.  Direct  Consequences  of  the  Glycosuria  and  Polyuria. — (a)  The 
exaggerated  thirst  (polydipsia)  is  always  secondary  to  the  polyuria. 
(6)  Nutrition  is  affected.  Much  sugar  is  lost  to  the  tissues;  two 
quarts  of  urine  with  5  per  cent,  of  sugar  produces  loss  of  400  calories, 
one-seventh  of  the  total.  Therefore  the  nutritive  requirements  are 
great,  the  appetite  is  excessive  (polyphagia)  and  in  severe  cases  emacia- 
tion and  fatigue  are  pronounced.  The  loss  of  sugar  must  be  met  by 
increase  in  albumin  and  fat.  Increase  in  weight  may  follow  reduction 
in  the  sugar.  The  temperature  in  uncomplicated  cases  is  subnormal 
from  inanition. 

3.  Complications. — Complications  and  other  symptoms  result  from 
various  causes:  (a)  the  sugar  in  the  blood,  (b)  impaired  nutrition  and 
lowered  physiological  resistance;  both  conditions  predispose  to  (c) 
infection,  particularly  by  the  bacillus  tuberculosis,  (d)  poisoning 
(acidosis),  and  other  ill-understood  conditions,  which  jpromote  degen- 
erations and  toxaemia. 

1.  Nervous. — (a)  Intellectual  depression;  insomnia,  headache  and 
neurasthenic  symptoms  are  common,  though  psychoses  are  less  fre- 
quent. In  rare  instances  focal  symptoms  may  develop  (as  in  uraemia) 
without  anatomical  findings.  Brain  symptoms  may  result  from  coin- 
cident syphilis,  arteriosclerosis,  etc.  (b)  Diabetic  coma  occurs  in  20 
per  cent,  and  causes  about  half  the  deaths  in  diabetes;  it  is  most  fre- 
quent in  youth,  and  in  acute  and  severe  types;  Naunyn  holds  that 
it  is  favored  by  a  strict  antidiabetic  diet.  All  cases  of  coma  which 
develop  in  diabetes  are  not  diabetic;  patients  may  succumb  (i)  to 
cerebral  apoplexy,  tuberculosis,  embolism,  thrombosis,  sepsis,  or 
urcemia,  (ii)  to  heart  failure,  which  may  cause  sudden  death,  or  coma 
with  death  after  a  short  time  or  (iii)  diabetic  coma  proper,  which  is 
probably  due  to  toxaemia  (acidosis),  and  closely  resembles  experi- 
mental acid  poisoning.  Most  writers  believe  that  ^^-oxybutyric  acid 
is  causal,  though  in  three  of  the  author's  cases  it  was  not  present 
in  the  urine  (Long).  Coma  is  imminent  when  the  daily  output  of 
ammonium  exceeds  45  grains  (3  gm.),  for  this  measures  the  acidosis. 
It  may  occur  suddenly  without  obvious  cause,  or  may  follow  severe 
exertion,  excesses,  excitement  or  gastro-intestinal  disorders.  In  some 
cases  there  are  prodromal  headache  vertigo,  stupor,  restless  anxiety  or 
symptoms  resembling  those  of  acute  alcoholism.  The  pupils  are 
dilated,  the  reflexes  abolished,  the  pulse  is  small,  and  averages  100 
to  120,  and  the  temperature  is  usually  subnormal.  Convulsions  are 
most  uncommon.  The  breath  has  the  wine-like  acetone  odor.  The 
breathing  is  characteristic;  inspiration  is  deep,  long-drawn  and  ener- 
getic and  expiration  is  short  and  slightly  sighing;  in  tliis,  Kussmaul's 
dyspnoea,  the  inspiratory  energy  contrasts  strongly  mth  the  general 
bodily  weakness;  respiration  may  be  normal  in  rate,  but  is  generally 
somewhat  accelerated;    there  is  no  stridor,  nor,  at  the  onset,  any 


DIABETES  MELLITUS  911 

cyanosis.  The  urine  is  generally  albuminous  and  almost  always  con- 
tains small  granular  casts  (Kiilz  and  Adelhof);  the  addition  of  a  few 
drops  of  ferric  chloride  gives  the  Burgundy  wine  color;  sugar  is 
present,  though  it  may  occasionally  disappear  as  the  coma  develops. 
Partial  consciousness  may  return,  but,  with  few  exceptions,  death 
occurs  within  a  few  hours  to  two  days,  with  subnormal  temperature, 
slowed  respiration  and  cardiac  weakness.  The  autopsy  reveals  no 
constant  brain  changes,  (c)  Degeneration  (toxsemic)  in  the  posterior 
columns  of  the  cord  may  develop,  (d)  The  peripheral  nerves  may  be 
affected.  Neuralgia  is  common  and  may  indicate  incipient  neuritis, 
or  may  appear  and  disappear,  varying  with  the  amount  of  sugar  in 
the  blood  and  urine.  It  is  often  an  early  symptom;  it  may  be  uni- 
lateral or  more  often  bilateral,  most  frequently  affects  the  sciatic 
nerves,  and  is  not  uncommonly  a  most  obstinate  and  recurrent  symp- 
tom. Neuritis,  as  a  general  rule,  occurs  in  the  severe  forms  of  diabetes, 
and  in  its  later  stages.  It  may  be  manifested  only  by  obstinate  neu- 
ralgia, painful  parsesthesia  in  the  legs,  muscular  cramps  or  in  30  to 
50  per  cent,  of  diabetics,  decrease  or  abolition  of  the  patellar  reflexes. 
Neuritis  may  involve  the  cranial  nerves,  mostly  the  abducens,  then 
the  oculomotor,  hypoglossus,  spinal  accessory  and  facial,  or  with 
greater  frequency  the  spinal  nerves;  the  lower  are  affected  more 
often  than  the  upper  extremities,  and,  like  diabetic  neuralgia,  bilateral 
involvement  of  the  crural  or  sciatic  nerves  is  the  most  common  type. 
Neuritis  may  be  single  or  multiple  (polyneuritis).  Its  symptoms  are 
those  of  neuritis  or  polyneuritis  (q.v.),  as  paralysis,  altered  sensation, 
abolished  reflexes,  reaction  of  degeneration  and  trophic  disturbances, 
as  falling  of  the  hair  and  nails,  glossy  skin,  and  perhaps  also  herpes 
or  perforating  ulcer  of  the  foot  {mal  perforant).  In  severe  cases  tabes 
issimulated,  pseudotabes  diabetica  (see  Multiple  Neuritis),  (e)  The 
special  senses  may  be  involved.  Retinal  diseases  occur  under  three 
forms:  (i)  albuminuric  retinitis,  accompanying  contracted  kidney; 
(ii)  retinitis  centralis  punctata  with  characteristic  small,  shining  central 
spots,  usually  with  hemorrhagic  points,  and  always  bilateral;  (iii)  the 
ordinary  hemorrhagic  type  (see  Plate  V,  Fig.  1).  Retinitis  occurred  in 
19  per  cent,  of  Galezowski's  114  cases.  Neuritis,  neuroretinitis  and 
retrobulbar  neuritis  with  consecutive  atrophy  are  progressive,  and  occur 
more  frequently  in  severe  than  in  mild  cases,  sometimes  as  early, 
sometimes  as  late,  complications.  Twenty  per  cent,  of  diabetics  with 
retinitis  die  within  one  year,  and  60  per  cent,  live  over  two  years 
(Nettleship). 

Amblyopia  and  amaurosis  are  complications  of  early  diabetes,  and 
often  first  induce  the  patient  to  seek  medical  advice.  Paralysis  of  the 
ocular  muscles  occurs  in  7  per  cent,  of  cases;  accommodation  paralysis 
is  the  most  frequent  type,  and  then  that  of  the  external  rectus;  the 
most  probable  cause  is  neuritis;  Mauthner  assumes  that  there  is  a 
nuclear  hemorrhage.  Cataract  occurs  in  4  per  cent,  of  cases.  Other 
ocular  changes  are  rare.     Aural  comphcations  include  external  fur- 


912  CONSTITUTIONAL  DISEASES 

uncles  and  otitis  media,  which  has  a  tendency  to  hemorrhage  and 
diffusion,  as  mastoiditis. 

2.  Circulatory. — (a)  The  blood  may  become  somewhat  concen- 
trated, for  much  water  is  required  to  eliminate  the  sugar;  the  amount 
of  sugar  (normally  0.1  to  0.15  per  cent.)  is  increased  in  diabetes  to 
0.3  or  0.5  per  cent.  Fat  in  the  blood  (lipsemia)  is  a  frequent  finding; 
what  appears  to  be  fat  is  sometimes  albumin  (Futcher)  or  cholestearin 
in  combination  with  fatty  acids;  Frazer  in  one  case  found  14  per 
cent,  of  fat.  Bremer's  test  is  based  on  changes  in  the  haemoglobin; 
thick  smears  of  blood  are  made  on  a  slide,  which  is  heated  and  treated 
with  1  per  cent,  congo  red  solution  for  two  minutes;  diabetic  blood 
will  not  stain,  but  the  control  slide  of  normal  blood  stains;  this  reac- 
tion, according  to  Bremer,  often  results  during  remissions  in  the 
glycosuria  and  in  the  preglycosuric  stage;  it  sometimes  occurs  in  other 
conditions,  as  Hodgkin's  disease.  Williamson's  test  is  based  on  the 
fact  that  diabetic  blood  decolorizes  a  weak  alkaline  solution  of  methyl 
blue.  It  is  as  follows:  20  c.c.  of  blood,  40  c.c.  of  distilled  water,  and 
1  c.c.  of  1  to  6,000  aqueous  solution  of  methylene  blue  are  added  to 
40  c.c.  of  liquor  potassse,  and  are  placed  in  test-tubes  in  a  beaker 
of  water,  which  is  boiled  for  four  minutes;  the  blue  color  disappears. 
The  alkalescence  of  the  blood,  which  is  reduced  in  various  conditions 
of  inanition,  is  greatly  lessened  in  diabetes,  particularly  when  /?-oxy- 
butyric  acid  engages  the  ammonium  and  other  salts  and  when  coma 
develops.  (6)  The  arteries  are  frequently  sclerosed  in  diabetes. 
Arteriosclerosis  causes  many  common  symptoms,  as  cardiac  hyper- 
trophy or  dilatation,  angina  pectoris,  cardiac  asthma,  hemiplegia, 
albuminuria,  senile  gangrene,  and  intermittent  claudication.  (c) 
The  heart  may  be  altered  in  various  ways  (v.s.).  Hypertrophy  occurs 
in  about  10  per  cent,  and  is  less  ominous  than  atrophy,  which  occurs 
in  uncomplicated  diabetes  of  the  young.  Heart-failure  may  occur 
after  moderate  exercise,  or  may  develop  precipitately,  ending  in  coma 
or  asphyxia  and  correctly  separated  by  Frerichs  from  genuine  diabetic 
coma.  Von  Noorden  observed  five  instances  of  sudden  death  in  140 
fatal  cases.  "Functional  heart  symptoms"  occur  in  10  per  cent,  of 
cases.  The  pulse  is  usually  accelerated,  and  its  tension  is  elevated. 
Cardiac  or  renal  dropsy  is  uncommon  in  diabetes. 

3.  Respiratory. — (a)  Tuberculosis  is  most  frequent  in  the  poor 
classes,  and  in  the  young,  but  much  less  so  in  older,  obese  and  gouty 
subjects ;  about  25  per  cent,  of  diabetics  contract  tuberculosis.  Haemop- 
tysis is  very  rare  (Seegen  and  Leyden);  the  sputum  is  abundant; 
it  is  usually  stated  that  the  tubercle  bacilli  are  scant  or  absent;  in 
the  secondary  necrosis,  to  which  all  diabetic  tissues  are  prone,  the 
marked  clinical  and  pathological  lung-findings  may  sharply  contrast 
with  the  small  number  of  tubercle  bacilli  found  in  the  sputum.  The 
course  is  rapidly  fatal.  (6)  Gangrene  is  much  less  common  than 
tuberculosis.  Fever,  pulmonary  hemorrhage,  and  purulent  sputum 
are  common.     Foetor  is  less  conspicuous  than  in  other  forms  of  pul- 


DIABETES  MELLITUS  913 

monary  gangrene,     (c)  Intercurrent  pneumonia  may  develop,  and  is 
usually  fatal. 

4.  Digestive. — (a)  The  mouth  is  generally  dry  and  acid  (from 
decomposition  of  sugar);  the  saliva  is  scanty  and  poor  in  ferment; 
stomatitis  is  common,  and  the  growth  of  aphthae  is  promoted  by  the 
acid  reaction  of  the  mouth,  though  it  is  preventable  by  cleanliness. 
The  teeth  may  decay  from  alveolar  periostitis  or  drop  out  from  tropho- 
neurotic changes,  (h)  The  stomach  is  affected  with  remarkable  infre- 
quency,  considering  the  oral  findings,  and  the  polyphagia.  Marked 
anorexia  is  uncommon,  though  the  patient  may  refuse  fatty  and 
nitrogenous  food.  The  stomach  is  usually  dilated,  (c)  The  bowels 
are  generally  costive.  Schmitz  claims  that  obstinate  constipation  pre- 
disposes to  coma,  though  in  the  author's  experience,  most  diabetics 
are  constipated.  Intestinal  or  gastro-intestinal  catarrh  sometimes  seems 
to  precipitate  coma,  but  it  may  be  merely  an  associated  symptom. 
(d)  The  liver  is  usually  enlarged  (hypersemia  and  fatty  degeneration), 
and  sometimes  tender.  Gall-stones  are  concomitants  in  10  per  cent, 
of  cases,  according  to  Bouchard,  but  Naunyn  is  correct  in  denying 
that  they  have  any  intrinsic  relationship  to  diabetes.  French  authors 
(Hanot  and  Chauffard)  have  described  a  pigmentary  cirrhosis  in 
diabetes  (diabete  bronze),  which  has  already  been  referred  to  under 
Ijiver   cirrhosis,   and   chronic   pancreatitis;     this   syndrome   probably 

/develops  in  the  following  sequence:  (i)  haemolysis,  (ii)  pigment  deposit 
in  the  liver,  pancreas,  and  skin  from  the  altered  blood  (haemochroma- 
tosis),  (iii)  chronic  interstitial  inflammation,  chronic  hepatic  cirrhosis, 
and  (iv)  chronic  pancreatitis,  causing  diabetes,  (e)  Pancreatic  symp- 
toms are  few,  because  the  external  pancreatic  secretion  is  essentially 
normal,  and  only  the  internal  glycolytic  secretion  is  affected. 

5.  Genito-urinary. — (a)  Albuminuriamay  be  present  (see  Urine). 
The  kidneys  are  frequently  hypertrophied  and  hyperaemic;  various 
degenerations  may  be  noted,  including  Ehrlich's  glycogenic  degener- 
ation. Interstitial  nephritis  may  follow  and  replace  diabetes,  chiefly 
in  gouty  and  corpulent  individuals.  (6)  Cystitis  is  not  rare;  the  urine 
may  actually  ferment  in  the  bladder,  just  as  it  readily  decomposes 
in  the  urinal;  this  may  lead  to  pyelonephritis  or  pneumaturia  (v.s.). 
Cystitis  may  cause  temporary  disappearance  of  the  glycosuria,  (c) 
In  the  female,  menstruation  may  be  disturbed  or  suspended.  The 
sexual  inclination  is  usually  lessened  in  severe  cases,  but  may  be 
increased  in  mild  cases  from  genital  pruritus  (v.i.).  Conception  may 
occur  even  in  advanced  cases,  but  in  33  per  cent,  there  is  spontaneous 
abortion  or  premature  delivery.  In  severe  diabetes  interruption  of 
pregnancy  is  indicated,  but  care  must  be  taken  that  diabetes  gravi- 
darum is  not  confused  with  lactosuria;  the  maternal  danger  in  unin- 
terrupted pregnancy  is  great,  from  exacerbation  of  the  disease,  coma, 
collapse  and  infection,  though  Stengel  has  recently  concluded  that  the 
danger  is  overdrawn.  Fungi  readily  develop  about  the  labia  and 
vagina;  this  is  promoted  by  lessened  general  resistance  and  local 
contact   with  the  saccharine  urine.     Aphthae,  leptothrix  and   other 

58 


914  CONSTITUTIONAL  DISEASES 

parasitic  deposits  are  frequent,  particularly  in  careless  subjects;  pru- 
ritus pudendorum,  vulvitis,  vaginitis,  urethritis  (which  may  simulate 
gonorrhoea),  furunculosis  and  even  gangrene  may  develop,  (d)  In 
the  male,  the  sexual  appetite  may  be  increased  early  in  the  disease 
but  later  is  replaced  by  impotence,  which  is  probably  due  to  spinal 
degeneration.  Phimosis,  balanitis,  small  erosions  near  the  urethra, 
urethritis,  itching  at  the  meatus  causing  tenesmus,  curious  nodes  in 
the  corpora  cavernosa,  furuncles  and  necrosis  may  first  engage  the 
physician's  attention.  Genital  symptoms  in  men  are  less  conspicuous 
than  in  women. 

6.  Cutaneous. — The  skin  is  dry,  rather  harsh  and  itches  when 
there  is  much  polyuria  and  emaciation.  Sugar  is  said  to  be  present 
when  the  patient  sweats.  Itching  is  caused  by  toxaemia  irritating  the 
cutaneous  nerves,  as  in  ursemic  and  cholsemic  pruritus.  Skin  eruptions 
include  pityriasis  tabesentium,  urticaria,  erythema,  eczema,  bullae, 
acne,  purpura  and  herpes.  Infection  is  favored  by  reduced  physio- 
logical resistance  and  possibly  by  hyperglycsemia;  furunculosis  (10  to 
25  per  cent.)  is  due  largely  to  the  staphylococcus,  and  may  initiate 
lymphangitis,  phlegmon  or  gangrene;  erysipelas  is  promoted  by  re- 
duced general  and  local  resistance.  Gangrene  is  most  frequent  in 
late  or  middle  life,  and  in  mild  cases;  it  usually  begins  on  the  toes 
and  extends  upward,  either  as  dry  or  moist  gangrene;  it  is  said  to 
result  from  obliterating  endarteritis,  but  in  the  writer's  experience, 
occurs  three  times  less  frequently  than  the  ordinary  plaque-like  ather- 
oma. Unfortunately  gangrene  is  usually  progressive.  Wounds  in 
diabetics  heal  better  than  in  pre-antiseptic  times,  but  delayed  healing, 
infection,  and  gangrene  are  still  frequent.  Enlargement  of  the  lym- 
phatic glands  is  seldom  absent  in  severe,  progressive  forms  with  ema- 
ciation ;  the  glands  are  hard,  painless,  and  probably  secondary  to  skin 
infection  or  irritation. 

Course  and  Prognosis. — The  onset  may  be  acute  or  chronic,  and 
the  course  may  be  short  (covering  weeks)  or  protracted  and  remittent 
(covering  twenty  years  or  more).  Various  complications  modify  the 
duration  and  outcome.  Von  Noorden's  summary  of  the  general 
prognostic  signs  covers  the  ground  completely.  Favorable  signs  are: 
(a)  onset  late  in  life;  (b)  long  duration  prior  to  the  time  of  obser- 
vation, with  no  grave  complications  nor  any  considerable  emaciation; 
(c)  traumatic  causation;  (d)  syphilitic  origin;  (e)  the  occurrence 
invariably  of  mild  forms  of  diabetes  in  the  family  of  the  patient;  (/) 
precedent  and  co-existent  obesity;  (g)  co-existent  uric  acid  diathesis; 
(h)  slight  glycosuria  and  tolerance  of  moderate  amounts  of  carbo- 
hydrates; (i)  marked  oscillations  and  increasing  tolerance  of  carbo- 
hydrates; (j)  circumstances  which  permit  of  dietetic  and  general 
hygienic  prescriptions.  Unfavorable  prognostics  are:  (a)  onset  in 
early  life,  especially  in  childhood;  (6)  great  loss  of  strength,  despite 
a  brief  duration  of  the  diabetes;  (c)  a  history  of  severe  forms  in  the 
family;  (d)  early  appearance  of  grave  secondary  diseases  and  com- 
plications;   (e)  a  high  degree  of  glycosuria,  with  complete  intolerance 


DIABETES  MELLITUS  915 

of  carbohydrates;  (/)  excretion  of  /?-oxybutyric  acid;  coma;  (g)  poor 
circumstances  which  render  impossible  the  dietetic  treatment,  or  the 
avoidance  of  bodily  and  mental  overwork. 

Diagnosis. — The  diagnosis  is  certain  only  when  the  urine  in  every 
case  is  examined  as  a  routine  procedure,  because  only  then  can  the 
lighter  cases,  which  are  amenable  to  treatment,  be  discovered.  In 
many  cases  the  thirst,  polyuria,  emaciation,  itching,  and  the  compli- 
cations per  se  are  suggestive.  Pentosuria;  16  familial  or  hereditary 
cases  are  recorded.  Pentose  reduces  Fehling's  solution,  even  after 
fermentation  of  the  urine.  Bial's  test  is  made  as  follows:  a  small 
amount  of  the  following  solution,  orcin  1  gm.,  liq.  ferri  chloridi  25 
drops,  and  30  per  cent,  hydrochloric  acid  in  500  c.c.  of  water,  is  heated 
to  boiling,  and  added  to  the  urine  which  turns  green  if  pentose  is 
present. 

Treatment. — 1.  Diet.— Regulation  of  diet,  dating  from  Rollo  one 
century  ago,  is  the  most  essential  point.  The  carbohydrates  normally 
supply  nearly  half  the  bodily  requirements  for  food  and  energy.  The 
diabetic  loses  a  large  part  by  their  escape  through  the  kidneys.  Further- 
more, their  ingestion  implies  a  waste  of  digestive  energy,  an  irritation 
of  the  tissues  by  the  unused  sugar,  and  a  growing  decrease  of  the 
tolerance  of  the  tissues  for  them.  A  man  weighing  70  kilograms 
(150  lbs.)  requires  a  diet  representing  2,500  calories,  {.  e.,  roughly  35 
calories  for  each  kilogram.  The  dietary  must  therefore  regard  not 
merely  the  glycosuria,  but  the  maintenance  of  body-weight  and  energy. 
It  is  useless  to  suppress  the  symptom,  glycosuria,  when  the  patient 
emaciates.  The  object  in  view  is  to  limit  the  carbohydrates,  and 
replace  them  with  albumin  and  fat.  Naunyn  and  Weintraud  have 
proven  that  exclusion  of  carbohydrates  for  some  weeks  increases  the 
tolerance  for  carbohydrates  taken  afterward;  i.e.,  the  "sugar-con- 
suming function"  is  rested  and  in  part  restored. 

General  Outlines  of  Dietary. — Explicit  written  directions 
should  be  given  to  each  patient.  All  diabetics  may  eat  the  following 
foods:  meat,  the  muscular  parts  of  beef,  veal,  mutton,  and  game,  and 
the  tongue,  lung,  heart,  brain,  marrow,  and  sweet-breads;  also  fatty 
livers,  which  contain  but  little  glycogen;  meat  peptones,  somatose 
and  kindred  preparations,  gelatin,  and  meat  jellies;  fish,  caviar,  cod- 
liver  oil,  clams,  oysters,  lobsters,  and  crabs;  eggs  (10  to  20  per  cent, 
of  fat);  animal  and  vegetable  fats,  bacon,  suet,  olive  oil,  cocoa  butter; 
butter  contains  85  per  cent,  fat,  and  should  be  used  on  meats,  eggs,  or 
spinach  or  melted  in  milk;  rich  cream;  all  cheeses  (3  to  30  per  cent, 
fat),  especially  Swiss  varieties;  vegetables,  cress,  tomatoes,  cabbage, 
cauliflower,  sprouts,  artichokes,  mushrooms,  truffles,  olives,  onions, 
garlic,  celery  leaves,  lettuce,  cucumbers  and  radishes;  of  fruits,  only 
whortleberries,  young  raspberries,  and  green  gooseberries  should  be 
eaten,  though  fruit  sugar  (levulose)  is  better  tolerated  than  starch 
or  cane-sugar.  Desserts,  (souffles)  of  eggs,  gelatin,  and  lemon;  tea, 
coffee,  diabetic  cocoa  (Rademann's)  and  von  Hoevel's  saccharin 
chocolate,  may  also  be  taken. 


916  COXSTITUTIOXAL  DISEASES 

To  some  cases,  and  in  definite  amounts,  von  Xoorden  allows  the 
following  (after  determining  the  limit  of  tolerance,  as  outlined  under 
Urixe  [glycosuria,  v.s.]) ;  beans  and  peas  (oj);  turnips,  carrots,  celery 
bulbs,  wax  beans  (5j);  radishes  (5j);  walnuts  6;  hazel-nuts  10;  al- 
monds 8;  (no  chestnuts);  apples,  pears,  apricots,  peaches  (gj  toij); 
berries  (gss  to  j);  cooked  apples,  plums,  pears,  peaches,  cherries 
(3j);  milk  (8  to  9  §),  (of  which  many  practitioners  allow  a  larger 
measure). 

Gradual  ivitMraical  oj  carbohydrates  is  tolerated  better  than  abrupt 
restriction.  Glutin  flours  differ  but  little  from  ordinary  flours  in  their 
percentage  of  starch.  Aleuronat  flour  contains  but  half  the  starch 
of  ordinary  flour.  Von  Mehring  believes  that  fat  is  best  absorbed 
when  some  carbohydrates  are  given  T\-ith  it.  If  some  starch  can  be 
given,  Mosse  prefers  to  allow  potatoes  which  are  more  easily  assimi- 
lated and  contain  but  16  to  24  per  cent,  of  starch  (bread  contains  55 
per  cent.).  Ingestion  of  more  than  5  ounces  of  butter  daily  may  in- 
crease the  ^-oxybutyric  acid,  but  even  7  ounces  may  be  taken  if  the 
butter  is  carefully  washed  in  cold  water,  which  extracts  the  lower 
fatty  acids  (von  Xoorden).  Saccharin  should  be  used  in  place  of 
sugar,  gr.  iss  daily;  it  is  280  times  as  sweet,  and  is  antifermentative, 
but  an  excess  may  occasion  dyspepsia.  Xaun}Ti  ad\dses  an  occasional 
fast  day,  and  Austin  Fhnt  kept  his  cases  in  bed,  and  without  food 
from  Saturday  night  until  ^Monday  morning.  As  the  disease  is  event- 
ually progressive,  a  schematic  diet  should  not  be  insisted  upon; 
reasonable  restriction,  with  occasional  dietetic  treats  is  less  often  vio- 
lated by  the  diabetic,  who  is  always  hungry  for  bread  and  potatoes. 
The  patient's  weight,  color  and  strength  are  of  more  significance  than 
the  urine.  Though  alcohol  is  a  protoplasmic  poison,  it  aids  in  the 
absorption  of  fat,  prevents  tissue  waste,  contributes  energy  and  heat, 
and  is  a  nervous  sedative  and  cardiac  tonic. 

Special  diabetic  treatment  oj  the  individual  jorms  (according  to  von 
X'oorden);  (a)  mild  jorms  oj  glycosuria.  In  elderly  persons  it  is  not 
necessary  to  determine  "^^th  great  accuracy  the  sugar  tolerance.  The 
patient  may  eat  bread,  potatoes  and  vegetables  according  to  his  desire, 
for  the  quantity  of  sugar  (1  to  2  per  cent.)  in  the  urine  is  usually 
insignificant.  The  older  the  patient  and  the  more  corpulent,  the  more 
careful  should  the  physician  be  about  reducing  the  body-weight;  fatty 
foods  should  be  increased,  butter  being  used  freely  on  bread,  potatoes, 
vegetables  and  meat;  and  the  patient  should  have  bacon,  eggs,  fatty 
cheese,  light  wine,  coffee,  tea  and  carbonated  water  (total  of  one  to 
one  and  a  half  pints).  Muscular  exercise  is  essential,  but  should  be 
regulated  according  to  the  bodily  strength  and  condition  of  the  heart. 
A  course  at  Carlsbad  is  beneficial  for  obesity,  gout  or  mild  circulatory 
weakness.  In  young  persons,  carbohydrates  should  be  given  with 
much  greater  caution,  as  carelessness  in  diet  is  more  frequent,  and  the 
glycosuria  more  often  progressive.  The  limits  of  tolerance  for  carbo- 
hydrates should  be  closely  watched.  All  carbohydrates  must  be  for- 
bidden excepting  bread  and  potatoes,  in  addition  to  which  the  patient 


DIABETES  MELLITUS  917 

should  have  the  following  articles:  2  ounces  of  butter,  wdth  bread, 
cheese,  and  potatoes  (480  calories) ;  2  eggs  (150  calories) ;  3  to  4  ounces 
of  olive  oir^dth  salad,  cucumbers,  etc.  (90  calories);  1  ounce  of  fatty 
cheese  (115  calories);  1  quart  of  milk  (590  calories);  and  one  ounce 
alcohol  (210  calories);  meats,  v.s.  (b)  Moderately  severe  forms 
embrace  cases  in  which  the  excretion  of  sugar  is  arrested  or  reduced 
to  small  amounts  (1  to  2  per  cent.)  only  by  total  abstinence  from 
carbohydrates.  The  rise  or  fall  of  the  tolerance  limit  should  be 
watched  every  month,  and  every  four  or  six  months  all  carbohydrates 
must  be  withdrawn  for  three  weeks.  The  diet  must  contain  much 
fat;  butter,  3  to  4  ounces  (890  calories)  must  be  weighed  out  every 
morning,  and  eaten  on  bread,  vegetables,  meat,  fish,  etc.,  either  in 
solid  form  or  melted.  Olive  oil,  two-thirds  of  an  ounce  (186  calories) 
should  be  taken  on  salad  (lettuce,  chicory,  cress,  cucumbers,  tomatoes, 
red  cabbage),  and  the  same  amount  as  mayonnaise  dressing  for  salad, 
cold  meat,  fish,  lobster,  etc.  Bacon,  two-thirds  of  an  ounce  (140  calories), 
5  eggs  (390  calories),  and  one  ounce  of  brandy  (280  calories)  should 
be  given.  In  addition  the  patient  should  have  meats,  and  some  of 
the  articles  mentioned  in  the  conditional  list  under  general  diet,  (c) 
In  severe  forms,  despite  a  continued  rigid  diet,  sugar  is  constantly 
excreted.  These  cases  usually  occur  in  early  life  with  emaciation, 
frequent  complications  and  a  fatal  issue  after  a  few  months  or  years. 
Careful  dietetic  treatment  may  retard  the  progress  of  the  disease, 
prevent  complications,  and  delay  the  fatal  issue.  The  dietetic  treat- 
ment is  the  same  as  in  moderately  severe  cases.  Carbohydrates  aggra- 
vate the  diabetes,  but  cannot  be  wholly  interdicted.  Less  starch  and 
more  fats  and  alcohol  are  given  than  in  other  cases. 

2.  General  Treatment. — Zimmer  demonstrated  the  value  of  (a) 
exercise  in  lessening  glycosuria,  but  as  in  obesity,  we  have  to  deal  with 
an  added  factor,  the  improved  appetite.  The  condition  of  the  heart 
must  govern  the  amount  of  exercise  to  be  taken  as  Frerich  early  noted 
that  fatal  syncope  and  diabetic  coma  may  occur  after  exhausting 
exertion.  (6)  The  mouth  and  skin  require  special  attention.  Clean- 
liness averts  in  large  part  gingivitis,  furunculosis  and  genital  com- 
plications. Frequent  warm  (not  cold)  baths  and  change  of  underwear, 
gentle  brushing  of  the  teeth  and  soothing  salves  for  eczema  and 
similar  eruptions  are  imperative,  (c)  Diabetics  for  the  most  part 
should  be  kept  at  home  and  at  work,  for  they  often  become  restless 
and  desire  to  wander.  A  prolonged  stay  in  a  quiet  place  is  better 
than  travel.  Sea  bathing  and  exposure  to  cold  and  dampness  are  to 
be  avoided,  (d)  Suggestive  treatment  may  often  be  combined  with 
the  dietetic  and  medicinal  therapy  in  depressed  subjects,  particularly 
in  neurotics,  (e)  Mineral  springs  are  suitable  only  for  mild  cases  and 
those  with  obesity,  gout  and  slight  circulatory  disturbance,  in  whom 
there  is  increased  tolerance  for  carbohydrates.  Carlsbad  and  other 
spas  are  contra-indicated  in  severe,  youthful,  very  aged,  reduced  and 
nephritic  cases.  (/)  The  mode  of  life  should  be  quiet,  and  avoidance 
of  excesses  is  indicated. 


918  CONSTITUTIONAL  DISEASES 

3.  Treatment  of  Complications. — (a)  Tuberculosis  is  the  most  serious 
complication.  The  liberal  diet,  necessitated  by  tuberculosis,  is  contra- 
indicated  by  glycosuria.  A  low  altitude  and  mild  climate  should  be 
selected.  (6)  Gastro-intestinal  catarrh  often  precipitates  diabetic  coma. 
As  in  infantile  disorders,  starvation  for  one  or  two  days  is  more  effi- 
cient than  attempts  at  intestinal  disinfection ;  only  boiled  water  should 
be  given;  alcoholic  stimulation  is  often  indicated  when  there  is  ex- 
haustion, red  wine  acting  as  a  stimulant  and  astringent,  (c)  Con- 
stipation (q.v.)  should  be  relieved  by  rhubarb  and  sodium  bicarbonate; 
severe  purges  must  be  avoided,  {d)  Nervous  symptoms  of  the  neur- 
asthenic order  are  observed  in  neurogenous  diabetes ;  sodium  bromide, 
opium,  codeine  or  acetanilide  may  be  indicated.  Of  all  remedies,  opium 
alone  exerts  an  appreciable  influence  upon  the  glycosuria;  it  was 
recommended  by  Dobson  (1774);  its  affects  are  observed  more  in 
the  severe  than  in  the  light  type,  i.e.,  it  decreases  the  transformation 
of  albumins  into  sugar,  but  does  not  control  the  transformation  of 
carbohydrates  into  sugar;  the  average  dose  may  be  gradually  increased 
without  the  patient  exhibiting  toxic  symptoms,  or  suffering  from  its 
reduction  afterward.  Codeine  may  be  given  in  doses  of  gr.  j  to  x, 
though  it  is  seemingly  less  effective  than  opium;  it  may  be  combined 
with  sodium  bromide  5ss.  Inunctions  of  mercury  are  seldom  valuable, 
but  are  indicated  when  cerebral  or  pancreatic  syphilis  is  suspected. 
(/)  Neuralgia  and  neuritis  should  be  treated  dietetically;  the  salicy- 
lates, salol  and  aspirin  may  benefit  mild  cases  as  well  as  somewhat 
modify  coincident  gout  or  intestinal  fermentation.  (g)  Acidosis, 
acetonsemia,  and  diabetic  coma  are  serious  complications.  Acidosis 
is  said  to  be  promoted  by  a  rigid  dietary  (Naunyn,  von  Mehring); 
in  pronounced  acidosis  even  von  Noorden,  who  opposed  Naunyn's 
view,  recommends  an  oatmeal  diet,  with  butter  aa  §viij  at  frequent 
intervals;  he  adds  eggs  to  this  dietary  which  is  preceded  for  a  few 
days  by  a  vegetable  diet.  Some  writers  would  also  exclude  fats. 
Sodium  bicarbonate  and  sodium  citrate  5ij  to  §iij,  t.i.d.,  and  calcium 
carbonate  3]  once  or  twice  a  day  may  possibly  postpone  threatening 
coma.  Much  water  should  be  given  by  mouth,  by  rectum  or  sub- 
cutaneously  with  sodium  carbonate  §iss  to  Oij.  Developed  coma  is 
practicably  incurable.  Oxygen  inhalations,  alcoholic  stimulation, 
strychnine,  mild  laxatives  (not  drastics)  and  subcutaneous  or  intra- 
venous injections  are  given,  but  rarely  with  success,  (h)  Gangrene 
should  be  treated  expectantly  until  there  is  a  possible  halt  in  the 
process,  and  definite  demarcation;  positive  rules  of  treatment  are 
laid  down  with  difficulty.  In  personal  experience,  advanced  diabetics 
stand  operative  shock  and  anaesthesia  poorly.  Most  of  them  have 
died  from  alarmingly  rapid  syncope  or  from  typical  dyspnoeic  coma. 
Other  operations  may  be  performed,  when  indicated  as  absolutely 
necessary  life-saving  procedures,  and  only,  if  possible,  after  strict 
dieting.    Boils,  furuncles,  etc.,  are  treated  expectantly. 


DIABETES  INSIPIDUS  919 


(B).  DIABETES  INSIPIDUS. 

Definition. — A  chronic  malady  characterized  by  large  amounts  of 
urine  of  low  specific  gravity.  It  was  described  by  Willis  (1674),  who 
first  differentiated  between  diabetes  mellitus  and  insipidus  (without 
taste,  i.e.,  non-saccharine).  It  is  uncommon;  Eichhorst  observed 
7  cases  in  35,942  cases  (0.02  per  cent.),  Futcher  7  in  403,535  (0.001 
per  cent.),  and  55  occurred  in  113,600  in  the  Berlin  Charite  (0.048 
per  cent.). 

Etiology. — Two  groups  of  cases  are  observed:  (a)  the  idiopathic 
(nervous  or  vasomotor)  and  (6)  the  symptomatic,  which  occur  in  (i) 
brain  disease,  especially  basal  syphilis  and  less  often  tumors  of  the 
medulla  and  the  floor  of  the  fourth  ventricle,  cerebral  traumatism, 
basilar  meningitis,  apoplexy,  hydrocephalus,  and  lesions  of  the  middle 
cerebellar  lobe  or  corp.  trapezoides  of  the  pons.  (It  is  possible  that 
the  kidneys  may  be  at  fault,  losing  their  power  to  concentrate  the 
urine.)  (ii)  It  may  result  from  abdominal  diseases,  aneurysms,  tumors 
or  tuberculous  peritonitis,  (iii)  Insolation,  diabetic  ancestry  (Trous- 
seau), malnutrition  (Ralfe)  with  tuberculous,  syphilitic  or  gouty 
antecedents,  acute  infections  and  alcoholism  are  numbered  among 
its  possible  causes.  Most  cases  occur  in  males.  In  Strauss'  collection 
of  85  cases,  10  per  cent,  were  under  five  years  old,  14  per  cent,  under 
ten,  and  45  per  cent,  were  between  ten  and  twenty-five  years  of  age; 
according  to  Jacobi,  25  per  cent,  occurs  under  ten  years.  Weil  col- 
lected 23  cases  among  91  individuals  of  four  generations,  all  of  whom 
enjoyed  good  health.    Congenital  cases  are  recorded,  but  are  rare. 

Symptoms. — The  onset  is  usually  gradual,  though  abrupt  symptoms 
have  followed  fright,  (a)  The  urine  is  greatly  increased;  a  secretion 
of  20  to  40  pints  daily  is  not  rare,  and  even  one  of  90  pints  is  on  record. 
More  urine  is  passed  at  night  than  by  day.  It  is  said  that  less  urine 
is  excreted  than  water  ingested.  It  is  passed  rapidly  after  ingestion 
of  water  (tachyuria).  Its  specific  gravity  ranges  between  1,000.5 
or  1,001  and  1,005.  It  is  pale  and  the  total  solids  are  usually  normal, 
though  sometimes  the  urea,  chlorides  and  phosphates  are  increased, 
being  washed  out  from  the  tissues.  Albumin,  sugar  and  inosite  are 
very  uncommon,  (b)  Polydipsia  is  secondary,  though  it  is  perhaps 
the  earliest  symptom  noticed.  In  one  case,  a  physician  with  brain 
syphilis,  2  gallons  of  water  were  drunk  each  night  between  10  p.m. 
and  7  a.m.  (c)  The  skin  is  dry;  carbuncles  are  rare.  The  saliva  is 
decreased.  The  appetite  is  usually  not  increased,  though  phenomenal 
polyphagia  marks  some  cases.  Nervousness,  headache,  irritability, 
increased  knee  jerks,  impotence  and  severe  lumbar  pain  radiating 
into  the  legs,  are  quite  frequent.  Nutrition  is  often  good  in  the  idio- 
pathic cases,  and  no  unusual  metabolic  findings  are  noted;  in  the 
symptomatic  variety  the  condition  of  nutrition  depends  on  the  causal 
disease;  in  children  growth  may  be  retarded.  The  temperature  is 
low  and  chilling  occurs  readily.     Aside  from  obvious  causal  lesions, 


920  CONSTITUTIONAL  DISEASES 

there  is  no  constant  autopsy  finding  except  hypertrophy  of  the  kidneys 
from  increased  activity,  and  sometimes  dilatation  of  the  bladder  and 
renal  pelvis. 

Diagnosis. — Diagnosis  is  easy.  Differentiation  is  required  (a)  from 
diabetes  mellitus,  with  which  it  has  no  common  symptoms  except 
polyuria  and  polydipsia;  there  is  no  glycosuria,  acidosis,  complicat- 
ing gangrene,  carbuncles,  or  neuritis;  ih)  from  interstitial  nephritis,  in 
which  the  specific  gravity  is  higher,  the  urine  is  less  abundant,  is 
albuminous  and  contains  casts,  and  which  is  associated  with  cardio- 
vascular, retinal  and  uraemic  manifestations;  (c)  from  primary  poly- 
dipsia with  secondary  polyuria,  which  is  exceedingly  rare;  and  (d) 
from  transitory  polyuria,  which  is  distinguished  by  its  course  alone 
as  well  as  by  its  obvious  etiology,  as  recent  fever,  hysteria,  resorption 
of  massive  exudates,  excessive  medicinal  diuresis,  and  transient  ure- 
thral obstruction  with  sudden  release  of  urine. 

Prognosis. — The  prognosis  is  obviously  more  favorable  in  idiopathic 
forms,  although  cerebral  syphilis  doubtless  causes  many  obscure  cases. 
Less  than  one-half  of  the  patients  recover,  though  death  results  less 
frequently  from  the  disease  itself  (save  cerebral  or  abdominal  tumors) 
than  from  intercurrent  infections,  notably  pulmonary  tuberculosis. 

Treatment. — Aside  from  antisyphilitic  therapy,  drugs  are  of  little 
use.  Iodides  benefit  some  cases  in  which  there  is  no  reason  to  suspect 
syphilis,  other  than  the  therapeutic  results.  Opium  may  be  useful, 
as  in  the  saccharine  form,  and  large  doses  are  often  well  tolerated. 
Valerian  (5j  of  the  root,  t.i.d.),  gallic  acid  (gr.  v  to  xx,  t.i.d.),  ergot 
(fluid  extract  ttj^xx,  t.i.d.),  sodium  bromide  (5ss  t.i.d.),  acetanilide 
(gr.  V  to  x,  t.i.d.),  and  electrotherapy  are  recommended.  Strychnia 
has  clearly  helped  some  cases.  Talquist  considers  a  vegetable  more 
efiicacious  than  a  meat  diet.  Posner  advocates  chewing  gum  which 
apparently  decreases  the  polyuria  and  polydipsia. 


(C).  GOUT. 

Definition. — An  obscure  metabolic  disease,  characterized  by  acute 
periodic  or  chronic  inflammation  of  the  joints  with  uratic  deposits. 

Mentioned  by  Hippocrates,  gout  was  clearly  described  by  Thos. 
Sydenham  (1683),  who  sufi^ered  from  the  affection  for  forty  years. 
Murray  Forbes  (1792),  and  Wallaston  (1797),  recognized  the  uratic 
nature  of  the  joint  deposits. 

Etiology. — 1.  The  actual  cause  is  unknown.  In  1848,  Garrod 
advanced  the  hypothesis  that  uric  acid  accumulated  periodically 
(before  the  gouty  seizure)  in  the  blood.  His,  Vogel,  and  Magnus  I^evy 
and  others  deny  Garrod's  statement,  and  maintain  that  uric  acid  in 
gouty  subjects  is  increased  all  the  time;  that  the  urine  contains  less 
uric  acid  before  and  more  during  and  after  the  seizure.  Pfeiffer 
holds  that  the  uric  acid  is  usually  decreased,  and  that  it  is  really  less 
a  question  of  its  amount  than  of  its  insolubility  or  form.     Againthe 


GOUT  921 

idea  is  advanced  that  uric  acid  is  not  produced  in  excess,  but  is  re- 
tained in  the  body  because  of  periodic  attacks  of  renal  insufficiency. 
Whether  the  real  metabolic  change  concerns  the  uric  acid,  the  alloxuric 
or  purin  bodies  is  yet  undetermined. 

2.  The  extrinsic,  predisposing  factors  are  somewhat  better  defined. 
(a)  Heredity  is  an  apparent  factor  in  50  to  60  per  cent.;  transmission 
by  the  father  is  more  common  than  by  the  mother,  and  the  younger 
rather  than  the  older  children  suffer  from  hereditary  influences.  (6) 
Mode  of  life;  lack  of  exercise,  over-eating,  an  almost  exclusively  meat 
diet,  and  alcoholism  are  potent  factors.  The  old  verse  said  that  "Wine 
was  the  father,  Eating  the  mother,  and  Venus  the  midwife"  of  gout. 
Though  often  true  that  gout  affects  the  well-to-do  (arthritis  divitum), 
and  arthritis  deformans  the  poor  (arthritis  pauperum),  gout  is  not 
uncommon  among  the  lower  classes.  As  alcohohsm  is  a  widespread 
scourge,  it  would  seem  that  the  heavy  ales  and  beers  of  England  and 
Germany  are  more  injurious  (in  this  respect)  than  whisky  and  light 
wine.  Gout  may  occur  in  temperate  individuals.  Obesity,  diabetes., 
arteriosclerosis,  and  calculous  tendencies  are  concomitant  or  coordinate 
rather  than  causal  conditions,  (c)  Lead  poisoning  is  observed  in  20 
per  cent,  of  cases  or  more,  particularly  in  England,  and  its  relation 
to  gout  is  puzzling,  though  saturnine  nephritis  may  explain  it.  (d)  Men 
are  particularly  prone  to  gout  (1  to  13  or  25).  (e)  Age.  Gout  begins 
between  thirty  and  forty  years  in  38  per  cent.,  and  thirty  and  fifty  in 
60  per  cent.  Much  less  than  1  per  cent,  of  cases  begin  before  the 
seventeenth  year,  though  Gairdner  observed  one  case  in  a  nursling. 
(/)  England  leads  in  frequency  of  its  occurrence.  In  the  United  States 
it  is  rare,  though  Futcher  shows  that  the  cases  in  Baltimore  and  London  • 
hospitals  stood  as  2  to  3  (certainly  not  true  for  other  American  cities) ; 
again,  relatively  few  cases  seek  hospital  treatment. 

S3nnptoms. — These  may  be  considered  under  two  captions,  (1)  acute, 
and  (2)  irregular,  chronic  and  visceral  gout. 

1.  Acute  (regular,  sthenic  or)  typical  gout  usually  appears  without 
prodromes,  though  an  attack  is  sometimes  heralded  by  digestive 
disorder  (pyrosis,  gastralgia,  constipation),  "cerebral  congestion" 
(insomnia,  vertigo,  tinnitus,  irritability,  depression),  paresthesia, 
cramps  or  pain  in  the  muscles,  dark  lateritious  urine  or  other  vague 
symptoms.  The  paroxysm  is  remarkably  characteristic,  (a)  Local 
findings:  The  patient  is  awakened  one  to  three  hours  after  midnight, 
by  an  agonizing  pain  in  the  metatarsophalangeal  joint  of  the  large 
toe  (podagra).  The  pain  is  described  as  crushing  by  a  \ise  or  like 
burning  by  a  hot  iron.  Localization  in  the  toe  is  so  frequent  (95  per 
cent.,  Garrod,  or  73  per  cent.,  Scudmore)  as  to  be  practically  diag- 
nostic of  gout.  The  skin  over  it  becomes  hot,  red,  tense,  slightly 
oedematous  and  exquisitely  sensitive.  Serum  exudes  into  the  joint. 
The  pain  abates  toward  morning,  but  the  inflammation  increases. 
Each  early  morning  sees  a  repetition  of  the  pain  for  three  to  five  or 
less  often  for  six  to  seven  days;  the  paroxysmal  pain  and  the  local 
findings  then  gradually  subside  by  lysis;    in  two-thirds  of  the  cases, 


922  CONSTITUTIONAL  DISEASES 

the  skin  desquamates  over  the  joint.  Later  attacks  may  involve  the 
thumb,  knee  and  other  joints,  though  less  commonly  than  in  chronic 
irregular  gout  (v.i.).  The  local  symptoms  vary  in  intensity;  as  a  rule 
the  shorter  the  attack,  the  severer  are  the  symptoms.  The  pathological 
changes  probably  develop  in  this  sequence:  (i)  local  stasis  (inflam- 
mation), (ii)  necrosis,  and  (iii)  uratic  deposit;  the  ordinary  urates 
(biurate  of  sodium  in  conjunction  with  sodium  phosphate)  do  not 
cause  such  local  reaction,  but  the  biurate  alone,  even  in  most  dilute 
solutions  (0.004),  produces  inflammation  (Pfeiffer);  acute  residual 
swellings  (acute  gouty  tophi)  consist  of  this  biurate  which  has  been 
precipitated  by  the  carbonates  of  the  blood  (and  tissues).  Conval- 
escence is  complete  in  ten  to  fourteen  days,  often  with  greatly  improved 
spirits  and  health  after  the  gouty  attack.  During  the  seizure  (b)  con- 
stitutional symptoms  are  not  absent.  The  temperature  rises  to  100.5° 
or  101°,  rarely  over  102°.  The  pulse  is  usually  slow  and  hard,  some- 
times arrhythmic  and  seldom  exceeds  100.  The  heart  may  palpitate. 
Furring  of  the  tongue,  slight  leukocytosis,  anorexia,  nausea,  vomiting, 
epigastric  cramping  and  eructations  are  not  uncommon.  The  urine 
is  dark,  usually  decreased,  acid,  and  higher  than  normal  in  specific 
gravity;  the  difference  of  opinion  regarding  uric  acid  has  been  men- 
tioned under  etiology;  Bain  and  Futcher  find  a  close  parallelism 
between  the  uric  and  phosphoric  acids,  both  being  derived  from  dis- 
integration of  nuclein;  they  both  fall  below  normal  in  the  quiescent 
period  and  increase  during  the  attack;  sometimes  the  indican  and 
urobilin  are  increased.  Garrod's  test  for  urates  in  the  blood,  exudates 
or  transudates,  consists  of  allowing  it  to  clot,  adding  10  drops  of  30 
per  cent,  acetic  acid  to  5ij  of  the  serum,  and  obtaining  the  crystals 
after  twenty-four  hours. 

Subsequent  acute  seizures  may  sometimes  be  averted  by  diet  and 
exercise,  but  they  are  likely  to  recur,  notably  in  the  spring  and  fall. 
Excesses  in  alcohol  or  in  eating  may  precipitate  acute  gout;  indeed 
in  one  case  it  would  occur  within  fifteen  minutes  from  drinking  a 
glass  of  champagne;  trauma,  exertion  or  excitement  may  favor  relapse. 

Retrocedent  or  suppressed  gout  was  once  thought  to  develop  when 
an  acute  paroxysm  abated  "too  rapidly";  many  symptoms  attributed 
to  it  are  doubtless  due  to  coincident  arteriosclerosis  or  uraemia  {e.g., 
gastralgia,  vomiting,  cardiac  pain,  dyspnoea,  delirium,  convulsions, 
apoplexy,  coma  and  death). 

2.  Chronic,  irregular,  atypical  gout  generally  follows  acute  attacks 
which  increase  in  frequency,  decrease  in  acuity  and  show  slight  ten- 
dency toward  resolution.  Pfeiffer  claims  that  gout  deposits  (tophi) 
cannot  occur  without  acute  attacks.  In  some  cases  it  appears  to 
begin  as  chronic  gout,  particularly  in  the  aged,  the  cachectic  and  in 
women  with  a  gouty  family  history,  all  of  whom  lack  reactive  power 
(atonic  or  asthenic  gout),  (a)  Local  findings:  there  is  less  pain,  fever, 
and  redness  but  greater  and  more  permanent  swelling  than  in  the 
acute  form,  until  the  condition  eventually  becomes  fixed  and  chronic; 
the  "attacks"  may  be  most  rudimentary,  and  remissions  may  alternate 


GOUT  923 

with  exacerbations.  The  lower  extremities  and  hands  are  most  often 
affected;  it  may  also  develop  in  the  thumb  (chiagra),  knee  (gonagra), 
elbow  (pechiagra) ,  and  spine  (rhachisagra) ,  but  the  shoulder  is  very 
seldom  and  the  hip  almost  never  invaded.  In  some  cases  its  moving 
from  joint  to  joint  (urarthritis  multiplex  seu  vaga)  may  cause  confusion 
with  acute  rheumatism.  Uratic  deposits  {tophi  arthritici)  form  in 
the  cartilage  and  later  in  the  capsule  and  ligaments,  and  the  swelling 
never  recedes  essentially.  These  prominences,  and  the  attendant 
fibrosis,  lead  to  deformation,  subluxation,  crackling  on  movement, 
ankylosis  and  contractures.  Sometimes  fluctuation  is  noted,  especially 
in  the  big  toe.  The  proximal  joints  of  the  fingers  may  point  to  the 
radial,  and  the  others  to  the  ulnar  side.  Tophi  may  rupture,  evacuat- 
ing yellow-white  urates,  though  incompletely,  as  they  are  partly  diffused 
through  the  tissues;  these  gouty  ulcers  heal  tardily,  if  at  all,  for  their 
basis  is  fibrous  and  but  slightly  granulating  tissue.  Tophi  occur 
also  on  the  ear  (25  per  cent.),  bursae,  tendons,  aponeuroses  (which 
may  explain  some  of  the  cases  of  Dupuytren's  palmar  contracture), 
and  even  in  the  skin,  eyelids,  nose,  larynx,  penis  or  scrotum.  (6) 
Visceral  gout  includes  a  curious  mixture  of  real  gouty  complications 
and  incongruous  doubtful  symptoms  ("gouty  disposition,"  arthritisme, 
herpetisme,  and  the  so-called  "uric  acid  diathesis"). 

Complications. — Renal  complications  are  the  most  important  visceral 
complications,  and  sometimes  dominate  the  clinical  features.  In  1,440 
cases,  Garrod  observed  albuminuria  in  26.5  per  cent.,  more  often  in 
advanced  than  in  early  cases.  Its  exact  relation  to  gout  is  hard  to  define; 
it  may  follow  the  metabolic  changes,  or  according  to  Ebstein  may  pos- 
sibly constitute  a  primary  gout.  At  first  albuminuria  may  be  con- 
sidered toxic,  marantic,  congestive  or  arteriosclerotic  but  later  the 
renal,  cardiovascular  and  retinal  findings  of  interstitial  nephritis 
develop  with  all  its  accidents  and  complications;  uratic  deposits 
occur  in  the  intertubular  tissue  and  sometimes  in  the  secreting  tissue 
of  the  cortex  and  medulla,  in  15  per  cent,  of  cases,  according  to  Moore. 
Uratic  deposits  (calculi)  are  not  uncommon  in  the  renal  pelvis;  haema- 
turia,  oxaluria,  pyelitis,  cystitis  (and  perhaps  urethritis)  may  also 
occur. 

Arteriosclerosis  of  the  ordinary  type  is  promoted  by  the  individual's 
mode  of  life,  by  metabolic  changes,  alcoholism,  plumbism  and  nephritis; 
it  develops  early  and  causes  many  (and,  with  nephritis,  most)  of  the 
so-called  visceral  gout  symptoms,  as  the  cerebrospinal  (headache, 
vertigo,  brain  congestion,  epileptiform  and  apoplectiform  attacks, 
encephalomaiacia,  myelitis),  the  circulatory  (cardiac  hypertrophy, 
myocarditis,  aneurysm,  angina  pectoris,  atheromatous  valvular  lesions, 
phlebosclerosis),  and  the  respiratory  symptoms  (stasis,  bronchitis, 
asthma),  and  retinitis. 

Eczema  (IS  per  cent.),  scleritis  and  episcleritis  (with  small  circum- 
scribed points  of  inflammation,  and  sometimes  semimicroscopic  tophi), 
neuralgia  or  less  often  neuritis,  lumbago,  sciatica  and  pain  in  the 
brachial  plexus,  burning  and  psoriasis-like  patches  on  the  tongue, 


924  CONSTITUTIONAL  DISEASES 

digestive  symptoms  (v.  Peodromes),  and  burning  in  the  eyeballs  are 
probably  often  gouty.  On  the  other  hand,  the  "gouty  disposition" — 
in  some  descriptions — consists  of  very  vague  symptoms;  on  analysis 
neurotic,  paroxysmal  (calculous  colic,  migraine  or  asthma),  and  other 
conditions  which  are  common  in  persons  not  suffering  from  gout, 
account  for  many  so-called  visceral  gouty  manifestations. 

Diagnosis. — (a)  Acute  gout  is  most  typical  in  its  etiology,  history 
and  localization,  with  acute,  circumscribed  redness.  In  a  few  cases 
(urarthritis  multiplex),  a  diagnosis  of  acute  articular  rheumatism  may 
be  made;  fibrous  rheumatic  nodes  may  be  confused  with  tophi,  but 
if  the  possibility  of  gout  is  recognized,  there  is  usually  no  error.  (6) 
Chronic  gout  often  has  a  history  of  acute  attacks,  usually  involves  the 
extremities  and  distal  joints  of  the  hands  and  feet,  is  marked  by  unequal 
distention  and  thickening  of  the  soft  parts,  and  is  often  known  by  its 
association  with  early  arteriosclerosis,  contracted  kidney,  obesity,  renal 
calculus  and  diabetes.  The  rc-rays  cannot  determine  the  diagnosis 
(see  Arthritis  Deformans,  Diagnosis).  Visceral  gout  is  an  entity 
only  when  it  develops  in  a  patient  who  is  undoubtedly  gouty. 

Prognosis. — Gouty  patients  may  live  to  an  old  age,  but  the  usual 
recurrence  every  two  months  to  two  years  gives  a  tendency  to  chronic 
gout,  of  which  the  issues  are  (a)  uraemia,  (b)  arteriosclerotic  compli- 
cations, as  coronary  disease  or  apoplexy,  (c)  terminal  infections  as 
pericarditis,  pneumonia,  and  pleurisy,  which  may  be  induced  by  the 
(d)  gouty  marasmus  or  cachexia.  In  general  the  outlook  is  better 
in  frank  gout  than  in  irregular  gout,  and  better  in  cases  which  develop 
after  forty  years  of  age. 

Treatment. — 1.  The  Acute  Paroxysm. — (a)  Absolute  rest  is  indi- 
cated. (6)  For  pain,  the  use  of  colchicum  is  empirical;  some  prac- 
titioners believe  that  it  increases  the  elimination  of  uric  acid,  though 
the  claim  that  it  enables  the  tissues  to  break  down,  and  dispose  of 
the  uric  acid  seems  more  reasonable;  nevertheless,  it  causes  the  dis- 
appearance of  uric  acid  from  the  urine  of  those  passing  it  in  quantities, 
and  in  gout  it  relieves  pain  and  inflammation  and  acts  as  a  cholagogue; 
5iss  of  the  vinum  colchici  radicis  (not  seminis)  should  be  given  daily. 
It  must  be  administered  with  care  in  nephritic  and  marantic  subjects. 
If  long  used,  a  tolerance  to  its  action  is  acquired.  It  should  be  stopped 
when  pain  is  alleviated  and  it  does  not  act  well  when  diarrhoea  inter- 
venes, which  interferes  with  its  diuretic  effect.  (Full  therapeutic  doses 
produce  a  slow  pulse,  nausea,  vomiting,  pain  and  purging;  inversely 
to  its  action  on  the  bowels  there  is  diaphoresis  and  diuresis.  It  is 
eliminated  by  the  kidneys,  bowels  and  skin.  After  toxic  doses,  great 
nausea,  retching,  serous  and  finally  hemorrhagic  purging,  great  pain, 
headache,  vertigo,  prostration,  paralysis  of  the  peripheral  sensory  nerves, 
motor  part  of  the  cord  and  finally  of  the  respiratory  centre  [the  usual 
cause  of  death]  develop ;  ecchymoses  of  the  gastro-intestinal  tract  with 
swelling  may  be  seen  at  the  postmortem  examination.) 

If  colchicum  produces  no  effect,  sodium  salicylate  should  be  given, 
gr.  XV  every  two  hours  (5j  to  ij  daily);   it  usually  relieves  the  pain 


GOUT  925 

and  swelling,  and  probably  aids  in  solution  of  the  uric  acid;  its  early 
effect  is  greatest,  and  it  usually  fails  after  the  second  or  third  day. 
Finally,  jphenacetin  (gr.  viij  to  x)  and  morphine  are  indicated  in  severe 
paroxysms.  In  prolonged  attacks,  potassium  iodide  gr.  v  (which 
should  be  given  with  care  in  nephritis),  and  wine  of  colchicum  ttjx  are 
useful,  (c)  The  diet,  according  to  Pfeiffer,  should  consist  of  foods 
which  "release  uric  acid  in  a  free  form,"  as  meal  soups,  rice  and 
other  carbohydrates;  meat  and  eggs  should  be  withheld  (though 
given  in  chronic  forms,  and  in  the  intervals  between  attacks).  Plain 
or  acid  water,  as  Seltzer  (not  alkaline  water  as  Vichy)  should  be  given 
freely;  alcohol  and  lemonade  must  be  forbidden.  If  laxatives  are 
indicated,  calomel,  rhubarb  or  castor  oil  should  be  used,  id)  Local 
measures  should  be  largely  avoided  lest  added  necrosis  and  tophi 
develop;  especially,  vesicants,  the  use  of  the  ice-bag  and  massage; 
warm  applications  of  50  per  cent,  alcohol  or  lead  water  (tinctura  opii, 
liquor  plumbi  subacetatis,  aaoij  and  water  §j)  may  be  used. 

2.  The  Interval  Between  Attacks. — (a)  Regulation  of  diet  is  the 
cardinal  indication.  Moderation  in  the  quantity  is  more  important 
than  the  quality  of  the  food.  Quantity:  a  full  diet  increases  the  uric 
acid,  taxes  resorption  which  is  usually  impaired,  and  favors  acid 
fermentations  which  engage  the  diphosphates  and  carbonates  of  the 
food  necessary  for  the  formation  of  soluble  uric  acid  salts;  three 
medium-sized  meals  a  day  are  allowed.  Quality:  (i)  alcohol  should  be 
absolutely  forbidden;  (ii)  water  may  be  given  freely,  little  with  the 
meals  but  large  amounts  on  an  empty  stomach,  (iii)  Moderate 
amounts  of  fat  are  allowed,  (iv)  Fruits  and  vegetables  increase  diuresis, 
and  their  malates  and  citrates  help  to  dissolve  the  uric  salts,  (v) 
Meats  are  allowed  (though  there  are  various  opinions  on  this  subject). 
The  urea  they  produce  seems  to  dissolve  uric  acid  which  the  meat, 
if  given  in  moderation,  does  not  increase.  Meat  is  essential  partic- 
ularly in  marantic  cases.  There  is  no  difference  between  the  effect 
of  light  and  dark  meats;  those  rich  in  nuclein  (sweet-breads,  liver, 
and  kidneys)  must  be  avoided,  (vi)  Carbohydrates  should  be  largely 
decreased;  this  rule  is  empirical,  though  it  appears  that  following 
their  ingestion  the  uric  acid  (as  compared  with  the  urea)  increases 
nearly  two-fold.  Milk  should  be  avoided,  for  its  lactic  acid  is  injurious. 
(6)  Exercise  is  indispensable,  but  prolonged  or  fatiguing  effort,  hurry 
and  worry  are  to  be  avoided,  (c)  M edicinal  treatment  is  rdiih^vsecond- 
ary.  Alkalies  produce  an  increased  output  of  uric  acid,  but  they 
operate  only  by  preventing  decomposition  of  the  neutral  (bi-)  sodium 
phosphate  (the  chief  uric  solvent).  The  kind  of  alkali  used  is  not 
essential;  lithium  carbonate  is  inferior  to  sodium  carbonate  or  bicar- 
bonate, which  act  first  by  promoting  the  formation  of  bisodium  phos- 
phate, and  second  by  neutralizing  the  acid  formed  by  fermentation; 
it  may  be  given  (in  doses  of  gr.  x  upward)  for  a  long  period  of  time, 
and  has  no  effect  on  the  blood;  but  the  twenty-four-hour  collection  of 
urine  should  not  become  alkaline  (lest  alkaline  deposits  in  the  renal 
pelvis  develop).     Mineral  waters  merely  operate  in  the  same  way,  as 


926  CONSTITUTIONAL  DISEASES 

those  of  Saratoga,  White  Sulphur,  and  Bedford  Springs  in  this  country, 
Bath  and  Buxton  in  England,  Aix-les-Baines,  and  Contrexeville  in 
France,  and  Fachingen,  Carlsbad,  Homburg,  Wildbad,  and  Teplitz. 
Luff  advises  the  use  of  guaiacum  resin,  gr.  v  to  x,  t.  i.d.  Piperazin, 
lysidin,  urotropin,  urosin  and  sidonal  are  much  inferior  to  the  simple 
sodium  salt. 

3.  Chronic  Gout. — This  is  difhcult  to  treat.  For  general  dietetic, 
hygienic  and  medicinal  measures,  see  above.  Colchicum  wine,  tr^x, 
and  potassium  iodide,  gr,  v  to  x,  may  relieve  the  condition  of  the 
joints  and  the  gouty  asthma,  neuralgia,  and  eczema.  Tonics,  prin- 
cipally arsenic,  are  indicated  in  marantic  forms.  Tophi  should  not  be 
operated  on;  local  measures  are  useless,  save  gentle  massage,  dry 
heat,  moist  applications  or  salicylate  salves  at  night  (ac.  salicylic.  4, 
lanolin  40,  and  oleum  terebinthinaj  1  part),  though  all  treatment 
generally  fails. 


(D).  ARTHRITIS  DEFORMANS  AND  CHRONIC  RHEUMATISM. 

After  excluding  gouty,  tuberculous,  syphilitic,  gonorrhoeal  and  hsemo- 
philic  affections,  there  remains  a  group  of  articular  affections  of  which 
the  chief  are  arthritis  deformans  and  the  so-called  chronic  rheumatism. 
It  is  almost  certain  that  a  number  of  totally  different  affections  are 
gathered  under  these  names.  Their  classification  is  most  unsatis- 
factory. 

Arthritis  deformans,  which  has  been  noted  in  Egyptian  mummies, 
is  a  progressive  or  at  least  chronic  affection,  marked  by  changes  in 
the  synovial  sac,  cartilages  and  bone,  causing  functional  disturbance 
of,  and  usually  deformity  in,  the  articulations,  usually  symmetrical 
and  polyarticular;  also  called  rheumatoid  arthritis,  and  chronic 
deforming  rheumatism. 

Etiology. — (a)  The  predisposing  factors  are  (i)  heredity,  which  is 
causative  in  from  2  (Charcot)  to  13  per  cent.  (Garrod);  (ii)  age;  55 
per  cent,  of  cases  occur  between  twenty  and  fifty  years  of  age;  5  per 
cent,  under  twenty  years  and  40  per  cent,  over  fifty  years  of  age  (Gar- 
rod);  (iii)  sex;  though  Stewart  and  McCrae  consider  that  the  sexes 
are  equally  involved,  Garrod  observed  82  per  cent,  in  women  (for 
the  disease  possibly  sustains  some  relation  to  the  genital  functions); 
(iv)  fatigue,  cold,  dampness,  poor  hygiene,  trauma  or  sorrow  may 
also  be  predisposing  factors. 

(6)  The  immediate  cause  is  unknown.  There  are  many  theories: 
(a)  the  neuropathic  theory  (Mitchell),  is  that  it  results  from  a  cord 
lesion;  this  is  now  nearly  abandoned;  (b)  the  infective  theory  is  based 
upon  finding  bacteria  in  the  joints,  enlarged  spleen  and  lymph  glands, 
and  its  occasional  development  after  influenza,  angina,  and  scarlatina ; 
ScheuUer  found  a  bacillus,  Chauffart  a  diplococcus,  and  Bannatyne 
and  Blaxall  have  described  microorganisms  of  inconstant  types;  (c) 
the  rheumatic  theory,  according  to  which  it  is  a  chronic  rheumatism; 


ARTHRITIS  DEFORMANS  AND  CHRONIC  RHEUMATISM       927 

Garrod  and  Bannatyne  find  few  heart  lesions,  though  Pribram  finds 
about  one-fifth  as  many  as  in  rheumatism. 

Pathology. — Whether  the  synovia  or  cartilages  are  first  involved  is 
undetermined;  the  a;-rays  do  not  solve  the  question;  practitioners, 
who  see  cases  early,  hold  that  the  serous  sac  is  first  affected,  and  sur- 
geons find  the  cartilage  most  often  diseased.  The  synovial  villi  hyper- 
trophy and  the  cartilage  slightly  fibrillates,  cleaves,  and  finally  atrophies. 
The  bone  becomes  thin  in  some  places  and  tuberous  in  others  (Hay- 
garth's  nodosities)  from  periosteal  proliferation;  the  joint  surfaces 
become  eroded  and  in  part  grow  together. 

1.  Diffuse  Progressive  Type. — (a)  The  acute  form  is  uncommon. 
There  is  some  fever,  rise  in  the  pulse  rate,  and  depression,  and  the 
joints  become  red  and  swollen,  resembling  in  some  ways  acute  artic- 
ular rheumatism,  but  differing  from  it  in  several  essential  points; 
that  is,  arthritis  deformans  is  less  fugitive,  involves  perhaps  the  small 
joints  more  frequently,  is  attended  by  less  sweating  and  very  seldom 
by  heart  complications,  does  not  react  to  salicylates  and  runs  a  much 
longer  course.  In  some  cases  it  has  even  resembled  typhoid,  because 
the  fever  and  splenic  enlargement  lasted  for  some  time  before  the 
joints  became  affected.  (6)  The  more  frequent  chronic  form  develops 
insidiously,  with  uncomfortable  sensations  in  the  joints,  pain  or  tear- 
ing nocturnal  pains  about  the  joints,  and  vasomotor  skin  symptoms. 
It  begins  most  often  in  the  small  joints  of  the  hands,  with  or  without 
swelling,  and  remits  and  recurs.    The  hands  often  sweat.    The  fingers 

Fig.  48. 


Rheumatoid  arthritis.     (Musser.) 

become  fusiform  from  changes  in  the  joints,  capsular  thickening  and 
collateral  oedema  which  separate  the  fingers  from  each  other.  The 
oedema  often  disappears,  showing  more  clearly  the  bone  and  the  cap- 
sule thickening.  The  cartilages  become  uneven  and  crackle  on  move- 
ment, loosened  villi  may  become  free  bodies,  and  the  adjacent  bursae 
and  tendons  may  become  swollen.  The  fingers  deviate  and  become 
angular  from  flattening  of  the  saddle-shaped  epiphyses  and  muscular 


928  COXSTITUTIOXAL  DISEASES 

contractures  (now  extensor  and  again  flexor  in  type).  Extension  to 
other  joints  occurs;  the  elbow  becomes  flexed,  the  shoulder  often 
crackles  and  becomes  fixed;  the  large  toe  is  bent  out,  and  lies  under 
the  other  toes  which  are  often  extended  at  their  first,  and  flexed  at 
their  two  distal  articulations;  the  ankle  is  often  abducted;  the  knee 
is  swollen,  shapeless  and  flexed  from  fluid  effusion  or  contracture; 
in  a  few  cases  the  hip,  jaw,  and  spine  are  involved. 

Motion  is  limited  by  the  swelling,  muscular  contractures,  fixation 
of  the  joints  by  interlocking  extracapsular  nodosities,  and  capsular 
induration.  The  contiguous  muscles  atrophy  from  disuse,  local 
inflammatory  invasion  or  reflex  influence  on  the  cord.  The  skin 
may  become  puffy,  glossy  or  even  atrophic.  The  reflexes  are  chiefly 
increased,  as  the  patellar  (in  80  per  cent.).  Neuritis  is  not  uncommon. 
In  64  cases  in  which  the  vertebrae  were  involved,  Braun  found  nervous 
symptoms  in  88  per  cent.,  as  weak  muscles,  occipital  neuralgia,  involve- 
ment of  the  brachial  plexus  and  anaesthesia.  The  heart  was  not  affected 
in  any  of  Garrod's  500  cases.  Ansemia,  episcleritis  and  other  compli- 
cations are  uncommon.  The  majority  of  patients  do  not  improve  or 
recover,  and  recurrence  of  the  disease  is  very  common.  In  some 
cases  the  process  is  arrested.  Aside  from  atheroma  and  nephritis 
few  intercurrent  diseases  develop. 

2.  Partial  or  Monarticular  Type. — -Pathologically  this  type  resem- 
bles the  form  described,  but  differs  from  it  in  that  it  presents  more 
profound  changes,  and  is  limited  to  one  or  few  articulations.  There 
is  the  same  capsular  thickening  and  cartilaginous  fibrillation;  the 
cartilage  often  softens,  ossifies  or  hypertrophies;  the  bone  rarefies 
or  becomes  cystic  and  soft  in  some  places,  with  fiattening  of  the  bone 
heads  and  widening  of  the  sockets,  particularly  in  the  shoulder  and 
hip;  in  other  places  bony  over-growths  form,  knoT\T:i  as  Haygarth's 
nodes,  or  a  new  socket  may  develop;  the  bone  may  eburnate  and  the 
joint  may  be  either  smooth  or  ridged.  As  a  rule  the  atrophic  prevail 
over  the  hypertrophic  changes.  They  resemble  the  extreme  senile 
change  (morbus  coxce  senilis);  trauma  or  a  nervous  basis  are 
considered  causal;  it  occurs  in  old  persons  and  largely  in  males. 
Clinically,  compared  with  the  general  progressive  type,  it  is  single 
or  at  least  rarely  symmetrical,  occurs  in  the  proximal  large  joints 
(hip  and  shoulder),  and  is  less  often  attended  by  subluxation.  The 
elbow,  spine  and  smaller  joints  are  less  involved. 

3.  Vertebral  Type. — Struempell  (1885)  named  this  type  chronic 
ankylosing  spondylitis;  vertebral  arthritis  deformans  occurs  with 
ankylosis  of  the  spine,  shoulders  and  hips.  Marie  (1898)  made  it  a 
separate  type  (spondylose  rhizojny clique),  characterized  by  complete 
vertebral  ankylosis,  scoliosis,  ankylosis  of  shoulders  and  hips,  exemp- 
tion of  all  other  joints,  incidence  almost  exclusively  in  males,  and  its 
appearance  in  the  young  immediately  after  bony  development  has 
ceased.  Von  Bechterew  (1892)  described  a  similar  type  due  to  hered- 
ity, trauma  or  meningeal  inflammation  and  characterized  by  paresis 
of  the  muscles  of  the  neck,  trunk  and  extremities,  some  atrophy  of 


ARTHRITIS  DEFORMANS  AND  CHRONIC  RHEUMATISM       929 

the  back  and  shoulder,  signs  indicatmg  involvement  of  the  spinal 
nerves  (hypersesthesia,  pain  and  parsesthesia),  and  an  ascending 
degeneration  in  the  cord.  These  are  probably  but  subtypes  of  arthritis 
deformans. 

4.  Juvenile  Type  of  Still. — (a)  The  ordinary  progressive  (adult) 
form  may  be  observed,  running  an  unfavorable  course,  and  often 
with  almost  universal  ankylosis;  in  some  cases  the  great  toes  are 
lengthened.  (6)  "Still's  type"  occurs  in  poor  children  largely;  70 
per  cent,  of  cases  are  girls;  30  per  cent,  occurs  between  the  second 
and  seventh  years,  32  per  cent,  between  the  seventh  and  thirteenth 
years,  and  20  per  cent,  between  the  thirteenth  and  seventeenth  years. 
The  onset  is  often  subacute.  The  multiple  arthritis  affects  chiefly  the 
extracapsular  tissues,  and  there  is  seldom  crepitus.  The  spleen  is 
always  enlarged,  and  the  lymph  glands  near  the  affected  joints  are 
hard  and  large.    Anaemia  and  retarded  development  are  common. 

5.  Heberden's  Nodes. — Bony  nodes  develop  on  the  sides  of  the  end 
phalanges  near  the  joints.  They  begin  between  thirty  and  forty 
years,  but  are  seen  chiefly  at  about  sixty  years  of  age.     Though  at 

Fig.  49. 


Heberden's  nodes.     (Musser.) 


first  soft,  and  sometimes  painful  and  red,  they  become  hard,  indolent 
and  as  large  or  larger  than  a  pea.  Their  growth  is  more  often  inter- 
mittent than  continuous.  Some  disturbance  in  function  is  not  uncom- 
mon, but  only  in  extreme  cases  is  deformity  observed,  as  flexion  of  the 
end  phalanges  into  the  palm  or  deviation  toward  the  radial  side. 
Involvement  of  the  large  joints  is  rather  uncommon,  whence  the 
prognosis  is  favorable.  Some  consider  them  gouty,  though  Heberden 
dissented  .strongly. 

Diagnosis. — (a)  In  gout,  the  history,  localization,  fine  (not  coarse) 
crackling  in  the  knee-joint  and  radial  articulation  of  the  elbow,  greater 
spontaneous  pain,  infrequent  generalization  and  symmetry,  the  uratic 
deposits  and  tophi  in  the  ear  are  characteristic.  (6)  Acute  rheumatisTn 
(v.s.  Acute  Form),  (c)  Multiple  tuberculous  arthritis  may  cause  diag- 
nostic difficulty,  particularly  when  it  occurs  in  children,  for  pulmonary 

59 


930  CONSTITUTIONAL  DISEASES 

tuberculosis  may  complicate  arthritis  deformans;  but  the  tuberculous 
hip  and  knee  involvement,  the  fusiform  fingers,  the  hectic  fever,  involve- 
ment of  the  glands  and  serous  membranes  are  generally  distinctive. 
Poncet  has  recently  called  attention  to  an  ankylosing  tuberculous 
pseudorheumatism,  which  may  cause  confusion  (v.  Tuberculosis). 
(d)  Syphilis  {q.v.)  of  the  joints  occurs  particularly  in  persons  between 
four  and  fifteen  years  of  age,  and  in  about  40  per  cent,  of  hereditary 
forms;  the  epiphyses  are  irregularly  deformed,  (e)  Hcemophilic 
arthritis  is  distinguished  by  the  unmistakable  family  history  and  its 
three  stages  (i)  hsemarthros,  (ii)  panarthritis,  and  (iii)  adhesions, 
erosions,  deformity  and  ankylosis.  (/)  Chronic  articular  infections 
(chronic  pseudorheumatism),  especially  subchronic  and  chronic  gonor- 
rhoea! arthritis  (q.v.),  begin  acutely,  usually  affect  the  knees  first, 
then  possibly  after  months  the  ankles,  hands  (in  women  particularly), 
and  sternoclavicular  and  other  joints;  similar  chronic  arthritides  may 
follow  scarlatina,  diphtheria,  pneumonia,  and  grippe,  (g)  Nervous 
arthropathies  present  much  the  same  pathological  findings;  (i)  the 
arthropathies  of  tabes  (q.v.),  occur  rapidly  and  early,  without  pain, 
tenderness  or  other  inflammatory  evidence;  are  attended  by  much 
effusion,  are  atrophic  or  flail-like  rather  than  hypertrophic,  in  80  per 
cent,  involve  the  lower  extremities  and  are  accompanied  by  other 
signs  of  tabes,  (ii)  In  syringomyelia  (q.v.)  the  effusions  are  great, 
painless,  in  80  per  cent,  involve  the  upper  extremities,  and  are  asso- 
ciated with  the  syringomyelic  dissociated  anaesthesia,  and  panaritia. 
(h)  "Chronic  rheumatism"  follows  acute  rheumatism,  in  which  the 
changes  involve  less  the  bone,  cartilage  and  serous  sacs  than  the 
capsule  which  becomes  fibrous.  The  cartilage  may  become  somewhat 
fibrillated  and  fibrous  but  is  seldom  hypertrophied  or  destroyed.  The 
vascular  bands  become  callous  (Jaccoud's  fibrous  rheumatism),  and 
ankylosis  may  result.  It  is  maintained  by  some  that  this  ankylosis 
of  connective  tissue,  and  the  joint  obliteration  differentiate  fibrous 
rheumatism  from  arthritis  deformans,  but  clinical  differentiation  is 
often  impossible. 

Treatment. — Treatment  is  notoriously  futile  and  arrest  of  the  pro- 
cess results  rather  from  spontaneous  exhaustion  of  the  disease  than 
from  therapeutic  efforts,  (a)  "Rheumatic"  influences,  as  exposure  to 
cold  and  dampness,  overheating  while  at  work,  and  resting  in  damp 
garments  are  to  be  carefully  avoided.  Woolen  underwear  should  be 
worn.  General  hydrotherapeutic  measures  are  illy  borne.  A  warm 
climate  benefits  especially  those  cases  resembhng  (or  including)  chronic 
fibrous  rheumatism,  as  that  of  Mexico,  the  Hot  Springs  of  West 
Virginia  and  Arkansas,  (b)  Diet  is  not  of  such  importance  as  in 
gout;  indeed,  liberal  feeding  is  strongly  indicated,  (c)  In  acute 
exacerbations  rest  and  coal-tar  derivatives  are  indicated;  sahcylates  are 
generally  useless  save  in  really  secondary  rheumatism,  (d)  Passive 
movements  and  massage  relieve  stiffness  and  muscular  contractures. 
Massage  reduces  the  oedema  and  adhesions.  In  some  cases  forcible 
pressure,  as  with  the  thumb,  will  cause  some  absorption  of  the  (fresh) 


RICKETS  931 

osteoplastic  nodes;  it  may  be  easily  overdone,  and  once  every  day  or 
two  on  the  same  area  is  sufficient.  Cautious  active  exercise  is  also 
essential,  (e)  Extension  by  pulley  weights  sometimes  produces  wonder- 
ful results  according  to  Hoffa,  in  lessening  pain  and  exostosis,  though 
the  author  has  never  observed  any  essential  results.  (/)  Local  measures 
may  be  of  some  use.  The  x-rays  and  strong  electric  lights  may  afford 
temporary  alleviation  from  pain  but  do  not  seem  to  affect  the  basic 
change;  cases  of  fibrous  rheumatism  are  more  benefited  than  arthritis 
deformans.  The  same  may  be  said  of  local  applications  of  warm 
water.  Hot  air  causes  hypersemia  of  the  parts  and  is  sometimes  of 
real  (temporary)  benefit;  cages  of  wire,  asbestos  and  felt  are  devised 
to  enclose  the  joint,  leaving  around  it  an  air  space;  the  temperature 
is  gradually  raised  by  a  lamp  placed  under  a  connecting  elbow  to 
200  or  250°  F.  and  is  gradually  lowered.  Bier's  method  of  venous 
hyperoemia,  used  by  him  in  treatment  of  tuberculous  joints,  is  also 
advocated;  the  Esmarch  constrictor  above  the  joint  should  produce 
swelling  but  not  pain.  "Firing"  the  skin  with  the  Paquelin  is  bene- 
ficial in  lighter  grades  of  deforming  arthritis  and  in  fibrous  rheumatism. 
Encouraged  by  the  results  in  one  case  in  which  injections  of  iodoform 
and  olive  oil  were  given,  the  author  used  it  in  six  other  cases,  and 
either  without  benefit  or  with  great  increase  of  pain  and  swelling  (the 
injections  were  made  with  absolute  asepsis).  Operation  (resection)  may 
be  considered  in  nonprogressive,  monarticular  forms,  but  the  general 
poor  health  and  age  of  the  patient  rather  contra-indicate  it.  {g)  In- 
ternal medication  as  cod-liver  oil,  arsenic  and  syrup  of  the  iodide  of 
iron  may  seemingly  help  a  few  cases.  Luff  uses  guaiacol  carbonate 
with  marked  success;  the  initial  dose  of  five  grains,  t.i.d.,  is  increased 
two  grains  every  week  till  a  single  dose  of  twenty  grains  is  given. 


(E).  RICKETS. 

Definition. — A  metabolic  affection  of  early  infancy,  characterized 
chiefly  by  hypersemia  and  deficient  calcification  of  the  growing  bones. 
The  disease  was  first  well  described  by  Glisson  (1650).  The  name 
is  derived  from  an  old  English  word  meaning  "twisted,"  and  Glisson 
suggested  the  Greek  "rhachitis"  (vertebral  inflammation)  because  the 
spine  was  often  involved,  and  the  term  sounded  like  "rickets." 

Etiology. — Its  etiology  is  obscure.  All  theories  advanced,  such  as 
deficient  absorption  of  lime  salts  or  infection,  and  reduced  activity  of 
the  thymus,  are  insufficient,  (a)  The  diet  seems  to  be  of  prime  im- 
portance; proprietary  foods,  condensed  milk,  cow's  milk,  excess  of 
carbohydrates,  prolonged  lactation  or  nursing  during  pregnancy  are 
probable  factors.  Cheadle  considered  that  a  deficiency  in  animal  fats 
and  proteids  was  causative;  after  20  litters  of  lion  cubs  had  been  lost 
from  rickets  in  the  London  Zoological  Gardens,  Bland  Sutton  found 
that  a  diet  of  milk,  powdered  bone,  meat,  and  cod-liver  oil  prevented 
rickets.     (6)  Unsanitary  surroundings  may  be  causal,  as  lack  of  fresh 


932  CONSTITUTIONAL  DISEASES 

air  and  sunligiit,  crowded  quarters  and  kindred  factors  observed 
largely  among  the  poor  classes  in  large  cities,  particularly  in  Europe. 
Among  nurslings  Kassowitz  (Vienna),  observed  it  in  89  per  cent., 
and  Joucousky  (St.  Petersburg)  in  90  per  cent.;  in  children's  clinics 
abroad,  Marfan  (Paris)  found  rickets  in  50  per  cent.;  in  Holland, 
London,  Christiana,  Naples,  and  Rio  Janeiro  about  the  same  figures 
(50  to  80  per  cent.)  prevail;  in  the  United  States  it  is  most  frequent 
among  negroes  and  Italians.  Hereditary  syphilis  is  a  predisposing 
factor,  (c)  Age  may  be  of  etiological  importance.  In  more  than  600 
cases,  Baginsky  did  not  observe  it  in  children  under  three  months  of 
age;  his  figures  show  7  per  cent,  in  children  between  three  and  six 
months,  28  per  cent,  in  those  between  six  and  twelve  months,  35  per 
cent,  in  those  between  one  and  one  and  a  half  years,  and  18  per  cent, 
in  those  between  one  and  a  half  and  two  years  {e.g.,  88  per  cent,  of 
cases  occurred  in  children  between  three  months  and  two  years  of 
age).  The  occurrence  of  congenital  rickets  (apart  from  achondro- 
plasia, see  Diagnosis  of  Barlow's  Disease)  is  usually  denied  but 
there  is  some  authoritative  testimony  for  it.  Rickets  which  develops 
later,  up  to  puberty,  is  called  rhachitis  tarda. 

Sjmiptoms. — An  experienced  observer  may  diagnosticate  the  gradual 
onset  from  the  prodromes,  as  the  irregular  or  tardy  dentition ;  restless- 
ness, irritability,  insomnia  and  throwing  off  of  the  bedclothes;  sweat- 
ing, particularly  about  the  head  and  neck;  bronchitis;  digestive 
disturbances,  coated  tongue,  anorexia,  malnutrition,  meteorism  or 
diarrhoea;  immobility,  the  child  crying  when  moved  or  touched,  and 
general  hyperaesthesia.  However,  a  positive  diagnosis  is  not  justifiable 
until  the  bone  symptoms  develop. 

1.  Bone  Symptoms. — (a)  The  skull  usually  shows  the  earliest 
changes,  generally  in  the  first  year  of  life,  and  the  bone  changes  (v.i.) 
are  most  marked  in  the  skull  and  thorax.  The  face  appears  small 
and  the  head  large.  Nodes  or  bosses  of  bone  appear  on  the  frontal 
and  parietal  regions,  which  with  the  occipital  flattening  produce  the 
caput  quadratum  (tete  caree) ;  the  head  may  be  dolichocephalic.  The 
anterior  fontanelle  increases  forward,  and  in  some  cases  all  the  sutures 
open  toward  the  end  of  the  first  and  beginning  of  the  second  year. 
The  fontanelle  and  sutures  (which  normally  close  about  the  fifteenth 
or  eighteenth  month)  remain  open,  even  until  the  fourth  year  ({.  e., 
there  is  lack  of  normal  involution).  The  occiput  softens  {craniotahes) 
in  33  to  50  per  cent.,  near  the  lambdoid  suture;  the  occipital  protuber- 
ance remains  hard.  Craniotabes  may  less  frequently  occur  elsewhere, 
as  in  the  frontal  bones;  besides  the  actual  bone  changes  {v.i.),  the 
pressure  of  the  pillow  and  of  the  brain  further  its  development.  In 
extreme  cases  the  peri-  and  endocranium  actually  touch,  and  in 
moderate  degrees  the  skull  feels  "parchment-like."  Though  it  is 
not  absolutely  pathognomonic  of  rickets,  and  though  it  occurs  also  in 
syphihs,  craniotabes  is  rather  characteristic  when  there  are  also  the 
tender  quadrate  head,  head  sweating,  thin  occipital  hair  and  blue 
scalp  veins.     Craniotabes  may  be  an  element  in  the  general  and  local 


RICKETS  933 

spasms  which  occur  in  rickets.  The  frequent  systolic  murmur  heard 
over  the  greater  fontanelle  is  also  heard  in  other  affections  or  in 
health;  it  seldom  endures  beyond  the  fifth  year,  and  is  said  to  occur 
only  in  conjunction  with  a  similar  bruit  in  the  carotids.  The  upper 
jaw  becomes  long  and  narrow,  and  the  lower  jaw  becomes  hexagonal, 
probably  from  muscular  traction  on  the  soft  bones.  The  eruption  of 
the  teeth  is  delayed;  they  do  not  appear  until  the  second  or  even  the 
third  year;  the  second  teeth  are  crowded,  carious,  curved  and  eroded. 
(b)  In  the  ^^orax,  the  rhachi tic  "ro^ar?/"  appears  toward  the  end  of 
the  first  or  early  in  the  second  year;  it  is  so-called  from  the  bead-like 
succession  of  enlarged  chondrocostal  joints;  they  are  enlarged  epiphy- 
ses. The  chest  itself  is  altered  toward  the  middle  or  end  of  the  second 
year;  this  is  due  to  the  softness  of  its  bones,  the  traction  exerted  by 
the  diaphragm,  atmospheric  pressure  and  sometimes  by  external 
influences,  as  holding  of  the  child  with  a  hand  on  the  chest,  or  coinci- 
dent respiratory  inflammation.  Louis'  angle  is  often  prominent, 
and  the  sternum  juts  forward,  causing  "chicken  breast"  (pectus 
carinatum).  There  is  also  a  depression  outside  of  the  costochondral 
junctions  which  extends  outward  and  downward,  and  is  accentuated 
by  some  eversion  of  the  costal  arch.  The  thoracic  deformity  promotes 
respiratory  complications  and  dyspnoea,  which  in  turn  aggravate 
it.  With  the  deformity  of  the  chest,  we  may  group  lumbar  kyphosis 
which  is  arcuate  and  not  angular,  the  thickened  or  bent  clavicle 
and  the  thickening  of  the  spine  or  edges  of  the  scapula,  (c)  In 
the  extremities,  the  epiphyses,  particularly  of  the  ulna,  radius,  tibia 
and  fibula,  are  enlarged;  this  occurs  at  the  end  of  the  first  or 
beginning  of  the  second  year  at  the  same  time  as  the  rosary,  cranio- 
tabes  and  wide  fontanelle.  The  epiphyses,  like  the  ribs  and  skull, 
are  tender  and  painful.  It  may  look  as  though  there  were  "double 
joints."  Deformities  may  develop  from  muscular  traction  or  from 
the  weight  of  the  body;  the  arms  may  inchne  outward  and  forward; 
the  forearms  may  become  convex  toward  their  extensor  surfaces. 
The  thighs  sometimes  become  convex  anteriorly  and  outwardly;  the 
legs  bow  outward  or  less  often  forward,  especially  when  early  walking 
is  allowed  or  encouraged.  Spiral  or  other  extreme  deformities  are 
less  frequent.  The  gait  is  waddling.  Greenstick  or  actual  fractures 
sometimes  occur,  (d)  The  flat  rhachitic  pelvis  develops  by  the  weight 
of  the  body  pushing  the  sacrum  into  the  pelvis  and  the  counter-pressure 
of  the  thighs  narrowing  the  anterior  pelvis,  so  that  the  pelvic  aperture 
may  become  heart-shaped;  the  acetabula  lie  more  anteriorly,  and  the 
iliac  crests  flare  outward,  (e)  Pathology  of  the  bone  affection.  Nor- 
mal bone  grows  in  length  as  follows:  there  are  two  zones  in  the  epi- 
physeal surface  facing  the  shaft;  (a)  the  first  zone  is  nearest  the  shaft, 
is  faintly  yellow,  and  measures  h  mm.;  it  is  the  zone  of  preliminary 
calcification,  into  which  normally  the  bloodvessels  grow,  and  form 
medullary  canals  by  absorbing  small  areas  of  bone,  and  in  which 
osteoblasts  appear  and  calcification  develops.  (In  rickets  the  calci- 
fication is  imperfect  and  irregular  in  this  zone,  and  the  bloodvessels 


934  CONSTITUTIONAL  DISEASES 

grow  not  merely  into  these  calcified  areas  but  beyond  them,  even 
into  the  cartilage  area,  and  absorb  what  little  new  bone  is  formed.) 
(b)  The  second  zone  lies  outside  the  one  described,  is  sharply  demarked 
from  it,  is  normally  bluish,  measures  1  to  2  mm.  in  thickness,  and  is 
known  as  the  hyperplastic  zone,  in  which  the  cartilage  cells  divide 
and  proliferate.  (In  rickets  this  zone  becomes  larger,  proliferates 
irregularly  and  is  invaded  by  bloodvessels,  and  irregular  foci  of  abor- 
tive calcification;  the  demarkation  between  the  first  and  second 
zones  is  ill-defined).  Normal  bones  grow  in  thickness  by  bony  increase 
beneath  the  periosteum.  (In  rickets  this  layer  becomes  several  milli- 
meters thicker,  irregular  and  nodose).  Normal  bone  develops  in  the 
skull  and  face  in  the  connective  tissue.  (In  rickets  the  lime  salts  are 
either  not  deposited,  are  insufficiently  deposited  [craniotabes]  or  over- 
deposited  as  bosses  [osteosclerosis].)  The  essential  element  of  these 
rhachitic  changes  is  undue  hypercemia  and  irregular,  deficient  calcifica- 
tion; which  one  is  primary  remains  a  disputed  point;  the  bones  may 
contain  but  20  or  30  per  cent,  of  the  normal  amount  of  lime  salts. 

2.  General  Symptoms. — (a)  Muscular  weakness  is  pronounced,  as 
evidenced  by  impaired  breathing,  the  tardy  efforts  to  hold  up  the  head, 
and  disinclination  to  walk,  (b)  Nutrition  is  usually  poor;  there  is 
anaemia,  sometimes  with  leukocytosis  and  often  with  emaciation;  the 
irritability  and  sweats  have  been  mentioned  under  prodromes,  (c) 
The  nervous  system  is  affected.  Mentality  is  unimpaired.  Rickets 
patients  frequently  grind  their  teeth.  Spasmodic  conditions  are  not 
infrequent,  as  generalized  convulsions,  tetany  and  spasm  of  the  glottis, 
all  of  which  will  receive  separate  consideration,  (d)  Temperature 
is  not  symptomatic  of  rickets  and  always  denotes  complications,  (e) 
Digestive  disturbances  are  common;  there  may  be  anorexia,  diarrhoea 
without  pain  or  tenesmus,  more  commonly  constipation  and  distention 
of  the  abdomen  which  can  occur  without  any  digestive  disorder,  from 
enlargement  of  the  liver  and  spleen,  and  possibly  from  the  thoracic 
changes.  The  amount  of  chalk  in  the  fseces  may  be  increased  (Bagin- 
sky).  The  spleen  is  enlarged  in  70  per  cent.,  and,  less  often  and  less 
markedly,  the  liver.  (/)  Rickety  children  catch  cold  easily  and  bron- 
chitis frequently  leads  to  atelectasis  and  bronchopneumonia,  (g)  The 
heart  may  be  luxated  from  the  altered  thoracic  conformation,  which 
also  frequently  causes  hypertrophy  of  the  right  ventricle,  (h)  The 
urine  remains  normal,  the  alleged  increase  in  calcium  and  phosphorus 
salts  being  quite  inconstant,     (i)  Eczema  is  common. 

Course,  Complications,  and  Prognosis. — (a)  The  onset  is  insidious 
and  the  clinical  course  covers  a  year  or  more,  (b)  Complications 
include  but  few  of  immediate  danger,  as  bronchitis,  pneumonia,  and 
spasm  of  the  glottis  which  may  result  fatally.  Later  complications 
include  the  contracted  rhachitic  pehas,  which  is  of  obstetrical  import- 
ance, kyphosis  and  pulmonary  tuberculosis,  which  is  found  in  36  per 
cent,  of  the  fatal  cases,  sometimes  with  abdominal  complications 
(tabes  mesaraica);  its  early  diagnosis  depends  almost  entirely  upon 
auscultation,  for  percussion  is  peculiarly  deceptive  when  the  chest  is 


RICKETS  935 

deformed,  (c)  The  prognosis  is,  with  these  exceptions,  excellent  as 
to  life,  and  with  care,  as  to  deformity,  for  many  protuberances  and 
deformities  may  regress. 

Diagnosis. — The  diagnosis  is  based  chiefly, — and  then  with  cer- 
tainty— upon  the  changes  in  the  skull  and  skeleton.  Errors  are  easily 
possible  from  precipitate  diagnosis,  based  on  the  purely  prodromal 
phenomena,  but  otherwise  confusion  is  rarely  serious,  (a)  Barlow's 
disease  (q.v.),  which  is  misnamed  acute  rickets,  has  no  connection 
with  it.  (6)  Syphilis  predisposes  to  rickets  but  is  otherwise  distinct 
and  separate;  it  usually  develops  at  a  time  (first  to  sixth  month) 
when  rickets  is  most  uncommon,  and  is  usually  stamped  by  other 
syphilitic  stigmata,  as  cutaneous  and  mucous  syphilides;  when  it 
invades  the  epiphyses,  the  femur  is  usually  its  seat,  and  there  may  be, 
between  the  cartilage  and  bone,  a  wall-like,  very  tender,  painful  and 
usually  doughy  swelling  which  also  is  rather  fusiform,  compared  with 
the  rounder  rhachitic  nodes;  epiphyseolysis  with  great  dislocation  of 
the  fragments,  may  occur  in  syphilis,  but  never  in  rickets;  in  doubt- 
ful cases  an  ex  juvantibus  diagnosis  may  be  made,  (c)  Vertebral 
tuberculosis  (q.  v.  and  also  compression  of  the  cord)  is  easily  dis- 
tinguished; the  rhachitic  kyphosis  is  arcuate,  not  angular;  other 
symptoms  of  either  disease  are  almost  invariably  present,  (d)  Hydro- 
cephalus {q.ii.,  for  differentiation). 

Treatment. — 1.  Hygienic. — Fresh  air  and  sunlight  produce  wonder- 
ful results  particularly  in  the  country,  mountains  or  at  the  sea-side. 

2.  Dietetic. — In  nurslings  (who  seldom  develop  the  disease)  or  in 
quite  young  babies,  the  use  of  a  wet-nurse  may  entirely  cure  the 
disease.  In  other  children  it  may  be  less  a  question  of  food  than  of 
digestion,  which  may  require  pepsin,  taka-diastase,  nux  vomica,  or 
hypophosphites. 

3.  Medicinal. — No  specific  remedy  is  known,  but  the  results  pro- 
duced by  phosphorus  make  it  more  important  than  any  other  drug. 
Under  its  use  the  child  becomes  easier  and  brighter;  the  nervous 
symptoms  abate,  as  the  insomnia,  convulsions,  tetany,  or  laryngospasm; 
the  osseous  symptoms  are  improved,  bone  is  deposited  and  dentition 
occurs,  though  less  obviously  in  clinical  experience  than  in  animal 
experiments  in  which  it  seems  certain  that  small  doses  stimulate  bone 
formation  directly  and  rapidly.  Phosphorus  itself  is  given  in  doses 
of  gr.  250  to  lio  in  pill  form,  or  as  the  ol.  phosphoratum  (1  per 
cent,  solution)  nj^j,  t.i.d.;  the  oil  or  emulsion  should  be  freshly  pre- 
pared, for  both  degenerate  readily  on  exposure  to  fight.  (Its  toxic 
symptoms  are  malaise,  fever,  thirst,  anorexia,  and  weakness;  vomiting 
of  food,  mucus,  bile,  later  blood  and  sometimes  phosphorescent 
material  may  occur;  there  may  be  abdominal  pains,  diarrhoea  or 
constipation,  phosphorescent,  clay-colored  or  bloody  faeces;  jaundice 
may  develop ;  the  liver  at  first  may  be  large,  but  becomes  small ;  there 
may  be  cholaemia;  albumin,  bile,  casts,  leucin  and  tyrosin  in  the 
urine  and  hemorrhages  from  the  uterus,  abortion  or  miscarriage  and 
bleeding  from  other  surfaces.)      Cod-liver  oil  was  recommended  by 


936-  CONSTITUTIONAL  DISEASES 

Bretonneau  in  1827;  it  carries  out  Cheadle's  theory  that  animal  fats 
and  proteids  are  essential,  and  comforms  with  Sutton's  experiences 
(v.  s.).  If  it  is  well  tolerated  by  the  stomach,  the  general  level  of  health 
may  be  elevated  by  its  use;  if  not,  cream  and  butter  should  be  given. 
Iron  (syr.  ferri  iodid.)  is  a  good  tonic.  Calcium  salts  are  now  less 
used  than  formerly,  as  it  has  been  proven  that  a  sufficient  quantity 
is  present  in  the  food  and  is  absorbed. 

4.  Orthopedic. — During  the  florid  stage  the  child  should  be  kept 
quiet  upon  a  firm  mattress.  He  should  be  kept  off  his  feet.  Later, 
corrective  measures  are  indicated  for  the  kyphosis  and  deformity  of 
the  limbs.  Mikulicz  holds  that  the  apparently  monosymptomatic  genu 
valgum  adolescentium  is  only  a  rhachitis  tarda,  and  that  genu  valgum 
and  varum  should  always  be  treated  with  rest,  cod-liver  oil  and  phos- 
phorus. 

(F).  OBESITY. 

Etiology. — Obesity  (adiposity,  corpulence  or  polysarcia  adiposa) 
is  favored  (a)  by  heredity;  it  frequently  occurs  in  entire  families; 
congenital  cases  are  known;  (b)  by  mode  of  life;  lack  of  exercise,  over- 
eating and  alcoholic  indulgence,  are  potent  factors,  (c)  The  meno- 
pause is  frequently  attended  by  increase  in  weight,  (d)  Varioiis 
diseases  may  cause  it,  as  those  of  the  nervous  or  osseous  system, 
making  exercise  impossible;  and  gout,  diabetes,  various  anaemias, 
chronic  valvular  disease,  and  emphysema,  which  act  rather  by  pre- 
venting adequate  exercise  than  by  deficient  oxygenation  or  from  the 
condition  of  the  blood.  Adipose  tissue  may  develop  from  tissue 
albumin. 

SjTnptoms. — The  general  habitus  requires  no  description.  Fat 
develops  in  the  subcutaneous  tissues,  in  parts  where  it  is  normally 
found,  as  in  the  omentum  and  around  the  kidney,  and  it  may  cause 
fatty  infiltration  and  degeneration  of  all  internal  organs  excepting  the 
brain  and  spleen;  even  the  blood  may  contain  fat  (lipaemia). 

1.  Cardiac  Symptoms. — The  heart  is  embarrassed  by  increased 
resistance  to  the  capillary  flow,  by  the  fatty  infiltration  (and  degen- 
eration) of  the  myocardium,  and  by  fat  accumulation  in  the  chest 
wall,  omentum  and  mediastinum.  The  pulse  is  more  often  frequent 
than  slow,  though  cases  of  bradycardia  are  noticed  (see  Stokes'  triad 
under  Fatty  Heakt)  .  Cardiac  hypertrophy  may  occur.  (Edema  is  not 
uncommon. 

2.  Respiratory  Symptoms. — The  breath  sounds  and  heart  tones  are 
faint,  and  thoracic  percussion  is  difficult  because  of  the  subcutaneous 
fat.  Bronchitis  is  common  and  probably  results  from  the  ready 
sweats  and  consequent  chilling.  Dyspnoea  may  occur  on  exertion 
only,  or  may  develop  from  pulmonary  oedema. 

3.  Digestive  Symptoms. — Digestive  disturbances  may  develop.  The 
large  liver  is  less  frequently  fatty  than  congested  and  hypertrophic. 
Constipation  and  hemorrhoids  are  frequent. 


OBESITY  937 

4.  The  Urine. — The  urine  may  be  scant  in  comparison  with  the 
fluids  ingested;  coincident  oxaluria,  lipuria,  lithuria,  albuminuria  or 
glycosuria  tnay  be  noticed.  Actual  impotence  is  not  uncommon,  as 
well  as  mechanical  obstacles  to  coitus. 

Two  other  groups  of  symptoms  mark  extreme  obesity,  viz.:  (5) 
lessened  physiological  resistance  to  infections,  as  typhoid  or  pneumonia 
and  to  surgical  measures  or  phlebotomy,  and  (6)  such  complications 
or  associated  affections  as  diabetes,  gout,  calculous  disease  and  less 
often  contracted  kidney,  arteriosclerosis,  and  apoplexy.  Somnolence 
may  be  marked. 

Treatment. — Treatment  is  (a)  that  of  the  fundamental  condition, 
as  gout  or  diabetes,  and  (b)  dietetic.  Various  "cures"  have  been 
formulated  which  are  enumerated  because  they  possess  more  than 
historical  interest — (i)  Banting's  cure.  Banting,  a  merchant,  was 
treated  so  successfully  by  Wm.  Harvey  for  obesity  that  he  addressed 
a  "Letter  to  the  Public  on  Obesity"  (1863).  This  diet  was  largely 
albuminous,  and  consisted  of  fish,  meat,  eggs,  tea  without  sugar  or 
milk,  vegetables,  fruit,  some  red  wine,  and  toast  without  butter.  This 
diet  may  cause  indigestion,  nervousness,  insomnia,  palpitation  or  gout, 
(ii)  Ebstein,  himself  a  sufferer,  proposed  (1872)  a  diet  with  larger 
proportions  of  fat;  his  diet  consisted  of  meat,  fish,  eggs,  tea,  legumin- 
ous vegetables,  fruit,  fats  and  butter,  but  restricted  the  carbohydrates; 
digestive  disorders  may  also  occur  under  this  system,  (c)  Oertel 
allowed  more  carbohydrates,  limited  the  fats  and  fluids,  and  insisted 
upon  sweats  and  graduated  exercises.  From  the  following  it  will  be 
seen  that  all  these  methods'  are  "starvation  cures,"  with  restriction 
of  water  in  Oertel's  method.  The  average  man  requires  118  gm. 
(4§)of  nitrogen,  56  gm.  (2§)  of  fat,  and  500  gm.  (17§)  of  carbo- 
hydrates (Voigt  and  Pettenkofer),  equaling  3,054  calories. 

The  diet  of  Banting  contains  172  gm.  (5.7  §)  of  nitrogen,  8  gm. 
(25)  of  fat,  and  81  gm.  (2.7§)  of  carbohydrates,  equaling  1,112 
calories. 

The  diet  of  Ebstein  contains  102  gm.  (2.3  §)  of  nitrogen,  85  gm. 
(2§)  of  fat,  and  47  gm.  (1.6  §)  of  carbohydrates,  equaling  1,401 
calories. 

The  diet  of  Oertel  contains  183  gm.  (6  5)  of  nitrogen,  38  gm.  (1.3  §) 
of  fat,  and  143  gm.  (4.8  §)  of  carbohydrates,  equaling  1,690  calories. 
(A  calorie  is  the  temperature  required  to  raise  1,000  gm.  water,  1°  C; 
a  gram  of  albumin  equals  3.2  calories,  of  fat  8.4,  and  of  carbohydrates 
3.8  calories.) 

Banting's  method  supplies  to  the  body  about  33  per  cent,  of  the 
heat  and  energy  normally  required;  Ebstein's  less  than  50  per  cent, 
and  Oertel's  slightly  more  than  50  per  cent.  The  lesson  taught  then 
is  moderation  in  eating  (v.  Gout).  In  any  reduction -cure  the  patient 
may  suffer  from  breaking  down  of  the  body  proteids,  which  causes  the 
weakness  that  is  experienced.  In  all  cases  the  total  amount  of  nitrogen 
in  the  urine,  which  constitutes  90  per  cent,  of  the  nitrogen  excreted, 
should  be  watched;  if  more  is  excreted  than  ingested  the  nitrogenous 


938  CONSTITUTIONAL  DISEASES 

food  should  be  increased  to  obviate  weakness,  both  muscular  and 
cardiac.  The  diet  then  should  consist,  as  in  gout,  of  moderation  in 
all  foods,  with  restriction  of  the  carbohydrates,  whose  easy  reduction 
into  water  and  carbonic  acid  spares  the  tissue  waste.  The  fluid  in- 
gested should  be  measured,  and  with  due  individualization,  should  be 
reduced  to  2  or  3  pints  daily.  Alcohol  should  be  forbidden,  as  it  is  a 
carbohydrate.  Beer  contains  not  only  3  to  5  per  cent,  of  alcohol,  but 
sometimes  double  this  percentage  of  soluble  starch  and  dextrine. 

(c)  Active  and  graduated  exercise  is  indispensable,  except  in  cases  of 
marked  cardiac  disease.  It  should  be  regular,  induce  sweating,  and 
bring  all  muscles  into  play,  but  should  not  cause  exhaustion.  Passive 
movements  {v.  Fatty  Heart,  Myocarditis  and  Dilatation),  and 
massage  are  indicated  when  active  exercise  is  contra-indicated. 

(d)  The  patient  should  sleep  not  more  than  seven  hours,  and  should 
bathe  daily  to  avoid  skin  complications  and  to  promote  perspiration. 
Thyroid  extract  is  not  to  be  taken,  except  perhaps  under  special  indica- 
tions, for  it  breaks  down  the  albumins  rather  than  the  fats,  often 
excites  the  heart,  sometimes  induces  glycosuria  and  is  wholly  super- 
fluous (with  proper  dietetics  and  exercise). 


(6).  ADIPOSIS  DOLOROSA  OR  DEROUM'S  DISEASE. 

This  affection  was  described  by  Dercum  (1892),  as  a  "disorder 
characterized  by  unequal  symmetrical  deposits  of  fatty  masses  in 
various  parts  of  the  body,  preceded  or  attended  by  pain."  There 
were  only  31  reported  cases  up  to  1904,  most  of  which  were  females. 
It  usually  develops  in  middle  life,  chiefly  after  the  fortieth  year,  though 
the  author  has  a  case  under  treatment,  aged  thirty-five  years. 

Pathology. — Its  pathology  is  not  yet  developed,  as  but  five  autopsies 
have  been  made  (1903).  In  the  cases  of  Dercum  and  Burr,  an  inter- 
stitial neuritis  was  found,  which  is  likewise  noted  in  the  fatty  tumors 
which  have  been  removed  during  life.  It  is  interesting  to  note  that 
symmetrical  lipomatosis  has  been  observed  in  multiple  neuritis.  In 
Dercum's  and  Burr's  cases  the  thyroid  gland  was  atrophied.  Adeno- 
carcinoma and  gliosis  of  the  hypophysis  have  been  reported. 

Symptoms. —  Two  cardinal  clinical  features  are  observed,  as  the 
term  adiposis  dolorosa  indicates;  (1)  the  obesity  is  either  diffuse  or 
may  be  localized  fatty  tumors,  or  sometimes  both  in  combination; 
lipomata  occur  on  the  trunk  and  proximal  parts  of  the  extremities, 
but  never  on  the  face,  forearms,  hands,  legs,  or  feet.  Indeed  the  thin- 
ness of  the  wrists  and  legs  contrasts  sharply  with  the  massive  body, 
thighs,  and  upper  arms.  The  fatty  tumors  range  from  the  size  of  a 
pea  to  large  dimensions.  The  pendulous  abdominal  fat  may  hang 
down  like  an  apron.  In  one  of  the  author's  cases  the  locahzed  abdom- 
inal fat  was  disposed  in  the  shape  of  a  circular  life-buoy,  sagging 
down  over  the  thighs.     In  another  it  almost  resembled  oedema  or 


ADIPOSIS  DOLOROSA  OR  DERCUM'S  DISEASE  939 

myxoedema,  save  for  its  circumscribed  distribution  and  facial  exemp- 
tion. 

2.  The  pains  may  be  neuralgic  or  parsesthetic.  The  trunk  is  often 
tender. 

Subcutaneous  hemorrhages,  hsematemesis,  epistaxis  and  metrorrhagia 
are  not  uncommon.  The  patients  are  often  nervous,  perhaps  hysterical. 
Asthenia  is  common,  and  subjects  often  lack  initiative  and  readily 
tire  on  exertion.  In  the  later  stages  epilepsy  has  developed,  and  death 
from  asthenia,  psychosis,  nephritis  or  intercurrent  affections  is  re- 
corded. A  number  of  cases,  including  one  of  the  author,  have  im- 
proved under  administration  of  thyroid  extract. 


SEOTIO]^  IX. 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


DISEASES  OF  THE  BEAIN. 

(A).  CEREBRAL  LOCALIZATION. 

The  anatomy  and  physiology  of  the  brain  are  most  important  in 
topical  diagnosis.  Autopsy  findings  in  carefully  studied  cases,  animal 
experimentation,  and  the  constantly  increasing  surgical  intervention, 
have  developed  not  merely  the  nature  of  lesions,  but  also  important 
results  regarding  their  localization.  The  old  doctrine  of  Flourens  that 
all  parts  of  the  brain  were  equally  important,  met  its  first  contradiction 
in  Broca's  discovery  (1861),  that  motor  aphasia  was  due  to  disease 
of  the  third  left  frontal  convolution.  In  1870,  Fritsch  and  Hitzig  dis- 
covered that  stimulation  of  certain  areas,  now  known  as  the  motor 
cortex,  invariably  resulted  in  contraction  of  definite  muscles  of  the 
opposite  side  of  the  body.  Since  then,  Bevor,  Horsley,  Meynert, 
Jackson,  Flechsig,  Ferrier,  Munk,  Glotz,  Nothnagel,  Charcot,  Wer- 
nicke, and  others,  have  contributed  to  the  development  of  brain  locali- 
zation, although  much  still  remains  unclear  and  tentative. 

I.  The  Motor  Cortex. 

This  embraces  chiefly  the  central  convolutions  on  either  side  of  the 
fissure  of  Rolando  (the  ascending  frontal  and  ascending  parietal  lobes 
and  anterior  two-thirds  of  the  superior  parietal  lobe),  the  foot  of  the 
three  frontal  convolutions,  especially  the  lower,  and  on  the  inner  sur- 
face of  the  hemisphere,  the  paracentral  lobule.     In  this  area  lie  the 

941 


942 


DISEASES  OF  THE  NERVOUS  SYSTEM 


large  pyramidal  cells  which  Betz  discovered  were  the  origin  of  the 
motor  or  pyramidal  tracts.  The  centres  are  not  sharply  marked,  but 
run  somewhat  into  adjacent  areas,  especially  those  with  physiological 
associations.  The  leg  centre  occupies  the  upper  quarter  of  the  ascend- 
ing frontal  and  ascending  parietal  convolutions,  and  part  of  the  superior 
parietal  lobe  (all  adjacent  to  the  longitudinal  fissure),  and  passes  over 
to  the  inner  aspect  of  the  hemisphere  to  the  paracentral  lobule,  which 
is  the  centre  for  the  thigh,  pelvis,  and  gluteal  muscles  (Fig.  51).  A 
lesion  in  the  falx  cerebri,  or  dura  near  the  longitudinal  fissure  may,  in 

Fig.  50. 


General  distribution  of  centres  in  cerebral  localization  ;  outer  surface  of  brain. 

rare  cases,  involve  both  paracentral  leg  centres,  and  produce  cerebral 
paraplegia,  although  most  paraplegias  are  spinal  in  origin.  The  arm 
centre  is  the  largest,  covers  the  middle  two  quarters  of  the  central  con- 
volutions, lies  below  and  probably  somewhat  overlaps  the  leg  centre. 
In  Fig.  52,  it  is  seen  that  there  are  certain  general  as  well  as  separate 
centres  for  the  thumb  and  fingers.  The  head  centre  is  below  that  of  the 
arm,  covering  the  lowest  quarter  of  the  central  convolutions  {i.e.,  the 
entire  operculum),  the  upper  part  of  the  Sylvian  fissure,  and  the  pos- 
terior part  of  the  lowest  frontal  convolution  (and  possibly  the  first  and 
second  frontal  gyri).  The  face  centre  lies  directly  beneath  the  arm 
centre,  and  is  mostly  located  on  the  anterior  ascending  convolution, 
the  upper  facial  component  lying  higher  than  the  lower  facial  centres. 
The  eye  centre  of  the  facial  is  bilateral,  and  probably  consists  of  several 
foci.     The  mouth  apparently  has  several  centres.    The  motor  speech 


THE  MOTOR  CORTEX 


943 


area  is  principally  in  the  lower  left  frontal  gyrus,  and  is  probably  the 
chief  centre  for  chewing.  The  trunk  centre  is  less  clearly  defined;  it 
probably  lies  in  the  posterior  part  of  the  first  frontal  convolution,  and 
also  on  its  median  aspect,  just  anterior  to  the  paracentral  lobule.  The 
more  complicated  the  function,  the  larger  is  the  centre  (as  for  the  tongue, 
fingers,  mouth),  and  the  more  unilateral  the  localization  in  the  brain. 
Muscles  used  rhythmically,  or  in  pairs,  are  supplied  to  some  extent 

Fig.  61. 


Cerebral  localization  ;  inner  surface  of  hemisphere. 

from  both  hemispheres,  as  the  muscles  of  the  forehead,  and  of  respira- 
tion, swallowing,  chewing,  vocal  cords,  and  to  some  degree,  of  the  legs 
and  trunk.  Protrusion  of  the  tongue  to  one  side  has  a  monolateral 
centre,  though  its  protrusion  in  the  median  line  and  its  withdrawal 
depend  on  both  hemispheres. 

Total  lasting  hemiplegia  of  the  opposite  side  of  the  body,  with  sensory 
disturbance,  aphasia,  and  intellectual  disturbance,  results  from  com- 
plete destruction  of  the  entire  motor  cortex  of  one  side.  Cortical  hemi- 
plegia is  less  common  than  monoplegia,  which  results  from  partial 
cortical  foci.  Monoplegia  (paralysis  of  one  member,  as  of  the  arm 
alone),  always  suggests,  but  does  not  absolutely  prove,  the  presence  of 
a  cortical  lesion.  The  paralyzed  limbs  are  flaccid,  and  later  undergo 
contractures.  Pure  monoplegias  of  cortical  origin  are  rare,  although 
the  arm  or  leg  may  be  paralyzed  alone  from  a  small  softening,  hemor- 
rhage, cyst,  or  tumor,  or  from  traumatism.  Crural  (leg)  monoplegia 
is  rare  (few  instances  being  reported  by  French  writers),  and  is  due 
largely  to  vascular  lesions  in  the  paracentral  lobule  (anterior  cerebral 
artery).  Some  sensory  disturbance  may  be  noted.  Pure  brachial 
(arm)  monoplegia  may  result  from  vascular  lesions,  small  tumors  or 
trauma;  complex  movements  as  writing  are  most  involved.  The 
finest  differentiation  or  selection,  as  of  the  thumb  alone,  fingers,  or 


944 


DISEASES  OF  THE  NERVOUS  SYSTEM 


wrist,  is  noted  in  this  form*  Sensory  disturbance  is  common  (v.i.). 
Pure  facial  monoplegia  is  unknown,  although  a  faciolingual  form 
with  motor  aphasia  is  observed.  Associated  monoplegia  is  more  usual. 
It  consists  most  commonly  of  paralysis  or  paresis  (partial  paralysis) 
of  the  arm  and  face  (brachiofacial  monoplegia,  passing  under  this 
name,  although  not  strictly  a  monoplegia).  Next  in  frequency  is  the 
arm-and-leg  type  (brachiocrural)  in  which  two  contiguous  centres 
are  involved.  A  leg-and-face  type  never  occurs,  because  their  centres 
lie  too  far  apart.  A  lesion  involving  one  cortical  area  after  another 
speaks  for  cortical  localization.  Cortical  paralyses  are  not  attended 
by  the  reaction  of  degeneration.  In  cortical  lesions  with  paralysis, 
twitchings  or  convulsive  movements  are  common,  and,  from  their 
resemblance  to  epileptic  convulsions,  are  called  "cortical,  partial,  or 
Jacksonian  epilepsy";   50  per  cent,  of  cases  are  small  cortical  tumors 


Fig.  52. 


HEAD  TO  ORPOSITE  StDE 


TO  MID  LINE. 
CHEWING 


ASSOCIATED 

MOVEMENTS 

OF  EYES 


HNGERS_ALONE 
THUMB  ALONE 


FISSURE  OF  ROLANDO 
a'  fissure  OF  SYLVIUS 


Cerebral  localization  in  detail. 

Fi,F2,  Fa,  first,  second  and  third  frontal  convolutions.  AF,  ascending  frontal  convolution  and 
AP,  ascending  parietal  convolution.  SP,  supramarginal  and  AR,  angular  convolution.  Oi, 
O2,  Os,  first,  second  and  third  occipital  convolutions.  Ti,  To,  T3,  first,  second  and  third  tem- 
poral convolutions.     The  explanation  of  line  AA  is  given  under  INTERNAL  CAPSULE. 

or  cysts;  the  lesion  partly  destroys  the  motor  cortex  (paralysis),  and  at 
the  same  time  causes  irritation  (convulsions)  precisely  as  contractions 
are  produced  in  animals  by  electrical  stimulation  of  the  cortex;  they 
are  mainly  (a)  mechanical,  as  irritation  or  increased  intracranial  ten- 
sion (rapidly  growing  tumors),  or  (6)  due  to  vascular  affection  (hemor- 
rhage, embolism,  or  inflammation).  Stationary  lesions  rarely  produce 
Jacksonian  epilepsy,  unless  they  are  located  in  the  cortex.    The  spasms 


THE  MOTOR  CORTEX  945 

may  involve  but  one  part,  as  the  arm  (monospasm),  which  is  exclu- 
sively a  sign  of  cortical  irritation,  or  they  may  pass  from  one  centre 
to  others.  They  always  commence  in  one  centre  locally,  and  extend 
in  a  fixed  order.  If  the  arm-region  is  the  seat  of  a  tumor,  the  Jack- 
sonian  epilepsy  flexes  the  fingers,  moves  the  thumb,  then  the  forearm, 
arm  and  shoulder,  and  then  passes  down  the  cortex  region  (see  Fig.  50 
for  leg,  arm,  face  centres),  so  that  it  involves  the  face,  mouth  and 
finally  the  leg.  If  the  lesion  is  in  the  face  area,  the  various  facial 
muscles  contract,  and  the  eye  deviates,  then  the  next  area  above  the 
arm  centre  participates,  and  finally  the  higher  leg  centre  is  implicated. 
That  is,  the  spasm  never  skips  from  the  face  to  the  leg  centre,  but  it 
involves  the  arm  first.  If  the  leg  area  is  involved,  the  spasms  pass 
consecutively  down  to  the  arm  and  then  to  the  face,  i.e.,  they  never 
skip  the  arm,  nor  involve  the  face  before  the  arm  is  convulsed. 

The  spasms  are  often  preceded  by  a  tingling  in  the  part.  The  con- 
vulsions are  mostly  clonic,  or  clonic  broken  by  tonic  spasms,  and 
consciousness  is  very  often  maintained.  Unconsciousness  may  intervene 
when  the  fits  reach  the  other  side  of  the  body,  when  the  lesion  is  deep 
and  below  the  cortex,  or  when  they  are  very  frequent,  a  hundred  or 
more  daily.  The  opposite  side  is  involved  through  the  commissural 
fibers  of  the  corpus  callosum;  "bilateral  representation  in  both  hemi- 
spheres, which  saves  certain  groups  of  muscles  in  hemiplegia,  neces- 
sitates their  involvement  in  severe  spasms"  (Gowers).  Jacksonian 
differs  from  regular  epilepsy  in  that  no  cry  is  observed,  the  commence- 
ment is  local  and  more  gradual,  and  consciousness,  if  lost,  disappears 
gradually,  not  precipitately.  The  convulsions  may  precede  or  accom- 
pany the  paralysis.  The  seizure  lasts  several  seconds  to  a  minute  or 
two,  and  is  followed  by  some  vertigo,  nausea,  stupor,  or  disturbance  of 
speech;  if  spasms  occur  without  paralysis,  paresis  in  the  involved  parts 
follows,  due  to  transient  exhaustion  of  the  cortex.  Jacksonian  epi- 
lepsy in  its  lightest  forms  may  be  sensory. 

Regarding  sensory  localization  in  the  cortex,  opinions  vary,  and  our 
knowledge  is  far  less  exact.  Munk  holds  that  the  sensory  and  motor 
areas  are  the  same,  while  Charcot,  Nothnagel,  and  Ferrier  hold  that 
the  sensory  areas  are  separate  (v.i.).  Some  vasomotor  disturbance 
is  common  in  cortical  lesions,  and  Landois  and  Eulenberg  have  demon- 
strated a  vasomotor  centre  here. 

Sequences  of  disease  in  the  motor  centres  depend  on  the  nature  and 
extent  of  the  lesion.  After  total  lesions  of  the  central  convolutions,  the 
hands  improve  very  little  in  adults;  other  members  improve,  to  some 
extent  at  least,  through  assumption  of  function  by  the  sound  side  of 
the  brain;  in  young  individuals,  the  sound  pyramidal  tracts  in  the 
cord  may  hypertrophy  to  even  double  their  original  size.  The  motor 
fibers  running  from  the  pyramidal  cells  of  the  cortex  to  the  anterior 
horns  of  the  spinal  cord,  constituting  the  upper  motor  neuron,  undergo 
descending  degeneration,  that  is,  degeneration  in  the  direction  of  the 
motor  impulse. 

60 


946  DISEASES  OF  THE  NERVOUS  SYSTEM 


II.  Cortex  of  the  Parietal  Lobes. 

Our  knowledge  of  the  function  of  this  cortex  is  less  definite  than 
that  of  the  motor  cortex,  (a)  Lesions  of  the  first  lobe  (P^  Fig.  52, 
the  Precuneus  in  Fig.  51),  supplied  by  the  anterior  cerebral  artery, 
cause  disturbance  in  motility  of  the  leg,  with  altered  muscle  sense, 
"mind  blindness,"  inability  to  read  (alexia),  and  according  to  some 
authorities,  hemianopsia.  (6)  Disease  of  the  swpramarginal  convolu- 
tion (S.P.  Fig.  52),  also  involving  the  motor  cortex,  produces  greater 
disturbance  of  sensation  than  when  the  lesion  is  confined  to  the  motor 
centres;  muscular  sense  is  disturbed,  usually  with  some  motor  paralysis 
or  paresis.  Three  cases  are  reported  in  which  there  was  disturbance 
of  muscle  sense  without  paresis.  Muscle  sense  is  disturbed  in  23  per 
cent,  of  all  cases  of  cerebral  hemiplegia,  though  in  more  than  50  per 
cent,  of  cerebral  paralyses,  no  special  sensory  disturbance  is  noted. 
Disturbance  in  muscle  sense  probably  indicates  that  a  cerebral  lesion 
is  located  in  the  cortex,  if  indirect  pressure  can  be  excluded.  There 
may  be  loss  of  the  stereognostic  sense,  whereby  the  patient  fails,  when 
his  eyes  are  closed,  to  recognize  the  geometric  form  of  solid  objects, 
as  a  key  or  ball.  Cortical  incoordination  (ataxia)  sometimes  results, 
probably  on  account  of  disturbance  in  the  association  fibers.  It  differs 
from  other  ataxias  (the  tabetic  and  cerebellar  forms),  in  that  the  mus- 
cular strength  is  usually  diminished,  and  the  finer  movements  are 
impossible,  though  the  coarser  movements  may  sometimes  be  carried 
out.  Cortical  hemiansesthesia  is  not  frequent,  (c)  Ptosis  and  paralysis 
of  the  orbicularis  oculi  are  said  to  result  from  lesions  of  the  gyrus  angu- 
laris  (A.R.  Fig.  52),  and  according  to  Monakow,  inability  to  read 
(alexia),  optic  aphasia  and  "mind  blindness."  Wernicke  correctly 
diagnosticated  softening  in  this  lobe  by  conjugate  deviation  of  the  eyes 
and  head  as  the  only  symptom.  Disease  of  the  posterior  inferior  part 
probably  causes  crossed  amblyopia. 

III.  The  Cortex  of  the  Occipital  Lobes. 

This  is  undoubtedly  the  visual  centre.  Its  exact  seat  is  somewhat 
disputed,  but  the  weight  of  evidence  shows  that  it  is  in  the  cuneus 
(Fig.  52)  and  the  first  occipital  lobe.  A  lesion  of  the  occipital  cortex 
produces  (a)  bilateral  homonymous  hemiopia  (hemianopsia),  (for  details 
of  which  and  the  following  see  Affections  of  the  Optic  Nerve). 
(b)  Hemichromatopsia,  an  homonymous  color  blindness,  especially  for 
green  and  red,  in  which  the  color  perceptions  are  confused  rather  than 
lost;  the  lesion  in  such  cases  is  superficial  and  anterior;  (c)  total  cor- 
tical blindness,  if  the  lesion  is  bilateral,  or  both  optic  radiations  are 
destroyed,  {d)  "Mind  blindness"  results  from  a  lesion  on  the  anterior 
outer  surface  of  the  left  occipital  region,  especially  the  second  occipital 
lobe  or  (according  to  others)  from  disease  of  the  gyrus  angularis. 


THE  FRONTAL  CORTEX  AND  APHASIA  947 

The  visual  memory  is  lost;  things  actually  seen  are  misinterpreted, 
and  the  patient  confuses  persons  and  things,  (e)  Alexia,  inability  to 
read,  also  called  "word  blindness/'  wherein  the  patient  can  read  but 
fails  to  understand  the  letters  or  words  he  sees  and  reads.  His  memory 
for  words  is  lost.  It  is  due  to  destruction  of  the  subcortical  long  and 
short  association  fibers  in  the  second  occipital  lobe  (von  Monakow) 
and  the  gyrus  angularis;  it  most  commonly  follows  vascular  disease. 
(/)  O'ptic  aphasia  results  from  foci  in  the  left  occipital  lobes  (and  also 
in  the  angular  and  supramarginal  convolutions),  and  consists  of  mis- 
interpretation of  visual  impressions,  so  that  the  patient  miswrites  and 
misnames  objects  seen,  though  able  to  name  them  when  he  feels  them. 
(g)  Crossed  amblyopia  sometimes  occurs. 


IV.  The  Cortex  of  the  Temporal  Lobes  (T^,  T2,  T3,  Fig.  52). 

The  outer  surface  of  the  posterior  half  of  the  first  (and  second)  tem- 
poral convolution  is  the  auditory  centre;  it  is  said  to  be  larger  on  the 
left  side;  disease  in  this  cortex  produces  (a)  deafness  in  the  opposite 
ear;  atrophy  of  this  lobe  is  encountered  in  congenital  deafness.  Deaf- 
ness is  usually  transitory,  because  fibers  seemingly  pass  to  both  ears 
from  each  centre.  If  this  lobe  is  destroyed  on  both  sides,  total  deafness 
results.  (6)  Conjugate  deviation  of  the  eyes  has  been  observed,  and  is 
said  to  be  a  reflex  from  auditory  impressions,  (c)  Disease  of  the  first 
temporal  lobe  produces  "word  deafness,"  also  known  as  "mind  deaf- 
ness" ;  it  is  a  loss  of  the  comprehension  of  speech.  Somewhat  in  front 
of  this  lobe,  it  is  supposed  that  musical  memories  are  stored.  In  the 
uncinate  gyrus  (Fig.  51)  the  special  sense  of  smell  probably  has  its 
centre.  Ferrier  refers  the  general  sensory  centre  to  this  lobe.  The 
gyrus  fornicatus  (Fig.  51)  is  said  to  be  the  centre  for  taste,  and  pos- 
sibly for  the  sense  of  pain. 


V.  The  Frontal  Cortex  and  Aphasia. 

Regarding  the  frontal  lobes  anterior  to  their  participation  in  the 
motor  cortex,  we  have  little  definite  knowledge.  Profound  disease 
may  develop  without  clinical  symptoms.  They  have  long  been  thought 
to  be  the  residence  of  (a)  the  psychical  functions,  especially  for  ethical 
and  abstract  thought  (Meynert,  and  Flechsig).  "Defect  in  character" 
followed  the  oassage  of  a  large  crowbar,  l-^-  inches  thick  and  3^  feet 
long,  through  both  frontal  hemispheres,  in  the  famous  crowbar  case 
of  Harlow.  Psychical  functions  probably  concern  the  frontal  lobes, 
although  the  relative  integrity  of  the  entire  brain  is  necessary  for  them. 
(6)  Flechsig  considers  the  frontal  lobe  the  anterior  association  centre, 
the  middle  one  being  the  cortex  of  the  island  of  Reil,  and  the  posterior 
one  the  large  area  posterior  to  the  motor  cortex,  (c)  Bruns  has  observed 
ataxia  similar  to  the  cerebellar  type,  but  this  probably  results  either 


948  DISEASES  OF  THE  NERVOUS  SYSTEM 

from  pressure  transmitted  to  the  cerebellum,  or  from  involvement  of 
the  trunk  centre,  (d)  The  motor  speech  area  lies  in  the  lower  frontal 
convolution.  Its  function  and  relations  can  be  well  considered  in  con- 
nection with  motor  and  other  varieties  of  aphasia.  The  history  of 
aphasia  marks  the  beginning  of  cerebral  localization,  and  three  French 
writers  have  determined  its  motor  centre.  Bouillaud,  in  1825,  referred 
aphasia  to  the  frontal  lobes;  Dax,  in  1836,  narrowed  the  localization 
to  the  left  frontal  region,  and  the  motor  centre  was  finally  confined  to 
the  posterior  part  of  the  lower  left  frontal  convolution,  in  1861,  by 
Broca,  whose  name  is  given  to  this  convolution.  The  sensory  element, 
necessary  to  all  voluntary  movements,  was  unknown  until  later,  when 
Meynert  and  Wernicke  discovered  the  auditory  centre  in  the  first  tem- 
poral convolution;  Wernicke  localized  ''word  deafness"  in  the  same 
convolution  of  the  left  side,  and  Naunyn,  and  others,  emphasized  the 
importance  of  the  gyrus  angularis  and  adjacent  parts  of  the  occipital 
lobes  in  cases  of  disturbance  of  writing,  visual  aphasia,  etc. 

Motor  Aphasia. — The  motor  speech  centre  lies  in  Broca 's  lobe,  the 
posterior  part  of  the  left  third  frontal  convolution ;  it  controls  the  motor 
centres  next  described  and  retains  the  impressions  or  memories  neces- 
sary to  their  exercise.  The  corresponding  lobe  on  the  right  side  has 
some  function,  being  the  actual  centre  in  left-handed  persons.  It  often 
assumes  the  functions  of  the  left  speech  centres,  after  disease  of  the 
latter,  especially  in  children.  Articulate  speech  also  depends  upon 
the  integrity  of  the  lower  part  of  the  ascending  frontal  convolution  of 
the  motor  cortex,  in  which  lie  the  centres  for  the  mouth,  lips,  tongue, 
jaw,  and  larynx,  (a)  These  constitute  the  cerebral  mechanism  of  speech, 
whose  disturbance  is  designated  motor  aphasia.  Motor  fibers  run 
from  the  cortex  through  the  centrum  ovale,  internal  capsule  (lying  in 
front  of  the  pyramidal  tracts),  cms  (inside  the  pyramidal  tracts)  to 
their  nuclei  in  the  pons  and  medulla,  whence  the  peripheral  bulbar 
nerves  to  the  tongue  and  larynx  take  their  origin.  (6)  These  lower 
tracts  constitute  the  bulbar  mechanism  of  speech,  disease  in  the  com- 
ponents of  which  causes  abolition  of  articulation  (anarthria),  or  more 
often  imperfect  articulation  (dysarthria).  The  elements  of  speech 
are  correct  in  dysarthria,  but  articulation  is  imperfect,  for  the  labials, 
palatals,  or  Unguals  are  imperfectly  delivered,  or  consonants  are  run 
together.  To  speak,  the  individual  must  have  ideas,  conceptions. 
To  illustrate,  a  cortical  lesion  in  Broca 's  convolution,  as  small  as  a 
hazel-nut,  may  produce  motor  aphasia,  which  is  either  absolute  or 
partial;  the  patient  may  pronounce  correctly  some  few  words,  pos- 
sibly only  under  emotion  or  in  certain  relations,  or  he  may  pronounce 
words  wrongly  formed,  although  he  recognizes  his  mistakes.  He  com- 
prehends what  is  said  to  him,  for  the  lesion  involves  no  special  sense 
element.  He  can  read  writing  and  print,  especially  if  educated,  because 
"  sight  may  stimulate  images  without  intervention  of  the  motor  centre," 
but  he  cannot  speak  voluntarily,  nor  repeat  what  is  said  to  him;  he 
cannot  read  aloud;   he  cannot  write  (agraphia)  as  a  rule,  because  im- 


THE  FRONTAL  CORTEX  AND  APHASIA  949 

pulses  cannot  pass  to  the  hand  centre.  He  may  be  able  to  copy  (v.  i. 
Table).    The  cortical  is  the  usual  form  of  motor  aphasia. 

A  subcortical  lesion  in  the  centrum  ovale  may  sever  the  fibers  between 
Broca's  convolution,  and  the  motor  cortex  for  the  tongue,  lips, 
etc.  The  patient  cannot  speak,  but  the  speech  centre  is  normal.  It  is 
a  rare  lesion,  and  is  known  as  pure  motor  aphasia  (Lichtheim).  The 
patient  can  write.  It  involves  the  commisural  fibers  by  way  of  the 
corpus  callosum  to  the  right  side,  and  usually  produces  permanent 
aphasia,  because  the  possibility  of  compensation  by  the  right  hemi- 
sphere is  precluded,  but  if  the  lesion  is  in  the  internal  capsule,  the 
aphasia  is  transient,  since  compensation  through  the  corpus  callosum 
is  established. 

Sensory  Aphasia. — In  speech,  as  in  every  voluntary  motion,  sensa- 
tion and  sensory  memories  are  necessary.  The  sensory  relations  of 
speech  are  hearing,  sight,  taste,  and  in  the  blind,  touch. 

Auditory  Aphasia. — Hearing  is  most  important,  and  develops  in 
the  child  long  before  speech.  When  a  child  begins  to  talk,  or  when  one 
who  has  lost  speech  relearns  it,  the  brain  cortex,  through  an  association 
of  centres,  learns  to  connect  certain  sounds  or  words  with  definite  objects 
or  conditions.  The  child  hears  through  the  auditory  nerves  which  run 
from  each  side  to  both  auditory  centres  in  the  first  temporal  convolution 
of  either  side.  He  hears  mechanically,  just  as  we  may  hear  without 
understanding  a  foreign  language,  and  learns  to  associate  the  sounds 
with  objects,  conditions  or  ideas,  for  which  an  auditory  speech  centre 
in  the  left  first  temporal  convolution  (in  right-handed  persons)  is  devel- 
oped. Here  sounds  coming  from  the  two  centres  of  hearing,  are 
remembered,  associated,  and  controlled.  Remembering  a  sound  he 
has  heard,  but  perhaps  has  never  spoken,  the  child  calls  into  play 
Broca's  convolution,  the  cortical  centres  for  the  lips,  tongue,  etc.,  and 
speaks.  Hearing  is  necessary  to  articulate  speech,  unless,  as  in  deaf 
mutes,  education  replaces,  by  sight  and  touch,  the  associations  usually 
acquired  by  hearing.  Destruction  of  the  auditory  speech  centre  pro- 
foundly disturbs  speech.  The  patient  then  hears  by  the  auditory 
nerves  and  centres,  or  reads  by  the  visual  apparatus,  but  does  not 
understand  what  he  hears  or  reads;  this  is  known  as  sensory  (auditory) 
aphasia,  or  word  deafness.  It  is  rarely  absolute,  and  recovery  is  more 
common  than  in  motor  aphasia.  The  subject  in  speaking  transposes 
words  (paraphasia)  but  does  not  realize  his  mistakes,  an  important 
distinction  from  motor  aphasia.  Often  he  later  becomes  speechless. 
He  cannot  repeat  words  nor  write  from  dictation.  Voluntary  revival 
of  words  is  lost  (Gowers).  Voluntary  writing  is  impossible,  but  copy- 
ing of  words  is  sometimes  maintained. 

Subcortical  auditory  aphasia,  or  pure  word  deafness  (the  rarer  form), 
results  from  disease  between  the  auditory  speech  centres  and  the  two 
centres  for  hearing.  It  must  therefore  be  below  the  cortex  in  the  white 
matter,  hence  called  subcortical.  Auditory  impressions  cannot  reach 
the  auditory  speech  centres  of  the  patient,  who  cannot  understand 
what  is  said,  cannot  repeat  or  write  from  dictation.    As  the  auditory 


950  DISEASES  OF  THE  NERVOUS  SYSTEM 

speech  centre  is  normal,  memory  for  words  is  retained,  and  the  patient 
can  read,  speak,  and  write. 

"  Amnestic"  aphasia  may  be  a  simple  difficulty  in  recalling  certain 
words  in  speaking  or  writing,  or  it  may  be  very  pronounced  (word 
deafness).  It  is  also  poorly  called  conduction  aphasia  (Wernicke), 
and  is  due  to  interruption,  probably  in  the  island  of  Reil,  of  the  fibers 
between  the  motor  and  sensory  speech  centres.  Gowers  states  that  it 
may  result  from  partial  recovery  from  motor  aphasia,  or  from  sensory 
aphasia. 

Visual  Aphasia. — Sight  is  very  important  in  sensory  speech.  The 
child  who  has  learned  sounds  (words)  and  is  able  to  speak  them,  reads 
by  associating  the  sounds  heard  and  spoken,  with  words,  letters,  or 
symbols  seen  by  him.  Memory  of  these  visual  concepts  is  stored  in  the 
supramarginal  and  angular  gyri.  Reading  music,  etc.,  is  learned  in 
the  same  way.  While  in  most  individuals  mental  processes  are  carried 
on  by  the  memory  of  words,  in  rare  instances,  visual  memory  may  be 
more  important.  Destruction  of  the  angular  and  supramarginal  con- 
volutions by  causing  a  loss  of  the  visual  Tnemories,  produces  alexia, 
word  blindness,  an  inability  to  read.  In  some  cases,  the  patient  can 
read,  but  without  understanding.  Isolated  alexia  is  always  due  to 
lesions  in  these  convolutions.  He  usually  cannot  write  (agraphia), 
and  cannot  copy,  but  can  speak  fairly  well  and  understand  what  is 
spoken.  If  the  optic  centre  in  the  occipital  lobes  is  intact,  he  cannot 
name  objects  after  seeing  them,  since  the  visual  memory  centre  is 
destroyed,  but  may  recognize  a  watch  by  hearing  it  tick  or  by  feeling  it. 
Lesions  just  below  the  visual  memory  centre,  involving  the  afferent 
fibers,  produce  pure  subcortical  word  blindness,  or  alexia,  that  is,  inabil- 
ity to  read,  with  hemianopsia  and  preservation  of  voluntary  speech 
and  writing.  Word  deafness  and  word  blindness  often  co-exist.  Six- 
teen cases  of  congenital  word  blindness  were  collected  by  Stephanson 
(1904). 

Pure  motor  and  sensory  aphasia  is  less  common  than  complicated 
forms.  The  diagrams  often  employed  to  illustrate  the  mechanism  of 
aphasia  are  open  to  the  objection  that  they  are  hypothetical,  and  do 
not  cover  all  cases.  The  anatomical  lesions,  mostly  arterial,  are  largely 
the  result  of  softening,  the  entire  sphere  of  speech  or  language  being 
supplied  by  the  artery  of  the  fossa  of  Sylvius.  Motor  aphasia  is  likely 
to  occur  with  disease  of  the  motor  cortex  or  cerebral  pyramidal  tracts, 
and  the  sensory  form  with  disease  of  the  optic  fibers.  Hemorrhage, 
trauma,  and  in  children,  tuberculosis  of  the  brain  or  meninges,  are  also 
causative.  Lasting  aphasia  in  children  is  usually  due  to  mental  causes, 
since  in  early  life  the  right  frontal  area  usually  takes  up  the  function 
of  Broca's  convolution.  Congenital  aphasia  may  follow  bilateral 
meningeal  hemorrhage.  Aphasia  also  occurs  in  idiocy  in  adults,  in 
melancholia,  migraine,  convulsions,  and  is  especially  apt  to  occur 
from  functional  causes  in  children,  as  from  fever,  fright,  worms,  etc. 
In  adults,  the  outlook  is  less  favorable  than  in  children.  Partial 
recovery  is  possible  in  cases  of  hemiplegia,  and  sometimes  with  care, 


THE  INTERNAL  CAPSULE  951 

reeducation  may  yield  fair  results.  The  following  table  (on  page 
952)  is  borrowed  from  Archibald  Church's  excellent  work  on  Nervous 
Diseases. 

VI.  Centrum  Ovale. 

Lesions  are  usually  hard  to  diagnosticate,  and  focal  symptoms  may 
be  entirely  absent,  if  a  lesion  occur  between  the  associative,  commis- 
sural, motor,  or  sensory  fibers  (corona  radiata).  When  present,  symp- 
toms are  usually  those  of  (a)  a  cortical,  or  (6)  an  internal  capsule  lesion. 
A  lesion  must  be  (a)  very  near  the  cortex  to  produce  either  Jacksonian 
or  general  convulsions.  A  monoplegia  and  subcortical  aphasia  may 
occur  in  this  location.  Sensory  disturbances,  as  hemianopsia,  may  be 
noted  in  a  subcortical  disease.  Aphasia  from  a  lesion  in  the  island  of 
Reil  may  produce  the  so-called  conduction  aphasia.  Psychical  symp- 
toms may  result  from  interruption  near  the  centre  of  the  association 
fibers  which  run  from  one  part  to  another  of  the  same  hemisphere. 
(Commissural  fibers  are  those  running  from  one  hemisphere  to  the 
other,  as  through  the  corpus  callosum,  disease  of  which  presents  no 
pathognomonic  sign,  according  to  most  neurologists.)  (6)  Internal 
capsule  symptoms  result  in  lesions  low  in  the  centrum  ovale.  Hemi- 
ansesthesia  and  sensory  symptoms  in  general  indicate  lesions  of  the 
internal  capsule. 

VII.  The  Internal  Capsule. 

It  is  compacted  and  consists  of  nearly  all  the  motor,  sensory,  and 
special  sense  fibers  from  the  brain  to  the  lower  parts.  It  has  an  exten- 
sive vascular  supply.  The  capsule  is  divided  into  an  anterior  limb, 
the  knee  and  a  posterior  limb. 

Anterior  Limb. — Its  function  is  not  clear,  although  it  contains  fibers 
from  the  frontal  cortex  to  the  optic  thalamus.  Lesions  here  are  very  rare. 
It  also  contains  fibers  which,  in  lower  horizontal  sections,  run  into  the 
knee  and  are  found  in  basal  median  bundle  of  the  crus,  whence  they 
run  to  the  pons  nuclei  for  the  eye,  head,  neck,  and  probably  also  for 
the  larynx,  tongue,  and  mouth. 

Knee. — The  knee  (see  Fig.  53)  contains  from  before  backward 
fibers  for  opening  of  the  eyes,  associated  movements  of  the  eyes  and 
head,  the  tongue  and  mouth;  Horsley  and  Beevor  have  been  able 
to  stimulate  them  electrically,  one  by  one.  This  segment  contains  the 
phonation  fibers  for  speech,  probably  including  those  of  the  larynx. 

Posterior  Limb. — The  posterior  limb  contains  in  its  anterior  third, 
the  fibers  for  the  shoulder,  elbow,  wrist,  fingers,  thumb,  and  body;  in 
its  middle  third  those  for  the  hip,  ankle,  knee,  and  toes;  in  its  posterior 
third  (Charcot's  "sensory  crossway"),  those  for  sensation  and  the 
special  senses.  The  number  of  fibers  to  a  part  depends  less  on  the 
size  of  a  muscle  than  on  its  development  in  fineness  of  movement;  for 
instance,  the  fingers  receive  a  relatively  large  number  of  fibers.     If  a 


952 


DISEASES  OF  THE  NERVOUS  SYSTEM 


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THE  INTERNAL  CAPSULE  953 

ruler  be  placed  anterior  to  the  line  (^4^1)  in  Fig.  52,  and  slowly  moved 
to  the  right,  preserving  its  parallelism,  it  will  be  seen  that  the  cortical 
motor  areas  touched  will  approximately  correspond  with  their  order 
in  the  internal  capsule.  The  most  common  sequence  of  lesions  of  the 
internal  capsule  is  cerebral  hemiplegia  of  the  opposite  side  of  the  body. 
Though  hemiplegia  may  result  from  lesions  elsewhere  in  the  motor 
tract  (cortex,  centrum  ovale,  crus,  pons,  or  medulla),  in  the  vast 
majority  of  cases,  hemiplegia  is  the  result  of  disease  of  the  internal 

Fig.  53. 


Localization  in  internal  capsule. 

capsule.  If  the  internal  capsule  is  destroyed,  total  hemiplegia  results, 
and  paralysis  of  the  arm,  leg,  and  lower  part  of  the  face  (the  upper 
part  of  which,  and  the  head  escape,  because  they  have  a  bilateral  supply 
from  both  hemispheres).  The  hypoglossus  is  but  moderately  involved 
as  a  rule,  and  aphasia  is  usually  temporary.  With  the  hemiplegia  are 
also  associated  hemiansesthesia,  hemianopsia,  and  unilateral  disturb- 
ance of  smell,  taste,  and  hearing,  by  lesion  of  the  fibers  ascending  from 
the  tegmentum;  with  the  hemiplegia  are  observed  contractures,  de- 
scending degeneration,  decrease  or  absence  of  the  skin  reflexes,  espe- 
cially the  cremasteric,  and  increase  of  the  tendon  reflexes.  Monoplegia 
is  rare,  because  the  tracts  are  so  compact  that  the  face,  for  example, 
is  rarely  alone  involved,  though  Duplay  and  Diday  record  isolated 
cases.  It  is  possible  that  a  linear  lesion  may  involve  the  outer  part  of 
the  capsule's  knee,  that  is,  it  may  involve  the  face  and  also  the  leg, 
leaving  the  arm  free  (Wernicke,  Charcot,  Kolisko).  Hemiansesthesia 
(skin  sensation  and  muscle  sense),  rarely  exist  without  some  paresis 
of  the  leg.  Some  tingling  or,  in  incomplete  lesions,  some  pain  may 
result,  even  when  the  leg-arm  areas  are  alone  involved,  for  some  sen- 


954  DISEASES  OF  THE  NERVOUS  SYSTEM 

sory  fibers  course  with  the  motor  fibers.  Hemi-tremor,  -athetosis  and 
-chorea  result  from  lesions  of  the  sensory  area,  usually  associated 
with  disease  in  or  just  below  the  optic  thalamus.  (The  course  of  the 
sensory  paths  will  be  considered  under  Localization  in  the  Spinal 
Cord.)  Back  of  the  general  sensory  tracts,  disease  may  injure  the 
optic  radiation  (running  between  the  occipital  sight  centre  and  the 
lateral  geniculate  body),  or  interrupt  the  auditory  and  other  special 
sense  fibers.  Psychical  disturbance,  aphasia,  alexia,  agraphia,  and 
permanent  involvement  of  any  cranial  nerve  are  not  symptomatic 
of  disease  of  the  internal  capsule. 

VIII.  The  Corpus  Striatum. 

This  is  composed  of  the  caudate  and  lenticular  nuclei.  It  is  doubtful 
whether  it  is  connected  with  the  cortex.  The  lenticular  nucleus  is 
extensively  connected  with  the  superior  peduncle  of  the  cerebellum 
and  the  tegmentum  of  the  crus.  The  caudate  nucleus  is  connected 
with  the  internal  capsule,  and  with  the  crus;  these  fibers  seem  to  end 
in  the  pons  and  cerebellum.  An  apoplexy  in  the  corpus  striatum  prob- 
ably causes  rise  of  temperature;  Nothnagel  's  law  still  holds  that  hemi- 
plegia is  permanent  only  when  the  internal  capsule  is  directly  injured, 
although  indirect  transient  hemiplegia,  from  simple  pressure  on  the 
capsule,  may  result  from  disease  of  the  corpus  striatum.  Landouzy 
reports  a  case  of  contralateral  hemiathetosis  from  isolated  disease  of 
the  lenticular  nucleus. 


IX.  The  Optic  Thalamus. 

This  is  surrounded  by  gray  matter,  continuous  with  that  surround- 
ing the  third  ventricle  and  central  canal  of  the  cord,  and  is  connected 
by  fibers  with  all  parts  of  the  cerebral  cortex,  the  tegmentum,  and 
superior  cerebellar  peduncle.  Nothnagel  (1879)  was  the  first  to 
describe  its  topical  symptomatology.  Sometimes  disease  in  this  locality 
is  latent;  again,  the  following  findings  are  observed,  alone  or  in  com- 
bination: (a)  Contralateral  hemianopsia  may  develop  from  a  lesion 
in  the  posterior  part  of  the  thalamus,  the  pulvinar  (Gowers),  or  a  lesion 
which  also  invades  the  lateral  geniculate  bodies  (von  Monakow). 
These  areas  are  connected  by  the  optic  radiation  with  the  optic  centre. 
This  hemianopsia  is  distinguished  from  that  caused  by  a  cortical  lesion 
by  the  hemianopsic  pupillary  reaction  and  the  absence  of  the  marginal 
field  of  vision,  (b)  Disturbance  of  the  mimetic  movements  of  expression 
may  develop  (Nothnagel,  Bechterew).  The  optic  thalamus  is  the  reflex 
centre  of  the  involuntary  movements  for  expression,  as  weeping  or 
laughing.  A  patient  with  hemiplegia  from  destruction  of  the  left  inter- 
nal capsule  cannot  voluntarily  move  the  lower  right  part  of  the  face, 
but  the  paralyzed  portion  of  the  face  moves  when  the  patient  laughs, 


THE  CORPORA   QUADRIGEMINA  955 

for  the  centre  is  in  the  posterior  part  of  the  thalamus.  On  the  other 
hand,  in  isolated  disease  of  the  optic  thalamus,  the  opposite  side — 
indeed  botlv  sides  of  the  face, — can  be  voluntarily  moved,  since  the 
facial  nerve  runs  in  the  internal  capsule,  but  the  patient  cannot  laugh  or 
weep,  (c)  Sensory  disturbances  may  occur,  such  as  hemiansesthesia, 
hemichorea,  hemitremor,  pain  in  the  opposite  arm  (Edinger),  or  hemi- 
ataxia,  but  it  is  not  absolutely  certain  in  some  of  these  cases  that  the 
sensory  portion  of  the  internal  capsule  was  not  involved.  There  may 
be  vasomotor  changes,  atrophy,  and  disturbance  in  the  evacuation  of 
the  bladder  and  rectum.  Von  Monakow  thinks  that  all  the  symptoms 
referred  to  the  thalamus  are  probably  referable  to  disease  exterior  to  it. 


X.  The  Corpora  Quadrigemina. 

These  are  masses  of  gray  matter,  whose  fibers  lie  over  the  aqueduct 
of  Sylvius  and  the  tegmentum.  There  is  much  variance  of  opinion 
regarding  their  function.  They  are  actually  connected  with  the  third 
nerve  nucleus,  and  some  hold  that  they  contain  the  centres  for  con- 
traction of  the  heart  and  stomach. 

Disease  in  the  anterior  corpora  quadrigemina  produces  (a)  moderate 
involvement  of  sight.  Some  writers  claim  that  total  blindness  or  hemi- 
anopsia may  result,  but  most  of  these  cases  had  tumors  with  optic 
neuritis ;  slight  disturbance  has  a  greater  localizing  significance  if  there 
is  no  coincident  neuritis.  These  bodies  are  connected  with  the  external 
geniculate  bodies  and,  by  way  of  the  internal  capsule,  with  the  optic 
radiation.  (6)  In  acute  lesions,  narrowing  of  the  pupil  is  suggestive 
of  this  localization.  In  old  lesions,  one  or  both  pupils  are  wide,  and 
without  reaction  to  light  or  accommodation,  (c)  The  eye  muscles  may 
be  partially  paralyzed,  especially  those  supplied  by  the  third  nerve; 
this  results  in  ptosis,  and  upward  movements  of  the  eyes.  The  dis- 
turbance is  not  associated.  Much  doubt  is  felt  in  considering  these 
symptoms  indicative  of  this  localization,  because  the  lesion  is  always 
so  near  the  nucleus  of  the  third  nerve.  Disease  in  the  posterior  corpora 
quadrigemina  may  result  (a)  in  ataxia,  according  to  Nothnagel,  though 
others  refer  it  to  actual  cerebellar  disease,  to  connections  with  the  cere- 
bellum through  the  nucleus  ruber,  or  to  disease  in  the  fillet  of  the  teg- 
mentum; (6)  in  trochlearis  paralysis;  in  which  the  eyes  cannot  be 
turned  inward  or  outward;  sometimes  it  results  in  abducens  paralysis; 
(c)  in  difficult  mastication  from  involvement  of  the  descending  branch 
of  the  quintus;  (d)  in  contralateral  disturbance  of  hearing,  since  the 
posterior  corpora  quadrigemina  are  connected  with  the  fillet  of  teg- 
mentum and,  by  means  of  the  ''sensory  crossway"  of  the  internal 
capsule,  with  the  hearing  centre  in  the  first  temporal  lobe. 


956 


DISEASES  OF  THE  NERVOUS  SYSTEM 


XI.  The  Crus  (Cerebral  Peduncle). 

Focal  symptoms  may  be  divided  into  motor  and  sensory  symptoms. 
The  motor  fibers  to  the  cranial  nerves  decussate  higher  than  the  pyra- 
midal tracts  which  decussate  in  the  medulla;  the  fibers  to  the  third 
nerve  cross  in  the  upper  crus,  although  some  enter  the  nucleus  of  the 
same  side.  Crossed  paralysis  (hemiplegia  alternans  oculomotoria 
superior)  is  common  in  crus  lesions.  It  consists  of  a  hemiplegia  of  the 
side  of  the  body  opposite  to  the  lesion,  and  a  paralysis  of  the  third  nerve 
on  the  same  side  as  the  lesion,  often  known  as  Weber's  paralysis,  though 
it  was  first  described  by  Gendrin.  From  Fig.  54,  it  is  seen  that  a  lesion 
involving  the  right  pyramidal  fibers  may  also  catch  those  of  the  third 

Fig.  54. 


Lesion  in  cms  (shown  by  dotted  lines) ,  producing  a  superior  alternating  or  crossed  hemiplegia;  the 
lesion  involves  the  pyramidal  tract  (PR) ,  the  cranial  nerves  (tongue  and  face,  CR)  and  the 
ouclomotor  nerve  (III,  F)  which  is  paralyzed  on  the  same  side  as  the  lesion  while  PR  and  CR 
are  paralyzed  on  the  opposite  side.  AS-Aqueduct  of  Sylvius;  Ill-nucleus  of  third  nerve; 
CGI-Corp.  geniculatum  int. ;  Fi-upper  part  and  Fo-lower  part  of  fillet;  NR-nucleus  ruber; 
SN-Substantia  nigra. 

nerve  on  the  same  side,  giving  a  left-sided  hemiplegia  (face,  arm,  and 
leg),  and  right-sided  oculomotor  paralysis,  which  is  peripheral  and 
usually  complete,  with  strabismus,  ptosis,  inability  to  look  up  or  down, 
and  a  wide  reactionless  pupil.  The  crossed  or  alternating  hemiplegia 
is  called  superior  to  designate  its  location,  because  inferior  alternating 
hemiplegia  may  also  occur  in  lesions  of  the  pons.  One  must  be  sure 
that  one  lesion  only  exists.  In  tumors  near  the  internal  capsule 
which  press  on  the  third  nerve,  the  same  symptom  complex  may  occur, 
and  is  recognized  by  noting  whether  the  hemiplegia  and  paralysis  of 
the  third  nerve  occurred  together  (indicating  a  crus  lesion)  or  whether 
the  third  nerve  paralysis  followed  the  hemiplegia  (indicating  a  lesion 
near  the  internal  capsule  pressing  secondarily  on  the  oculomotorius). 


THE  PONS  957 

A  lesion  in  the  tegmentum  of  the  crus  may  cause  (a)  sensory  disturb- 
ance, as  hemiansesthesia,  which  involves  skin  sensation  and  muscle 
sense,  and  of  which  over  thirty  cases  are  recorded;  such  a  lesion  is  in 
the  fillet;  hypsesthesia  (reduced  sensation)  is  more  common.  (6)  The 
special  senses  are  sometimes  involved,  producing  hemianopsia,  or  poor 
hearing  in  the  opposite  ear.  (c)  Ataxia  has  been  seen  alone  (6  cases), 
or  together  with  other  symptoms.  It  differs  from  the  cerebellar  type 
in  that  it  is  manifest  only  on  motion.  Involvement  of  the  red  nucleus 
(which  is  connected  with  the  cerebellum  or  with  its  arm),  produces 
cerebellar  ataxia,  (d)  Oculomotor  paresis  on  the  side  of  lesion  is  char- 
acteristic when  combined  with  crossed  hemiataxia,  hemiplegia,  hemi- 
ansesthesia,  or  possibly  with  tremor,  low  temperature,  and  vasomotor 
disorder.  Fig.  54  shows  how  a  tegmental  focus  can  rarely  miss  the 
diffuse  nuclei  of  the  third  nerve.  If  the  lesion  is  in  the  lower  part  of 
the  crus,  the  oculomotor  paralysis  is  usually  complete,  but  if  in  the 
tegmentum,  it  is  always  partial,  selecting  the  pupil,  the  lid,  or  the 
superior  or  internal  rectus  muscles. 

XII.  The  Pons. 

Lesions  of  the  pons  are  most  commonly  tumors,  hemorrhage,  soften- 
ing, or  abscess.  Its  structures  are  so  closely  arranged  that  sometimes 
both  sides  are  implicated,  and  this  may  produce  bilateral  hemiplegia, 
though  a  small  lesion,  as  a  long  thin  tumor,  may  give  no  localizing 
symptoms;  most  diseases  of  the  pons  produce  a  typical  picture.  From 
a  lesion  of  the  upper  pons,  i.  e.,  the  portion  above  the  facial  nucleus,  a 
hemiplegia  results  like  that  produced  by  lesions  of  the  internal  capsule, 
which  affects  the  face,  arm,  and  leg,  all  on  the  same  side  of  the  body. 
(See  Fig.  55,  focus  A.)  The  facial  paralysis  is  supranuclear,  partial, 
and  with  no  reaction  of  degeneration.  In  a  focu^  in  the  lower  pons 
(focus  B,  Fig.  55),  where  the  facial  fibers  have  already  crossed, 
the  tongue,  arm,  and  leg  are  hemiplegic  on  the  side  opposite  to  the 
focus,  and  the  facial  paralysis  is  on  the  side  of  the  lesion;  this  is 
the  crossed  or  alternating  paralysis  (hemiplegia  alternans  facialis), 
which  was  first  described  by  Millard  (1856),  and  then  by  Gubler 
(1859).  The  facial  paralysis  is  peripheral  and  nuclear,  involves  all 
branches,  and  gives  the  reaction  of  degeneration.  Sometimes  there 
is  also  some  slight  paralysis  of  the  face  on  the  hemiplegic  side  from 
involvement  of  some  fibers  from  the  cortex.  Other  alternating  par- 
alyses are  also  observed,  as  hemiplegia  with  crossed  paralysis  of  the 
third,  fourth,  fifth,  and  sixth  nerves,  the  paralysis  of  which  is  usually 
both  central  (nuclear)  and  peripheral.  Hemiplegia  may  occur  with 
conjugate  paralysis  or  paresis  of  the  lateral  eye  muscles,  as  the  external 
rectus  (abducens  nerve)  of  one  side,  and  the  internal  rectus  (third 
nerve)  of  the  other,  due  to  a  lesion  just  in  front  of  the  abducens  centre, 
involving  its  fibers,  or  sometimes  also  including  its  nucleus.  In  the 
conjugate  paralysis,  the  antagonist  muscles  pull  the  eyes  to  the  other 


958 


DISEASES  OF  THE  NERVOUS  SYSTEM 


side,  and  the  eyes  look  away  from  the  side  of  the  lesion,  toward  the  par- 
alyzed side.  This  is  not  to  be  confused  with  the  "forced  position"  of 
the  eyes  due  to  irritation,  known  as  conjugate  deviation,  in  which  the 
eyes  look  to  the  sound  side  of  the  body.  In  this  form  even  the  paralyzed 
internal  rectus  will  functionate  and  converge  when  one  eye  is  tested 


Fig.  55. 


DECUSSATION  OF  PYRAMIDS 


A  illustrates  a  lesion  in  the  upper  pons,  producing  the  usual  hemiplegia  (face,  arm  and  leg  para- 
lyzed on  the  opposite  side).  B  illustrates  a  lesion  in  the  lower  pons,  producing  alternating 
paralysis;  all  branches  of  the  face  (peripheral  paralysis)  and  tongue  on  tne  side  of  lesion  are 
paralyzed  with  paralysis  of  the  contralateral  arm  and  leg. 

at  a  time.  In  some  cases  both  internal  recti  and  one  abducens  may  be 
paralyzed,  resulting  in  fixture  of  the  eye  in  the  median  position ;  accom- 
modation and  convergence  are  preserved.  Involvement  of  the  motor 
branch  of  the  fifth  nerve  produces  difiicult  mastication.  While  alter- 
nating paralysis  is  the  usual  pons  lesion,  sometimes  double  hemiplegia 
occurs,  or  again,  involvement  of  the  third  to  seventh  cranial  nerves 
without  an  hemiplegia.  The  auditory  nerve  is  rarely  involved,  save  in 
acute  or  very  extensive  lesions  affecting  the  lateral  lemniscus.  Impli- 
cation of  the  cortical  fibers  of  the  hypoglossus  produces  impaired  move- 
ment of  the  tongue  (dysarthria),  nasal  speech,  and  poor  enunciation 
of  consonants,  especially  linguals  and  labials,  though  the  vocal  cords 
are  normal.  Dysarthria  and  dysphasia,  due  to  disease  of  the  cortical 
motor  paths  of  the  hypoglossus  and  vagus,  are  less  common  in  lesions 
of  the  pons  than  are  affections  of  their  nuclei  in  diseases  of  the  medulla 
oblongata.  Ataxia  may  result  from  involvement  of  the  fillet,  and  pos 
sibly  of  the  longitudinal  bundle  of  the  formatio  reticularis,  and  produces 
incoordination  on  voluntary  movement  only.     An  alternating  sensory 


THE  CEREBELLUM  959 

faralysis  may  occur,  as  (a)  hemiansesthesia  involving  the  muscle  sense, 
and  cutaneous  sensation  of  the  extremities  opposite  the  lesion,  caused 
by  disease 'of  the  tegmentum,  and  (6)  an  anaesthesia  of  the  fifth  nerve 
on  the  side  of  the  lesion.  Irritative  symrptoms  sometimes  develop,  as 
pain,  parsesthesia,  painful  convulsions,  which  usually  occur  in  acute 
cases,  and  which  are  peculiar  in  their  involvement  of  both  arms  or 
both  legs,  tonic  and  clonic  spasms  in  the  opposite  arm  and  leg,  con- 
tractures, paroxysms  of  coughing,  and  trismus.  The  patient .  may 
"look  toward  the  lesion"  when  the  eye  muscles  are  irritated.  A 
tendency  to  fall  toward  the  side  on  which  the  lesion  is  located,  is  indic- 
ative of  disease  of  the  middle  peduncle  of  the  cerebellum.  It  is  some- 
times difficult  to  decide  whether  the  focus  is  located  in  the  pons  or  in 
the  medulla.  Though  the  topical  symptoms  of  the  medulla  oblongata 
are  described  under  its  individual  diseases,  it  may  be  stated  that  an 
alternating  or  crossed  paralysis,  involving  the  third  to  seventh  nerves 
inclusive,  indicates  disease  in  the  pons,  and  that  aphonia,  dysarthria, 
and  dysphagia  are  symptomatic  of  localization  in  the  medulla,  especially 
when  the  hypoglossus  is  paralyzed,  shows  the  reaction  of  degeneration, 
and  produces  atrophy  of  the  tongue.  Glycosuria,  albuminuria,  dis- 
turbed respiration  or  heart  action  (by  involvement  of  the  vagus),  and 
vomiting  are  other  bulbar  symptoms.  Disease  in  the  medulla  may 
cause  paralysis  of  both  arms  and  legs,  or  rarely  of  one  arm  and  the 
opposite  leg  (this  latter  is  known  as  hemiplegia  cruciata). 

XIII.  The  Cerebellum. 

Physiology — The  functions  of  this  organ  are  not  fully  known. 
Certain  physiologists  admit  the  possibility  of  some  psychical  function. 
Its  sensory  relations  are  important,  because  of  its  reception  of  numer- 
ous fibers  from  the  spinal  cord,  including  the  direct  cerebellar  tract  and 
the  posterior  median  column  of  Goll.  It  is  an  "end  organ"  (Luciani) 
for  these  tracts,  through  which  and  its  relations  to  the  motor  tracts 
and  the  special  senses,  it  is  supposed  to  coordinate  and  harmonize 
the  movements  of  the  body,  to  maintain  equilibrium,  conserve  muscular 
strength  and  inhibit  the  contralateral  cerebral  motor  cortex.  In  other 
words,  it  associates  (a)  the  sensory  impressions  ascending  from  the  spine 
with  (6)  those  gained  by  hearing  (the  auditory  nerve  having  connections 
with  the  middle  cerebellar  lobe),  and  (c)  probably  with  those  impres- 
sions resulting  from  the  eye  movements. 

General  Pathology. — Disease  of  a  lateral  lobe  affects  the  same  side 
of  the  body,  but  lesions  of  the  middle  (vermiform)  lobe  influence  both 
sides.  Results  of  extirpation  in  animals  vary  somewhat,  and  will  be 
considered  only  from  their  clinical  aspect.  Krauss  found,  in  100  cases 
of  cerebellar  disease,  tumors  in  nearly  80  per  cent.,  abscess  in  10  per 
cent.,  cysts  in  7  per  cent.,  and  softening  and  hemorrhage  constituted 
the  balance.  Agenesis,  sclerosis,  and  gliomatosis  are  also  occasionally 
found.    Disease  of  one  hemisphere,  or  indeed  extensive  lesions  of  both 


960  DISEASES  OF  THE  NERVOUS  SYSTEM 

hemispheres  may  be  fully  compensated  by  the  cerebrum.  Acute  dis- 
ease of  the  cerebellum  produces  symptoms  more  frequently  than  does 
chronic  disease,  in  which  latter  the  cerebellum  has  opportunity  for 
accommodative  compensation.  Rapidly  growing  tumors,  abscess, 
and  sometimes  acute  vascular  disease  often  produce  the  following 
symptoms,  in  part  typical,  and  in  part  secondary  (general). 

Typical  Symptoms. — 1.  Cerebellar  ataxia  is  almost  always  present, 
and  occurs  when  the  patient  stands;  equilibrium  is  disturbed,  and  the 
body  sways;  this  is  known  as  static  ataxia.  Ataxia  also  occurs  when 
the  patient  moves  (dynamic  ataxia),  and  concerns  especially  the  trunk 
and  legs.  The  inco5rdination  is  due  to  disease  of  the  middle  lobe  or 
vermis,  and  the  consequent  withdrawal  from  the  cerebrum  of  the  cere- 
bellar coordination.  The  gait  is  that  of  an  inebriate  {demarche  d'iv- 
resse);  the  body  sways  and  the  individual  stumbles  a  zig-zag  course, 
and  sometimes  toward  the  side  of  the  lesion.  The  arm  and  hand  move- 
ments are  usually  normal.  Ataxia  may  also  result  from  lesions  of  the 
nerves,  spine  or  brain  (cerebellum,  cerebral  cortex,  internal  capsule  and 
probably  tegmentum).  In  the  ataxia  resulting  from  other  cerebral 
localization,  the  incoordination  affects  the  finer  movements,  is  asso- 
ciated with  disturbed  muscle  and  stereognostic  sense,  and  very  often 
with  paresis.  Bouillaud  first  described  cerebellar  ataxia,  and  differ- 
entiated it  from  the  tabetic  type.  The  essential  differences  are  (a) 
that  in  the  cerebellar  form  the  ataxia  disappears  when  the  patient  is 
lying  down,  and  (6)  that  closing  the  eyes  does  not  increase  it  (indeed, 
it  may  often  disappear). 

2.  Vertigo  is  very  frequent,  and  usually  occurs  rather  when  the 
patient  sits  than  when  he  lies  down.  He  thinks  that  objects  are  turn- 
ing around  him,  or  he  may  feel  himself  being  turned.  The  vertigo  is 
either  constant  or  paroxysmal,  and  is  due  to  lesion  of  the  vestibular 
nerve  which  connects  the  semilunar  canals  with  the  cerebellum  by 
means  of  the  corpus  restiforme. 

Secondary  Symptoms. — ^The  following  secondary  symptoms  are 
important  but  less  significant  than  ataxia  and  vertigo :  {a)  Choked  disk 
is  rarely  absent  in  cerebellar  tumors,  and  amaurosis  often  results  from 
increased  pressure  on  the  third  ventricle,  leading  to  hydrocephalus 
internus,  and  then  to  pressure  on  the  chiasm  or  optic  nerves,  (b) 
"Forced"  postures  and  movements  are  generally  considered  due  to 
disease  of  the  middle  peduncle  (crus  cerebelli  ad  pontem).  Forced  pos- 
tures of  the  head  and  trunk  are  observed;  one  eye  looks  upward  and 
inward,  while  the  other  is  directed  downward  and  outward.  Forced 
movements  consist  of  the  turning  of  the  patient  constantly  to  one  side, 
movement  in  a  circle  and  a  tendency  to  fall  toward  the  side  of  lesion 
and  sometimes  backward,  (c)  Muscular  weakness  (asthenia)  is  frequent 
in  animals  (Luciani),  and  is  occasional  in  man.  A  hemiparesis  occurs 
on  the  side  of  lesion.  The  patient  may  not  be  able  to  rotate  the  trunk, 
to  straighten  the  body  after  bending,  or  to  get  up  after  falling,  (d) 
The  patellar  reflexes  are  usually  normal  or  increased.  Sometimes  they 
are  lost  from  pressure  on  distant  structures,  or  from  spinal  disease. 


ANEMIA  OF  THE  BRAIN  961 

(e)  Vomiting  and  pain  in  the  head  or  nape  of  the  neck  are  frequent 
and  of  some  localizing  value.  (/)  Occasionally  the  following  symptoms 
develop;  nystagmus,  rhythmical  contractions  of  the  head,  convulsions, 
paralysis  of  the  cerebral  nerves  from  pressure  on  the  midbrain,  dis- 
turbed hearing,  intention  tremor,  muscular  rigidity,  irritability,  weak 
memory,  and  stupor. 

XIV.  Medulla  (See  Diseases  of  Medulla  Oblongata). 

(B).  CIRCULATORY  DISEASES  OF  THE  BRAIN. 

I.  Anaemia  of  the  Brain. 

This  term  has  been  much  confused  and  abused.  The  symptoma- 
tology of  anaemia  and  hypersemia  is  so  similar  that  differentiation  is 
sometimes  impossible. 

Etiology, — (a)  General  systemic  anaemia  may  result  from  chronic 
anaemia,  cachexia,  and  hemorrhages  of  medical,  surgical  or  obstetrical 
nature,  (b)  D  ecr  eased  blood  supply,  due  to  cardiac  insufficiency,  valvular 
stenosis,  stenosis  of  the  vessels  by  aneurysm  or  tumor,  and  puncture 
of  pleurisy  or  ascites  leading  to  paresis  of  the  thoracic  or  abdominal 
vessels  may  be  causal.  It  may  also  follow  the  evacuation  of  an  enor- 
mously distended  bladder  or  colon.  Sometimes  fasting  seems  to  be  a 
cause  in  individuals  who  faint  when  the  stomach  is  long  empty,  (c) 
Capillary  compression  by  hydrocephalus  or  tumors,  but  especially  by 
cerebral  hemorrhage,  may  produce  anaemia.  Sometimes  venous  hyper- 
aemia  may  act  in  the  same  way.  (d)  Local  causes  in  the  vessels  will 
be  considered  under  softening.  Ligature  or  compression  of  one  carotid 
produces  symptoms  only  when  the  other  vessel  is  atheromatous. 
Gerhardt  induced  convulsions  by  pressure  on  one  carotid,  and  con- 
sidered it  indicative  of  cerebral  atheroma  of  the  other  cerebral  vessels. 

Pathology. — ^The  meninges,  the  cortex,  and  the  white  substance  are 
pale,  the  brain  is  often  firm  and  dry,  and  fewer  puncta  vasculosa  are 
seen.  The  fluid  in  the  ventricles  is  often  increased.  Geigel  terms  the 
slow  capillary  flow,  "diamorrhysis." 

Symptoms. — Local  anaemia  of  the  brain  leads  to  imperfect  function, 
then  loss  of  function,  and  finally,  to  necrosis,  as  in  embolism  or  throm- 
bosis (q.v.).  General  anaemia  may  be  sudden  or  gradual  in  onset. 
In  sudden  ancsmia,  as  after  hemorrhage  or  in  fainting,  the  subject 
becomes  drowsy,  syncope  occurs,  and  after  return  to  consciousness, 
sight  is  impaired.  Amaurosis  is  also  frequent  without  syncope.  There 
is  ringing  in  the  ears,  and  the  pupils  at  first  contract  from  irritation  of 
the  third  nerve,  and  later  dilate  from  its  paralysis;  this  is  a  sign  of 
danger.  The  skin  is  pale  and  clammy,  the  muscles  are  lax,  and  nausea 
is  frequent.  Epileptiform  convulsions  often  occur  when  much  blood 
is  lost,  and  are  probably  due  to  irritative  anaemia  of  the  cortex,  or  pos- 

61  ' 


962  DISEASES  OF  THE  NERVOUS  SYSTEM 

sibly  of  the  pons  or  medulla.  Anaemia  of  the  medulla  causes  the  slow, 
sighing  respiration,  and  the  frequent  yawning.  Death  may  follow 
syncope,  and  was  called  nervous  apoplexy  by  the  old  writers.  In 
gradually  developing  ancemia,  as  pernicious  anaemia,  the  brain  power 
is  lessened,  and  irritability,  delirium,  insomnia,  headache,  vertigo, 
weak  muscles,  spots  before  the  eyes,  impaired  sight,  ringing  in  the  ears, 
and  sometimes  deafness,  may  result.  These  symptoms  are  aggravated 
by  sitting  or  standing,  and  are  relieved  on  lying  down.  Palpitation  and 
thoracic  oppression  are  common  symptoms.  The  pulse  varies  in  rate 
and  rhythm.  Increased  reflexes,  parsesthesia,  and  jerking  of  the  muscles 
are  frequent.    Some  mental  symptoms  usually  remain  after  recovery. 

Marshall  Hall  has  described  hydrencephaloid,  a  variety  of  cerebral 
anaemia,  which  is  seen  in  children  suffering  with  acute  diarrhoea,  and 
is  characterized  by  contracted  and  later  dilated  pupils,  depressed  font- 
anelles,  sunken  face,  pallor,  early  irritation  followed  by  stupor  or  even 
coma.  It  may  resemble  meningitis  from  the  strabismus,  rigidity  of  the 
neck,  and  convulsions.    It  is  usually  amenable  to  treatment. 

Treatment. — ^Treatment,  as  well  as  diagnosis  and  prognosis,  is  chiefly 
that  of  the  cause.  The  ancemia  is  treated  by  putting  the  patient  in  the 
recumbent  posture,  and  instituting  rest  in  bed,  iron,  arsenic,  a  full 
diet,  and  sometimes  small  doses  of  opiates.  Acute  anaemia  necessitates 
absolute  rest,  free  stimulation,  coffee  by  rectum,  faradization  of  the 
chest  and  abdomen,  and  enemata  or  subcutaneous  infusions  of  salt 
solution.  Firm  bandaging  of  the  extremities,  sometimes  called  auto- 
transfusion,  is  valuable.  Rest  and  cardiac  stimulation  are  indicated 
in  cardiac  cases.  For  hydrencephaloid,  warmth,  stimulation  and  fluids 
are  necessary.  Nitroglycerine  is  valuable  in  certain  cases,  which  are 
possibly  due  to  vasomotor  spasm. 


II.  Hyperssmia  of  the  Brain. 

Congestion  of  the  brain  is  an  obscure  lesion.  Andral  (1836)  de- 
scribed 8  varieties;  and  when  Trousseau,  in  1861,  attempted  to  refer 
some  varieties  to  epilepsy  and  Meniere's  disease,  he  drew  down  upon 
him  the  wrath  of  the  entire  Academy.  The  hyperaemia  which  is  de- 
scribed in  nephritis  is  usually  uraemic,  and  the  collateral  arterial  fluxion 
once  attributed  to  erysipelas  is  entirely  toxaemic.  Geigel  has  proposed 
the  term  "  endiamorrhysis "  for  the  normal  flushing  of  the  brain  by 
its  capillaries,  which  implies  a  normal  metabolism  and  exchange  of 
gases.  The  essential  element  is  the  rapidity  of  the  capillary  flow. 
When  the  vessels  dilate  from  paralysis  of  the  sympathetic  system,  the 
rapidity  decreases,  whence  there  is  not  hyperaemia  of  the  brain,  but 
rather  a  lessened  capillary  flow,  adidmorrhesis.  On  the  other  hand, 
when  the  vessels  contract  from  sympathetic  irritation,  the  brain  is  not 
anaemic,  but  on  the  contrary,  the  capillary  flow  is  accelerated,  hyper- 
didmorrhysis.  General  arterial  tension  is  not  important,  but  the  ten- 
sion of  the  vessel  wall  is  the  essential  element  (Geigel). 


HYPEREMIA  OF  THE  BRAIN  963 

Etiology. — Hypersemia  may  result  from  active  or  passive  conges- 
tion, though  many  doubts  are  entertained  in  regard  to  the  older  con- 
ception.   The  prevailing  description  may  be  adhered  to,  provisionally. 

Active  congestion  results  (a)  from  cardiac  overaction ;  (6)  from  over- 
filling of  the  brain  vessels,  when  arterial  blood  cannot  perfectly  reach 
the  lower  parts,  as  in  stenosis  of  the  isthmus  of  the  aorta;  (c)  from 
contraction  of  the  arterioles  in  other  parts;  (d)  from  dilatation  of  the 
brain  vessels  by  alcohol,  nitroglycerine,  coffee,  exophthalmic  goitre, 
excessive  brain  work,  neurotic  states,  and  insolation,  (e)  It  may  occur 
as  the  first  stage  of  inflammation.  (/)  In  plethoric  men,  with  florid 
faces,  thick  neck,  and  short  thorax,  active  congestion  may  cause  certain 
passing  brain  symptoms. 

Passive  congestion  results  (a)  from  general  mechanical  venous  stasis, 
as  in  valvular  heart  lesions;  and  (6)  from  local  venous  stasis,  as  sinus 
thrombosis;  according  to  Geigel's  conception,  it  is  held  that  venous 
stasis  leads  to  capillary  anaemia. 

Pathology. — The  pathological  findings  are  few,  for  congestion  dis- 
appears after  death;  the  brain  may  appear  ansemic  after  death  by 
strangulation  (Ackermann  and  Jolly),  and  the  head  may  become  con- 
gested after  death,  because  of  its  posture  alone.  The  sinuses  and  veins 
are  usually  turgid  and  sometimes  varicose,  and  the  color  of  the  brain 
is  darker  than  normal.  Microscopic  examination  shows  distention  of 
the  capillaries,  at  times  increased  blood  pigment,  or  actual  rupture  into 
the  perivascular  lymphatic  sheaths,  or  into  the  brain  substance. 

Symptoms. — No  symptoms  are  characteristic.  In  active  congestion, 
the  symptoms  vary  with  the  cause;  chronic  cause  fewer  symptoms 
than  acute  factors.  Whether  toxsemic  symptoms  of  the  acute  infections 
are  due  to  hypereemia,  is  an  open  question;  the  headache  in  early 
typhoid  has  often  responded  to  ergot  in  personal  experience,  and  this 
may  possibly  be  used  as  an  argument.  The  retina  has  seldom  been 
examined  in  such  cases.  Nothnagel  and  Gowers  report  cases  with 
paroxysmal  throbbing  of  the  vessels,  flushing  of  the  face,  headache, 
delirium,  sometimes  nausea  and  fever,  which  are  relieved  by  nose- 
bleed and  venesection;  some  describe  similar  symptoms  from  sup- 
pression of  the  menses,  or  of  bleeding  piles.  Irritability,  insomnia, 
spots  before  the  eyes,  ringing  in  the  ears,  and  increased  pulse  are  also 
said  to  occur.  In  progressive  paralysis,  the  transient  pyrexia,  heat  in 
the  head,  or  coma,  are  referred  to  congestion  of  the  brain.  In  middle 
and  advanced  life,  the  so-called  congestive  apoplexy  has  been  noted, 
which  consists  of  coma,  sometimes  with  transient  hemiplegia,  though 
many  cases  are  probably  due  to  small  hemorrhages,  softening  or  dis- 
ease of  the  vessels. 

Passive  congestion,  if  gradual  in  onset,  may  be  well  tolerated,  or  may 
produce  stupor,  dulness,  or  even  dehrium.  If  intermittent,  as  from 
coughing,  the  symptoms  are  a  sense  of  fulness  in  the  head,  headache, 
and  sometimes  convulsions;  these  are  increased  by  exertion,  by  the 
patient  lying  in  the  dorsal  decubitus,  and  by  constipation. 


964  DISEASES  OF  THE  NERVOUS  SYSTEM 

Diagnosis. — Focal  symptoms,  as  hemiplegia,  indicate  organic  dis- 
ease. The  mere  existence  of  such  symptoms,  as  flushing,  heat,  or 
pressure  in  the  head,  cannot  be  used  for  diagnosis,  because  they  are 
often  due  to  neurasthenia,  or  to  hypochondriasis.  Marie  and  Leube 
have  never  made  the  diagnosis  of  brain  hypersemia.  The  great  simil- 
arity between  the  symptoms  of  anaemia  and  hypersemia  of  the  brain 
has  been  noted. 

Treatment. — Active  congestion  is  treated  by  slight  elevation  of  the 
head;  by  venesection  in  extreme  or  very  plethoric  cases  in  adults,  or 
in  children  by  application  of  leeches  over  the  mastoid  bone,  the  veins 
of  which  connect  with  those  of  the  brain ;  by  free  purgation,  by  2  drops 
of  croton  oil,  followed  by  mercurials  and  concentrated  salines,  to  draw 
the  blood  to  the  large  abdominal  vessels;  by  hot  baths,  to  draw  the 
blood  to  the  periphery.  Some  practitioners  prefer  to  give  cool  baths, 
with  active  friction ;  by  vasoconstricting  measures,  especially  digitalis ; 
alcohol  and  opiates  (save  in  small  doses)  should  be  avoided,  and  bro- 
mides should  be  used;  ice  may  be  applied  to  the  head  and  carotids; 
a  light — especially  a  fluid  diet  should  be  given. 


III.  (Edema  of  the  Brain. 

Etiology. — (Edema  of  the  brain  results  from  the  same  general 
causes  as  general  oedema :  (a)  circulatory  disturbances,  as  venous  con- 
gestion in  cardiac  disease,  emphysema,  and  the  acute  infections;  and 
(6)  the  marantic  group,  including  cachexia  and  nephritis.  Collateral 
and  inflammatory  oedema  may  develop  around  brain  tumor,  abscess, 
or  hemorrhage.  In  some  instances  brain  oedema  occurs  in  the  death 
agony.    It  may  also  develop  when  the  brain  shrinks,  hydrops  ex  vacuo. 

Pathology. — The  brain  is  pale,  moist,  and  glistening  on  section, 
the  so-called  "wet  brain."  The  affection  may  be  general  or  local; 
the  ventricular  and  subarachnoid  fluid  is  usually  increased.  The 
volume  of  the  brain  may  be  somewhat  increased  in  the  generalized 
form. 

Symptoms. — The  symptomatology  is  indefinite,  and  a  certain  diag- 
nosis cannot  be  made  between  oedema  and  lessening  of  the  capillary 
velocity  (adiamorrhysis).  When  the  oedema  is  localized,  transient 
focal  symptoms  may  develop,  as  unilateral  convulsions,  hemiplegia, 
or  even  crossed  paralysis;  the  latter  was  observed  personally  in  cases 
of  nephritis.  Great  variability  in  the  symptomatology  of  organic  brain 
disease  may  be  due  to  associated  oedema.  Traube  held  that  brain 
oedema  causes  the  ursemic  manifestations  of  nephritis,  a  view  vigor- 
ously opposed  by  Cohnheim. 


CEREBRAL  HEMORRHAGE  965 


IV.  Cerebral  Hemorrhage. 

This  is  the  most  common  and  important  of  all  brain  lesions,  and  its 
symptoms  involve  an  enormous  part  of  brain  pathology.  It  is  usually 
hemorrhage  into  the  brain  substance,  and  is  spontaneous,  i.e.,  it  does 
not  result  from  trauma.  Although  apoplexy  strictly  refers  to  a  "stroke," 
which  is  symptomatic  of  various  other  lesions,  it  is  used  to  indicate 
hemorrhage  into  the  brain  (Rochoux). 

Etiology. — (a)  Miliary  aneurysms  are  the  chief,  and  according  to 
some,  the  sole  cause  of  hemorrhage  of  the  brain;  the  leading  issue  at 
present  relates  to  their  pathogenesis.    According  to  many  authors,  the 
causes  of   hemorrhage  are   (6)  those   of  arteriosclerosis    (alcoholism, 
plumbism,   syphilis,   hard   physical    work,  contracted    kidney,   gout, 
diabetes,  and  over-eating),  but  others  maintain  that  atheroma  does 
not  'per  se  predispose  to  hemorrhage.     Eighty  per  cent,  of  hemorrhages 
occur  after  the  fortieth  year  of  life.     It  may  occur  in  early  life  from 
glioma,  whooping-cough,  or  trauma.    More  cases  occur  in  men  (80  per 
cent.)  than  in  women.    Heredity  is  not  an  uncommon  factor,  but  relates 
rather  to  renal  and  arterial  lesions  than  to  an  actual  heredity  of  hemor- 
rhage; this  is  especially  emphasized  by  English  writers,  and  by  Dieu- 
lafoy.     Hemorrhage  is  most  common  among  civilized  races  and  in 
temperate  zones,  because  of  the  strenuous  habits  of  life.     For  years 
the  importance  of  the  apoplectic  habitus  (plethora,  ruddy  face,  short, 
thick  neck,  wide  shoulders  and  chest,  round,  small  body  and  large 
muscles)  has  been  emphasized,  although  Gowers  finds  most  of  his  cases 
in  thin  individuals.     Contracted  kidneys  are  found  in  33  per  cent,  of 
cases  of  cerebral  hemorrhage,  and  are  among  the  chief  causes  of  athe- 
roma and  miliary  aneurysm,      (c)  Increased  arterial  tension  is  usually 
considered  an  important  etiological  factor.    Hypertension  alone  is  less 
important  than  its  relation  to  arteriosclerosis  and  miliary  aneurysms, 
which  occur  where  the  blood  pressure  is  greatest,  as  where  the  vessels 
branch.     Rupture  is  also  seen  in  hypertrophy  from  stenosis  at  the 
isthmus  of  the  aorta.    Syphilis  is  usually  considered  a  factor,  but  it  more 
frequently  produces  softening  than  hemorrhage;  it  is  a  causal  factor  of 
aneurysms  of  the  large  vessels  of  the  brain.     Violent  exertion,  excess 
in  liquor,  excitement,  coitus,  straining,  overeating,  vomiting,  coughing, 
or  convulsions,  may  cause  rupture  of  an  already-diseased  vessel,  or  a 
miliary  aneurysm.     A  healthy  vessel  almost  never  bursts,  however 
high  the  blood  pressure.    Embolism  from  heart  disease  may  produce  the 
"  embolic  aneurysm."     Sometimes  trauma  is  a  factor,  usually,  however, 
v/ith  the  causes  mentioned,     (d)  Permeability  of  the  blood  vessels  causes 
a  few  cases.    In  nephritis,  purpura,  various  anaemias,  leukaemia,  septic 
infection  and  specific  fevers,  hemorrhage  by  diapedesis  through  the 
arterial  wall  is  sometimes  seen,  and  embolism  is  occasionally  causative. 
Pathology. — Hemorrhages  most  often  occur  in  the  branches  of  the 
arteria  fossae  Sylvii.     Among  its  branches  the  lenticulostriate  artery 
of  Duret,  called,  by  Charcot,  the  artery  of  hemorrhage,  is  the  seat  of 


966  DISEASES  OF   THE  NERVOUS  SYSTEM 

hemorrhage  in  60  to  75  per  cent,  of  cases.  Though  the  vessel  is  small, 
it  is  likely  to  rupture  because  (a)  it  is  so  near  to  the  large  internal  carotid 
and  its  course  is  very  direct;  (b)  the  blood  pressure  is  high;  (c)  the 
vessels  have  no  special  external  support;  (d)  there  is  no  collateral  cir- 
culation, hence  no  relief  to  pressure,  rendering  the  vessels  tortuous. 
Rupture  occurs  very  often  in  the  long  direction  of  the  nerve  fibers  of 
the  internal  capsule.  The  veins  stagnate  very  easily  in  this  locality. 
Hemorrhage  is  almost  always  arterial.  Miliary  aneurysms  were  de- 
scribed by  Brunner  in  1700,  but  Charcot  and  Bouchard  (1866)  empha- 
sized their  frequent  relation  to  brain  hemorrhage.  They  are  fusiform, 
more  rarely  sacciform,  enlargements  of  the  arterioles,  sometimes  mul- 
tiple, like  a  bunch  of  grapes,  measuring  too  to  ^  of  an  inch;  they 
may  be  seen  with  the  naked  eye,  but  are  best  observed  by  careful  wash- 
ing or  macerating  in  water,  and  examination  on  a  slide  under  a  low 
power.  They  are  found  mostly  in  persons  over  forty  years  of  age,  and 
in  the  locations  where  hemorrhages  are  most  common,  i.e.,  in  the 
central  ganglia.  Their  pathogenesis  is  obscure.  Charcot  and  Bouch- 
ard described  a  change  in  the  outer  tunic  (periarteritis)  but  Eichler 
and  Zeigler  held  that  intimal  changes  were  primary.  Roth  finds  that 
miliary  aneurysm  is  due  to  atrophy  of  the  muscular  coat;  this  is  at 
present  the  generally  accepted  theory.  They  are  the  chief,  and  perhaps 
the  sole,  cause  of  spontaneous  hemorrhage,  although  rare  cases  result 
from  simple  arterial  degeneration.  Large  aneurysms  will  be  considered 
separately. 

Localization. — Hemorrhage  is  most  common  about  the  lateral  ventri- 
cle, i.e.,  in  the  caudate  and  lenticular  nuclei,  the  internal  capsule  and 
the  adjacent  centrum  ovale,  extending  to  the  optic  thalamus,  but  rarely 
beginning  in  it.  Hemorrhage  in  the  white  matter  has  usually  an  elon- 
gated form.  It  is  much  less  common  in  the  cortex,  pons,  crus,  cerebellum 
or  medulla.  Though  it  occurs  mostly  in  the  substance  of  the  brain, 
hemorrhage  may  either  rupture  on  the  surface,  or  break  into  the  ven- 
tricles, causing  sudden  death;  this  is  the  usual  autopsy  finding  in  recent 
apoplexy.  Hemorrhage  is  usually  single.  The  multiple  form  is  ob- 
served in  ansemia.  When  the  skull  is  removed  in  cases  of  large  hemor- 
rhages, the  dura  is  tense,  the  convolutions  are  flattened  and  pale,  the 
falx  is  pushed  toward  the  other  side,  and  the  fissures  are  not  distinct. 
Fluctuation  may  be  felt  in  rare  cases,  and  on  section  the  focus  is  seen; 
it  sometimes  involves  the  entire  hemisphere,  or  may  be  no  larger  than  a 
pea,  but  usually  the  size  of  a  hazel-nut  or  walnut.  The  brain  around 
the  focus  is  softened  from  pressure,  oedematous,  and,  in  the  focus, 
torn  and  pulpy.  The  dark  clot  later  becomes  chocolate-colored, 
then  yellow-red,  and  finally  yellow-white.  The  wall  of  the  focus  is 
irregular  in  the  gray  nuclei,  and  regular  in  the  white  matter  and  threads 
of  bloodvessels  run  through  it.  Microscopically,  leukocytes  laden  with 
fat  drops,  hsematoidin  and  disorganized  tissue  are  found.  As  the  blood 
absorbs,  the  cavity  becomes  more  regular  and  encapsulated  by  inflam- 
mation, and  contains  a  serous  or  milky  fluid;  this  is  the  apoplectic 
cyst  of  Virchow.    Final  replacement  of  the  focus  by  an  apoplectic  scar 


CEREBRAL  HEMORRHAGE 


967 


is  much  less  common.  Traumatic  hemorrhage  may  occur,  though 
infrequently,  near  the  point  of  injury  or  contre  coup  on  the  opposite 
side;  it  sometimes  takes  place  after  a  week  or  more;  this  is  the  late 
traumatic  hemorrhage  of  Bollinger,  which  occurs  near  the  fourth  ven- 
tricle and  aqueduct  of  Sylvius,  and  probably,  in  areas  of  traumatic 


Fig.  56. 


Showing  course  of  individual  fibers  of  motor  tracts. 

softening.  Brain  hemorrhage  may  indirectly  press  on  other  parts, 
may  press  on  their  arteries  and  veins,  or  directly  sever  the  nerve  fibers 
of  the  internal  capsule. 

Secondary  degeneration  occurs  in  the  pyramidal  tracts,  mostly  as  a 
result  of  lesions  of  the  internal  capsule.  It  is  usually  partial,  and 
sound  and  diseased  fibers  intermingle;  it  descends  through  the  cru.'^. 
pons,  medulla,  and  cord,  in  the  latter  of  which  it  involves  the  inner 
part  of  the  anterior  columns  of  the  same  side  (the  uncrossed  or  direct 
anterior  pyramidal  tract),  and  part  of  the  lateral  columns  of  the  opposite 
side  (the  crossed  lateral  tract).  These  areas  become  progressively 
smaller,  and  cease  just  above  the  conus  medullaris.  In  children  a 
cerebral  lesion  may  cause  degeneration  in  the  anterior  horns  of  the 
cord  and  their  fibers.  An  ascending  degeneration  occurs  only  when 
the  large  pyramidal  tracts  of  the  cortex  are  diseased,  except  in  the 
young,  in  whom  degeneration  of  all  neurones  is  prone  to  follow  the 
destruction  of  one  neurone.  (See  figures  under  Localization  in 
THE  Spinal  Cord.)  Other  degenerations  may  occur,  (a)  The  optic 
radiation  degenerates  when  a  lesion  occurs  in  the  cortex  of  the 
cuneus,  and  also  degenerative  changes  in  the  external  geniculate  body 
and  pulvinar.  After  years  it  may  reach  the  optic  nerve.  (6)  Hemor- 
rhage in  the  second  and  third  frontal  lobes  leads  to  degeneration  in  the 


968 


DISEASES  OF   THE  NERVOUS  SYSTEM 


anterior  limb  of  the  capsule,  median  basal  fibers  of  the  crus,  and  the  fibers 
connecting  the  optic  thalamus  with  the  cortex,  (c)  Lesions  in  the  tem- 
poral lobes  cause  degeneration  in  the  lateral  part  of  the  crus.  (d)  De- 
generation in  the  median  lemniscus  follows  diseases  of  the  cortex,  the 
subthalamic  region  and  the  upper  part  of  the  pons;   it  crosses  to  the 


FiQ.  67. 


Horizontal  section  through  the  right  hemisphere;  1,  Cortex;  2,  white  substance;  3,  internal  capsule: 
4,  optic  thalamus;  5,  lenticular  nucleus;  6a,  anterior  horn;  and  66,  posterior  horn  of  the  lateral 
ventricle.     (After  Dijiiine.) 

opposite  nuclei  of  the  medulla,  and  after  years  destroys  the  ganglion 
cells  in  the  posterior  columns  of  the  cord.  Cerebellar  hemorrhage 
may  (rarely)  cause  degeneration  of  the  arm  of  the  pons  and  of  the 
corpus  restiforme. 

Symptoms. — Prodromes  are  most  rare.  Miliary  aneurysms  pro- 
duce no  symptoms  until  they  rupture,  and  premonitory  symptoms  are 
due  to  atheroma.     None  of  them  are  pathognomonic.     They  may  be 


CEREBRAL  HEMORRHAGE  969 

(a)  general,   as    described    under    congestion    and    softening    (v.i.); 

(b)  cardiorenal,  as  hypertrophied  heart,  high  arterial  tension,  and 
the  urinary^  findings  of  contracted  kidney;  or  (c)  sometimes  focal,  as 
diplopia,  alexia,  facial  paresis,  dysarthria  or  preparalytic  chorea. 
Possibly  in  some  cases  prodromal  symptoms  are  due  to  an  initial  small 
hemorrhage,  or  to  hemorrhage  developing  very  slowly. 

The  Insult  or  Stroke  and  Its  Primary  Symptoms. — The  "stroke,^' 
or  apoplexy  is  usually  sudden;  its  most  common  general  symptom  is 
coma,  which  may  be  absent  in  small  lesions,  and  its  most  common  focal 
symptom  is  hemiplegia.  It  may  develop  during  effort  or  excitement, 
or  again  without  cause,  as  during  sleep,  when  the  head  is  low.  In 
ingravescent  apoplexy  the  onset  may  be  gradual,  with  delirium,  con- 
vulsions, and  finally  coma;  it  is  due  to  hemorrhage  external  to  the 
lenticular  nucleus,  and  later  involves  the  internal  capsule  (hemiplegia). 
Death  may,  in  rare  instances,  occur  in  five  minutes  (Abercrombie) 
from  rupture  into  the  ventricles,  or  from  direct  pressure  on  the  medulla 
(fulminating  apoplexy) . 

The  insult,  or  stroke,  is  due  chiefly  to  anosmia  of  the  cortex,  and  to 
some  extent,  to  direct  brain  trauma,  pressure  by  the  hemorrhage  on 
other  vessels,  serous  infiltration  and  alterations  in  the  cerebrospinal 
fluid  (in  which  lumbar  puncture  sometimes  shows  blood).  Its  cardinal 
typical  symptoms  are  coma,  which  is  greater  the  nearer  the  lesion  is 
to  the  optic  thalamus  and  third  ventricle;  flushed  face,  or  some- 
times pallor  or  cyanosis;  usually  a  full,  tense,  regular  and  slow  pulse; 
long,  deep,  stertorous  breathing  (due  in  part  to  palate  paralysis);  the 
cheeks  puff  out,  but  are  drawn  in  on  inspiration,  as  a  result  of  paralysis 
of  the  buccinator  muscle;  inspiration  is  less  irregular  than  it  is  usually 
said  to  be;  yawning  is  frequent  (Todd) ;  the  temperature  usually  suffers 
an  initial  fall,  but  rises  when  reaction  sets  in,  though  lesions  in  the 
pons,  medulla  or  central  ganglia  may  cause  an  initial  rise.  The  pupils 
are  variable,  usually  wide,  from  paralysis  of  the  third  nuclei,  or  from 
sympathetic  stimulation;  they  are  sometimes  unequal,  and  in  deep 
coma,  reactionless.  They  may  be  narrow  from  irritation  of  the  oculo- 
motor nucleus  in  lesions  of  the  pons,  or  when  the  ventricles  are  involved. 
Convulsions  are  infrequent.  The  head  and  eyes  look  toward  the  side 
of  the  brain  lesion  ("conjugate  deviation"),  a  flaccid  hemiplegia 
occurs,  in  which  the  limbs  fall  limp  when  they  are  lifted;  the  paralyzed 
muscles  appear  semi-fluid  and  lax  (Heilbroner) ;  the  reflexes  are  gone, 
which  symptoms  will  be  described  in  detail  below.  There  are  invol- 
untary evacuations  of  urine  and  faeces.  Ollivier  described  an  increase 
of  the  urine  with  a  low  specific  gravity  (1,004),  atid  transitory  albu- 
minuria and  glycosuria;  these  are  usually  due  to  a  large  lesion  pro- 
ducing indirect  or  distant  pressure  on  the  medulla,  or  to  lesion  in  the 
medulla  itself. 

The  permanent  damage  can  only  be  estimated  when  the  reaction  is 
passed.  The  direct  focal  symptoms  are  those  of  the  hemorrhage  itself, 
and  the  subsequent  cyst  or  scar;  they  are  permanent  if  essential  structures 
are  involved,  as  the  internal  capsule.     Indirect  focal  symptoms  are  those 


970  DISEASES   OF   THE  NERVOUS  SYSTEM 

of  other  structures  disturbed  by  pressure,  oedema  or  inflammatory 
reaction.    Time  is  required  to  separate  these  two  classes  of  symptoms. 
The  pulse  and  respiratory  symptoms,  conjugate  deviation,  albumin- 
uria and  temperature  are  usually  indirect  symptoms. 
Details  of  improtant  symptoms : 

1.  Convulsions  are  not  common;  they  indicate  involvement  of  the 
pons,  ventricles,  cortex  or  corpus  striatum. 

2.  Conjugate  deviation,  described  by  Vulpian,  but  especially  by 
Prevost,  is  a  transitory  phenomenon  in  which  the  lateral  muscles  of 
the  head  and  eyes  are  paralyzed;  their  fellows  on  the  sound  side  con- 
tract, so  that  "the  patient  looks  at  his  lesion"  (Prdvost);  that  is,  in 
left  hemiplegia,  the  eyes  and  head  look  toward  the  right  side  of  the 
brain,  where  the  lesion  is  located.  The  centres  paralyzed  are  in  the 
lower  parietal  lobe  (gyrus  angularis  and  gyrus  supramarginalis,  Lan- 
douzy).  It  disappears  in  a  few  days,  because  the  sound  side  of  the 
brain  compensates  or  because  it  is  a  distant  pressure  symptom,  or 
at  the  most,  only  a  moderate  paresis  remains,  shown  by  nystagmus. 
Conjugate  deviation  may  also  be  due  to  irritation  or  convulsions 
(Jacksonian  epilepsy),  when  the  patient  "looks  away  from  his  lesion" 
(Landouzy),  i.e.,  toward  the  side  affected  with  convulsions.  These 
differ  from  the  deviation  in  localization  in  the  pons  (q.v.). 

3.  The  hemiplegia  (see  Localization,  Internal  Capsule)  is  due 
to  lesion  of  the  internal  capsule  (66  to  75  per  cent,  of  cases).  During 
deep  coma  it  is  often  difficult  to  determine  which  side  is  paralyzed. 
The  affected  side  is  usually  flaccid,  and  the  mouth  shows  greater 
puffing  on  the  hemiplegic  half.  If  the  coma  is  not  profound,  the 
sound  arm  and  leg  may  move.  Sometimes,  especially  with  hemor- 
rhage into  the  lateral  ventricle,  the  paralyzed  side  is  rigid  (early  rigidity 
or  contracture).  The  temperature  is  at  flrst  lower  on  the  hemiplegic 
side  from  paralysis  of  a  cortical  centre.  Later,  during  reaction,  it  is 
higher  on  the  side  of  paralysis  and  may  occur  with  oedema  in  this 
arm  and  leg.  After  consciousness  returns,  the  contralateral  hemi- 
plegia is  more  clearly  seen.  The  lower  two-thirds  of  the  face  (nose, 
mouth,  cheek)  are  paralyzed,  but  the  upper  third  (eye  and  forehead)  is 
usually  quite  free;  in  very  rare  cases  only,  a  total  facial  paralysis  is  seen. 
The  lids  can  be  moved,  but  the  nasolabial  fold  is  obliterated,  the  lips 
cannot  be  puckered  as  though  to  whistle,  the  mouth  is  oblique,  or  a 
little  triangular  when  the  teeth  are  shown.  The  upper  part  is  so 
often  unaffected  because  it  is  innervated  from  both  hemispheres,  or 
because  it  has  two  distinct  centres  and  paths,  whereas  in  peripheral 
facial  paralysis  all  branches  are  involved,  and  atrophy  and  the  reac- 
tion of  degeneration  occur.  If  the  optic  thalamus  (q.v.)  is  intact, 
the  paralysis  is  not  apparent  on  emotional  movements,  as  laughing. 
The  tongue  is  slightly  involved;  when  protruded  it  deviates  toward 
the  diseased  side  (Schiff,  Heidenhain),  because  the  sound  genioglossus 
muscle  pulls  the  tongue  forward  and  over  toward  the  hemiplegic 
side;  the  base  of  the  tongue  is  higher  on  the  paralyzed  side;  it  may 
lead  to  some  difficulty  in  the  external  speech  mechanism  (dysarthria), 


CEREBRAL  HEMORRHAGE  971 

while  internal  speech  {i.e.,  aphasia)  is  not  often  disturbed  unless 
there  is  psychical  alteration.  The  palate  may  hang  lower  on  the 
paralyzed  side,  but  this  is  of  little  importance  because  it  varies  physio- 
logically. Deglutition,  mastication  and  phonation  are  but  little  or 
only  transitorily  involved;  marked  difficulty  in  mastication  is  usually 
associated  with  total  hemiansesthesia.  In  the  trunk,  paralysis  of  the 
trapezius  and  levator  anguli  scapulae  causes  sagging  of  the  shoulder, 
while  other  muscles  of  the  neck  are  relatively  free.  (Wernicke 
thinks  certain  cerebral  fibers  of  the  spinal  accessory  are  involved, 
which  is  analogous  to  the  partial  facial  paralysis.)  The  accessory 
muscles  of  respiration,  as  the  scaleni,  are  involved  on  deep  inspiration, 
and  ordinary  respiration  is  somewhat  less  complete,  to  which  some 
would  refer  certain  lung  complications  as  atelectasis.  Hughlings- 
Jackson  finds  respiratory  movement  greater  on  the  paralyzed  side 
in  automatic  breathing  and  greater  on  the  sound  side  in  forced  breath- 
ing. Early,  the  paralysis  of  the  arm  and  leg  is  often  absolute,  some- 
times partial  (hemiparesis).  The  arm  is  usually  more  involved  than 
the  leg.  In  rare  cases  the  arm  may  be  free  in  linear  lesions;  again 
the  leg  may  be  unaffected,  or  the  face  remains  free  (see  Internal 
Capsule  Localization);  monoplegia  is  much  less  common  than  in 
cortical  and  subcortical  disease,  and  when  one  member  is  more  affected 
than  the  others,  there  is  still  partial  or  "dissociated"  hemiplegia. 
In  the  typical  case  the  arm  is  most  involved,  though  all  parts  on  one 
side  usually  are  somewhat  paralyzed.  The  arm  abductors,  hand 
flexors,  and  finger  extensors  are  most  affected.  In  the  leg,  the  extensors 
of  the  leg,  dorsal  foot  flexors  and  knee  flexors  are  most  implicated. 
The  paralysis  is  flaccid.  Considerable  improvement  may  follow  (see 
Secondary  Symptoms).  The  hemiplegia  is  almost  invariably  contra- 
lateral, i.e.,  opposite  to  the  side  of  the  lesion.  (In  the  older  literature 
hemiplegia  on  the  same  side,  or  collateral  hemiplegia  was  described; 
it  was  referred  to  the  rare  lack  of  decussation  of  the  pyramidal  tracts ; 
however,  if  the  motor  tracts  do  not  cross  in  the  brain,  they  usually 
cross  in  the  cord.  Collateral  hemiplegia,  of  which  Lederhose  collected 
45  cases,  is  due  (a)  to  more  than  one  lesion,  (b)  to  a  focus  pressing 
on  the  other  side  of  the  brain,  or  (c)  to  mistaking  the  early  rigidity 
of  the  paralyzed  side  for  the  normal  side,  Pineles  and  Ortner.) 

4.  Sensory  disturbance  has  been  considered  in  the  topography  of 
the  internal  capsule.  It  is  observed  mostly  during  the  insult  or  reac- 
tion, is  less  important  than  hemiplegia,  less  frequent,  less  distinct, 
less  complete  and  less  stable.  Some  hemiansesthesia  is  frequently 
found  in  early  cases  after  careful  examination,  as  disturbed  tactile 
sensation,  stereognostic  sense  and  sometimes  muscle  sense,  pains  and 
hypersesthesia  or  parsesthesia.  A  large  lesion  only,  can  cause  a  com- 
plete hemiansesthesia,  which  very  seldom  occurs  without  some  paresis. 
It  affects  the  skin  and  mucosa  of  the  nose,  mouth,  palate  and  eyes, 
but  leaves  the  cornea  intact  (Grasset),  which  is  supplied  by  the  oph- 
thalmic ganglion  (see  Diagnosis).  Cortical  hemiansesthesia  is  usually 
partial  and  most  often  united  with  a  monoplegia;    lesions  a  little 


972  DISEASES   OF   THE  XERVOUS  SYSTEM 

above  the  capsule,  may  produce  hemiansesthesia,  involving  the  fibers 
from  the  thalamus  to  the  cortex.  Hemiansesthesia  also  occurs  in 
lesions  of  the  crus,  pons,  medulla  and  spine  (q.v.). 

5.  The  special  senses  are  not  often  involved,  or  are  affected  but 
temporarily.  Hemianopsia  is  frequent  (Gowers  and  Ejnes),  usually 
occurs  with  conjugate  deviation,  is  temporary,  and  is  often  over- 
looked; it  probably  is  due  to  indirect  pressure  on  the  optic  thalamus. 

6.  The  reflexes  of  the  skin,  cornea,  pupils,  mucosae  and  tendons  are 
suspended  when  there  is  complete  coma.  Theoretically  they  should 
be  increased  by  T^dthdrawal  of  cerebral  inhibition,  but  the  central 
nervous  system  is  almost  wholly  paretic  during  severe  coma.  After 
the  stroke  they  return  slowly,  first  on  the  sound  side;  the  corneal 
reflex,  the  reaction  of  the  pupils  to  light,  the  epigastric  and  other  skin, 
and  tendon  reflexes  return  in  the  order  named;  the  patellar  reflex  is 
often  exaggerated.  On  the  hemiplegic  side,  they  return  slowly,  the 
periosteal  tendon  reflexes  and  patellars  often  become  exaggerated; 
this  is  due  to  interrupted  inhibition.  The  patellar  reflex  on  the  dis- 
eased side  may  return  only  after  a  considerable  time.  The  skin  reflexes 
return  slowly,  especially  the  epigastric,  cremasteric,  scrotal  and 
mamillary  ( Jastrowitz) ;  this  is  a  point  of  early  diagnostic  value; 
they  probably  have  a  higher  centre  than  have  the  tendon  reflexes, 
although  the  explanation  of  their  conduct  is  not  clear;  it  has  also  been 
suggested  that  there  is  a  cerebral  centre  controlling  Setchenow's 
inhibitory  reflex  centre  in  the  medulla;  when  this  higher  centre  is 
affected,  the  medulla  centre  wholly  inhibits  the  reflexes. 

The  Bahinski  sign  (toe  phenomenon)  indicates  organic  pyramidal 
disease  and  may  be  found  very  early;  when  a  sharp  object  is  slowly 
drawn  over  the  outer  part  of  the  sound  sole,  there  is  plantar  flexion 
of  the  large,  and  sometimes  of  the  other  toes;  when  dra^m  over  the 
diseased  sole  there  is  great  dorsal  flexion  (extension)  of  the  great  toe. 
After  the  prodromes  and  the  initial  primary  insult,  coma  and  reaction 
are  over,  the  chronic  symptoms  can  be  studied  to  the  best  advantage. 

The  Chronic  or  Secondary  Symptoms. — The  indirect  focal  symp- 
toms (conjugate  de\'iation,  coma,  etc.),  the  inflammatory  reaction  and 
collateral  oedema  disappear;  this  is  followed  usually  by  considerable 
improvement. 

1.  If  the  hemiplegia  is  indirect,  from  lesion  -wdthout  the  capsule, 
marked  improvement  or  rarely,  total  recovery  ensues.  Complete 
lasting  hemiplegia  follows  total  di%dsion  of  the  pyramidal  tracts,  due 
to  hemorrhage  from  the  anterior  choroid  artery  (Kolisko).  The  face 
may  recover  rapidly;  certain  muscles  are  entirely  unaffected  or  are 
involved  for  a  short  time  only;  this  is  explained  by  Broadbent's  theory 
that  muscles  used  in  pairs  are  little  involved  or  escape  entirely;  with 
some  modification  of  his  theory,  we  find  that:  the  intercostals,  mas- 
seters  and  trunk  muscles  used  together,  innervated  from  both  hemi- 
spheres and  having  little  differentiation  in  function,  escape  permanent 
paralysis.  The  muscles  of  the  arm  and  hand  have  especially  compli- 
cated functions,  are  more  often  used  alone,  are  innervated  almost 


CEREBRAL  HEMORRHAGE  973 

wholly  from  one  hemisphere,  and  therefore  suffer  the  greatest  per- 
manent damage.  In  adults  the  hand  is  usually  disabled  for  life. 
The  legs  are  much  used  together,  have  some  innervation  from  both 
hemispheres,  and  often  show  some  improvement  after  paralysis.  Just 
how  compensation  occurs  is  undetermined.  Broadbent  thinks  that 
the  bilateral  spinal  and  bulbar  nuclei  enable  "paired  muscles"  to 
be  innervated  from  the  sound  hemisphere.  Possibly  uncrossed  fibers 
in  the  anterior  (and  lateral)  columns  may  explain  the  phenomenon. 
Compensation  is  not  an  absolute  advantage,  for  Brown-Sequard  found 
the  sound  side  reduced  in  strength  in  50  per  cent,  of  his  cases.  The 
face  often  improves  after  an  attack.  In  the  arm  the  residual  paralysis 
affects  functionally  associated  muscle  groups  rather  than  individual 
muscles,  as  the  muscles  supinating  the  forearm,  those  abducting  and 
lifting  the  arm  and  shoulder,  those  moving  the  elbow,  opening  the 
hand,  and  apposing  the  thumb  (Wernicke  and  Mann).  The  shoulder 
improves  a  little,  the  elbows  considerably,  the  hands  very  little.  In 
the  leg,  the  flexors,  dorsal  flexors  of  the  foot  which  "shorten"  the 
leg  in  walking,  abductors  and  internal  rotators  of  the  hip  are  most 
involved.  The  hemiplegic  gait  is  awkward,  the  foot  is  swung  out 
and  around  in  a  half  circle  and  scrapes  the  ground.  The  power  of 
the  paralyzed  leg  is  greater  when  it  is  used  with  the  sound  leg,  as  in 
walking,  than  when  it  is  used  by  itself. 

2.  The  contracture,  the  important  posthemiplegic  manifestation,  is 
the  transitory  or  permanent  fixation  of  a  joint  in  an  abnormal  posture 
from  nutritive  or  functional  factors.  Passive  contractures  are  mechan- 
ical, as  from  muscular  shortening,  while  active  contractures  result 
from  disease  of  the  central  nervous  system.  Early  contractures  are 
often  regarded  as  tonic  spasm  (myotatic  irritability).  The  late  con- 
tracture develops  in  two  to  four  weeks  and  is  quite  typical;  the  shoulder 
is  lifted,  the  arm  adducted  to  the  chest,  the  elbow  rigid,  the  forearm 
pronated,  the  wrist  flexed,  and  the  fingers  flexed  even  violently  into 
the  palm.  When  the  wrist  is  passively  flexed  the  fingers  can  some- 
times be  extended.  In  general  the  contracture  involves  both  extensors 
and  flexors,  but  more  often  the  latter.  The  contractures  occur  in  the 
muscles  which  are  least  paralyzed.  In  the  lower  extremity,  the  con- 
tracture is  not  marked  (in  the  thigh  there  is  often  only  a  trace),  the  knee 
is  extended,  plantar  flexion  of  the  foot  occurs  {fes  equino-varu^) ,  the 
great  toe  is  dorsally  flexed.  Locomotion  is  difficult,  for  there  is 
bending  of  the  trunk  to  the  sound  side,  lifting  of  the  pelvis  because 
of  the  adduction  paralysis,  and  swinging  of  the  foot  over  the  sound 
foot.  There  may  be  pain  in  walking,  and  the  sound  leg  also  suffers 
some  slight  contracture.  Contracture  may  occur  in  the  face,  platysma 
and  sternomastoid,  but  the  trunk  is  rarely  affected.  Contractures  are 
increased  by  cold,  irritation,  and  movement,  and  decreased  by  massage, 
warmth  and  sleep.  They  may  be  caused  by  irritation  in  the  periph- 
eral nerves,  inflammation  in  joints  or  muscles,  interruption  of  inhibition 
in  the  pyramidal  tract  or  irritation  acting  on  lower  centres  as  the  pons 
or  medulla.    Hitzig  regards  them  as  involuntary  associated  movements. 


974  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  rare  cases  the  paralyzed  side  remains  lax  {hemiplegie  flasque  of 
Bouchard,  occurring  largely  in  children). 

3.  Associated  movements  are  variously  explained;  by  Westphal  as 
due  to  lessening  of  reflex  inhibition,  by  Hitzig  as  movements  attempted 
in  paralyzed  muscles  but  reflected  to  their  associates,  and  by  Leube 
as  due  to  bilateral  representation  in  the  hemispheres;  examples:  an 
effort  to  grasp  with  the  sound  hand  produces  a  similar  movement  in 
the  one  paralyzed;  yawning  or  coughing  produces  a  movement  of 
the  paralyzed  arm ;  movement  of  the  diseased  side  occurs  after  passive 
movement  of  the  sound  one;  movement  of  the  paralyzed  foot  results 
when  the  patient  attempts  to  flex  the  hip. 

4.  Hemitremor  is  uncommon.  The  muscles  are  stimulated  from 
the  brain  but  not  enough  vibrations  occur  for  actual  involuntary 
movement. 

5.  Atrophy  is  less  marked  than  in  peripheral  and  spinal  lesions,  but 
may  occur  in  both  spastic  and  flaccid  cerebral  forms,  though  more 
in  the  latter;  Steinert  recently  concluded  that  atrophy  is  as  frequent 
in  cerebral  as  in  peripheral  paralysis.  Charcot  referred  it  to  degen- 
eration of  the  anterior  horns  of  the  cord,  while  Quincke  and  Senator 
assume  that  it  results  from  injury  to  some  trophic  paths.  It  is  dis- 
tinct from  lack  of  development  in  the  young.  It  develops  in  a 
month  or  two,  has  no  relation  to  the  degree  of  paralysis,  is  often  asso- 
ciated with  disturbed  sensation  and  muscle  sense,  affects  principally 
the  arm,  occurs  in  large  lesions  which  are  either  (a)  cortical  in  the 
region  of  the  third  branch  of  the  artery  of  Sylvius,  or  (b)  central  in 
the  distribution  of  lenticulothalamic  artery.  The  electrical  irritability 
of  the  muscles  is  either  normal  or  somewhat  depressed.  The  skin  also 
may  atrophy. 

6.  Posthemiplegic  chorea  (Wier  Mitchell,  Charcot,  Raymond)  results 
in  80  per  cent,  of  cases  from  lesions  in  the  internal  capsule,  or  near 
it,  in  the  optic  thalamus,  the  lenticular  or  caudate  nuclei,  from  which 
irritation  is  reflected  to  the  brain  cortex.  It  sometimes  is  preparalytic 
(Grasset).  It  develops  months  or  years  after  small  lesions,  when  the 
hemiplegia  and  rigidity  are  largely  gone.  It  occurs  especially  in  the 
arm,  causes  movements  similar  to  but  coarser  than  those  of  chorea, 
sometimes  resembles  the  tremor  of  multiple  sclerosis  or  paralysis 
agitans,  and  is  often  associated  with  pain  and  sensory  disturbance 
(see  Localization,  Internal  Capsule).  In  posthemiplegic  athetosis 
(Hammond),  the  fingers  and  toes  are  incessantly  moved,  athetosis 
meaning  "without  fixed  position."  It  is  a  "mobile  spasm"  consist- 
ing of  somewhat  spasmodic,  slow,  coordinated  movements  in  paralyzed 
members;  it  is  frequent  in  partial  paralysis  acquired  early  in  life, 
is  slow  in  development,  appears  after  the  paralysis  has  regressed,  and 
has  the  same  localization  as  hemichorea.  The  following  differentiation 
by  Greidenberg  and  v.  Monakow  gives  the  main  characteristics  of 
the  two  affections: 


CEREBRAL  HEMORRHAGE 


975 


Hemichorea. 


-Hemiathetosis. 


1.  Face,  trunk,  whole  extremity  in- 
volved; may  pass  to  all  extrem- 
ities. 


2.  Excursion  active,  manifold,  tremor- 

like, purposeless,  increased  by  ex- 
ertion, tension  lost  by  irritation. 

3.  Contracture  little  or  none;   limbs  re- 

laxed;   no  great  deformity. 

4.  Hemiansesthesia  frequent. 


5.  Quiet  in  sleep. 

6.  Increased    by   movements    and    at- 

tempts to  suppress  them. 


1.  Chiefly  or  alone  in  forearm  and  hand 

(fingers)  and  in  leg  and  foot  (toes); 
simultaneous  innervation  of  an- 
tagonists; other  parts  paretic  and 
stiff. 

2.  Slow  rhythmic  hyperextension,  elas- 

tic resistance,  seems  purposive, 
joints  fixed. 

3.  Contracture  frequent,  but  spasmus 

mobilis  often  great. 

4.  Hemiansesthesia  rare  (almost  never 

in  children). 

5.  Not  always  quiet  in  sleep. 

6.  Lessened  to  some  extent  by  move- 

ment. 


7.  In  trophic  and  vasomotor  disturbance  (v.s.,  Musculae  Atrophy), 
the  paralyzed  members  are  usually  cool,  moist  and  sometimes  oedema- 
tous.  The  skin  is  glossy,  even  livid  and  fissured.  Npthnagel  observed 
iu  some  cases  paralysis  of  the  cervical  sympathetic  system  causing 
increased  temperature,  redness,  narrowing  of  the  eye  fissure,  drooping 
of  the  upper  lid,  retraction  of  the  eyeball,  lachrymation  and  narrow 
pupils.  Sometimes  there  is  overgrowth  of  the  hair.  Bed-sores  were 
considered  trophic  by  Charcot,  but  can  usually  be  avoided  by  care 
regarding  pressure  or  heat,  and  by  cleanliness.  Swelling  of  the  joints 
and  hypertrophic  neuritis  (Charcot)  on  the  hemiplegic  side  are  rare, 

8.  Psychic  disturbance  is  not  symptomatic  of  brain  hemorrhage,  and 
is  chiefly  referable  to  arteriosclerosis.  It  is  evidenced  by  self-concen- 
tration, weak  memory,  insomnia  and  irritability.  Carpani  found 
more  mental  alteration  when  the  left  half  of  the  brain  was  diseased. 
Laughing  and  weeping  are  referable  to  disease  of  the  optic  thalamus 
{q.v.),  or  to  disease  of  the  median  fibers  of  the  pons  (Brissaud), 

Diagnosis  of  Brain  Hemorrhage. — Two  cardinal  features,  coma  and 
hemiplegia,  together  with  the  typical  insult  facilitate  diagnosis.  In 
cases  with  slow  onset,  differentiation  from  thrombosis  {q.  v.)  is  difficult. 

Coma. — In  syncope  the  pulse  is  fast,  weak  and  often  irregular;  in 
"cardiac  apoplexy,"  an  insult  follows  heart  rupture,  myocarditis,  and 
various  forms  of  heart  failure,  and  differentiation  from  rapidly  fatal 
brain  hemorrhage  may  be  impossible.  It  is  always  dangerous  to  make 
a  diagnosis  of  alcoholic  coma;  an  intoxicated  individual  may  suffer 
injury,  basal  fracture  or  actual  apoplexy;  an  opinion  should  be  with- 
held until  such  complications  can  be  excluded,  even  though  the 
alcoholic  coma  is  usually  incomplete,  the  vomitus  and  breath 
smell  of  alcohol,  violent  struggling  is  frequent,  and  early  con- 
vulsions and  focal  symptoms  are  rare.  Opium  coma  is  charac- 
terized at  first   by  slow  onset,  slow   respiration,    slow,    hard   pulse, 


976  DISEASES  OF   THE  NERVOUS  SYSTEM 

flushed  skin,  great  contraction  of  the  pupils,  opium  in  the  urine  or 
stomach  washings,  and  absence  of  convulsions  and  focal  symptoms; 
later  there  are  Cheyne-Stokes  respiration,  rapid  pulse,  clammy 
cyanotic  skin  and  dilated  pupils.  Hemorrhage  in  the  pons  produces 
narrow  pupils,  which  are  often  unequal.  In  this  and  similar  intoxi- 
cations, the  focal  symptoms,  and  reflexes  of  apoplexy  are  lacking. 
While  in  general  the  diagnosis  of  apoplexy  during  the  coma  is  pre- 
carious, urcemic  coma  rarely  occurs  without  premonitory  symptoms, 
as  headache,  drowsiness,  delirium,  restlessness,  vomiting,  myosis, 
retinitis,  or  less  often  convulsions;  the  coma  is  often  less  profound 
than  in  cerebral  hemorrhage.  The  renal,  cardiac  and  arterial  findings 
of  nephritis  may  also  occur  in  apoplexy,  of  which  nephritis  is  a  fre- 
quent cause  (33  per  cent.),  and  it  must  be  remembered  that  focal 
symptoms  in  uraemia  sometimes  occur;  the  author  has  repeatedly 
observed  hemiplegia  and  even  crossed  paralyses.  In  deep  coma 
rigidity  may  be  observed  in  both  uraemia  and  apoplexy,  but  in  uraemia 
it  is  often  variable.  In  diabetic  coma,  the  fruity,  acetone  breath, 
acetone  in  the  urine,  headache,  unrest,  Kussmaul's  breathing  and 
absence  of  focal  symptoms  are  characteristic.  The  coma  may  be 
sudden,  granular  casts  are  frequent  and  the  sugar  may  disappear; 
the  diagnosis  is  then  only  suggested  by  a  clear  history  of  glycosuria. 
Symptomatic  apoplexy  is  oi  more  theoretical  than  practical  importance; 
transient  coma  and  hemiplegia  sometimes  occur  in  brain  oedema, 
congestion,  progressive  paralysis,  multiple  sclerosis,  and  more  rarely 
in  epilepsy  and  tabes.  Hemiplegia,  not  resulting  from  any  lesion 
may  occur  when  the  condition  of  the  blood  is  altered  (alcoholism, 
plumbism,  gout,  tuberculosis,  cancer,  uraemia,  diabetes,  pneumonia). 

Hemiplegia. — This  is  a  prominent  finding  in  embolism  and  throm- 
bosis (q.v.,  for  Differentiation);  an  exact  diagnosis  is  often  impos- 
sible. Kolisko  states  that  most  cases  with  the  clinical  diagnosis  of 
embolism  prove  to  be  hemorrhage,  and  vice  versa.  Hemiplegia  may 
occur  in  brain  abscess,  and  meningitis.  When  it  occurs  in  meningitis 
with  coma,  there  is  headache,  more  generalized  convulsions,  rigidity, 
hyperaesthesia,  optic  neuritis,  eye-paralyses  and  fever.  In  extradural 
haematoma  and  pachymeningitis,  the  Jacksonian  epilepsy  followed  by 
cortical  paralysis  is  distinctive,  i.e.,  the  focal  symptoms  are  prominent 
compared  with  the  general  symptoms  of  early  apoplexy.  Hemiplegia 
also  occurs  in  hysteria  iq.v.),  syphiUs,  brain  tumor,  trauma,  and  in 
some  cases  of  chorea  and  paralysis  agitans. 

Other  Locations  of  Hemorrhage. — (a)  Hemorrhage  may  occur  in 
the  meninges  (see  Diseases  of  Meninges),  (b)  It  may  occur,  though 
rarely,  in  the  cortex;  Jacksonian  epilepsy  in  subcortical  lesions,  con- 
vulsions and  rigidity  may  be  severe  and  lasting  (Mills),  (c)  Ven- 
tricular hemorrhage  is  usually  secondary  to  hemorrhage  in  the  corpus 
striatum  or  optic  thalamus  and  usually  reaches  all  the  ventricles.  It 
may  in  rare  cases  be  primary  from  aneurysms  or  ruptured  veins 
in  the  choroid  plexus  (Dana).  One-third  of  all  cases  are  in  persons 
under  forty  years  of  age.     It  occurs  usually  with  violent  symptoms, 


CEREBRAL  HEMORRHAGE  977 

convulsions  (33  per  cent.),  early  and  sometimes  bilateral  rigidity. 
The  conjugate  deviation  changes  and  turns  to  the  other  side,  the 
pulse  is  slowed,  the  temperature  falls,  the  reflexes  are  suspended, 
Cheyne-Stokes  breathing,  glycosuria  and  polyuria  (Pascheles)  develop, 
and  death  usually  results  within  a  day;  the  onset,  however,  is  some- 
times slow  (Broadbent).  (d)  Hemorrhage  in  the  crti^  (g.  v..  Localiza- 
tion) may  be  primary  but  is  usually  descending,  from  bleeding  near 
the  internal  capsule.  Crossed  hemiplegia  oculomotoria  (Weber's 
type),  crossed  ptosis  (Richards)  or  diplegia  (Paquet)  may  be  observed. 
(e)  Apoplexy  in  the  pons  {q.v.)  occurs  in  10  per  cent,  of  cases,  often 
in  the  median  line,  and  frequently  with  convulsions.  Paralysis  and 
convulsions  may  occur  in  the  arms  or  legs  only ;  the  trunk  musculature 
is  involved  more  frequently  than  in  higher  hemorrhages.  The  eyes 
look  away  from  the  side  of  the  lesion.  The  pupils  may  be  large  from 
paralysis  or  small  from  stimulation  of  the  third  nerve;  in  the  latter 
instance  opium  poisoning  must  be  differentiated.  Respiration  is 
affected  early,  vomiting  is  frequent,  there  is  often  early  high  fever 
and  death  is  usual  within  twenty-four  hours.  It  has  occurred  in  seven 
minutes.  (/)  Hemorrhage  in  the  medulla  will  be  considered  later. 
Early  or  instantaneous  death  is  frequent,  but  a  gradual  onset  is  known. 
It  is  rarely  diagnosticated.  It  may  very  rarely  induce  gastro-intestinal 
hemorrhage,  {g)  Cerebellar  apoplexy  occurs  in  5  to  8  per  cent,  of 
cases.  Vomiting  is  very  frequent  (50  per  cent.).  The  insult  is  some- 
times less  marked  than  in  the  usual  type,  and  "the  absence  of  hemi- 
plegia is  more  significant  than  its  presence,"  (Gowers).  Hemiplegia 
and  symptoms  from  the  fourth  ventricle  are  due  to  indirect  pressure 
or  secondary  ventricular  hemorrhage.  Cerebellar  symptoms,  as  ataxia, 
may  result  (see  Localization). 

Prognosis. — ^The  prognosis  concerns  (a)  the  immediate  danger  and 
(6)  the  ultimate  outcome,  (a)  The  immediate  prognosis  is  always 
serious.  In  hospital  cases  75  per  cent,  die  but  in  general  practice 
66  per  cent,  survive  the  first  stroke,  and  33  per  cent,  the  second,  and 
very  few  the  third.  When  death  occurs,  it  is  usual  in  one-half  to  two 
days,  but  the  outcome  is  uncertain  for  a  week,  because  light  cases, 
even  the  rare  forms  without  coma,  may  rupture  into  the  ventricle 
with  rapidly  fatal  result.  Coma  lasting  more  than  twenty-four  to 
thirty  hours  is  dangerous.  Early  low  fall  of  temperature  or  its  rapid 
early  rise  is  unfavorable,  indicating  a  large  focus.  For  the  same 
reason,  much  conjugate  deviation,  relaxed  sphincters,  impaired  breath- 
ing, trachial  rattling,  bilateral  or  ventricular  symptoms,  marked  glyco- 
suria or  albuminuria,  decubitus  in  the  first  week,  convulsions  and 
rapid  pulse  are  unfavorable.  The  mode  of  death  is  as  follows:  the 
breathing  becomes  more  rapid,  irregular,  of  the  ominous  Cheyne- 
Stokes  type,  and  rattling  from  accumulated  secretion  in  the  air- 
passages;  the  slow  and  regular  pulse  becomes  rapid,  small,  irregular, 
often  with  a  rise  of  temperature,  and  finally  ceases,  but  respiration 
for  a  time  continues;   death  occurs  in  total  coma. 

62 


978  DISEASES  OF  THE  XERVOUS  SYSTEM 

(b)  Ultimate  outcome — the  symptoms  of  shock  disappear  and  the 
patient  becomes  partly  conscious  or  deHrious;  the  period  of  reaction 
begins,  usually  within  forty-eight  hours  after  the  onset.  The  pulse 
becomes  faster,  the  temperature  rises,  pain  develops  in  the  head  and 
limbs  and  sometimes,  though  rarely,  the  paralyzed  limbs  become  rigid. 
Life  still  hangs  in  the  balance,  and  the  patient  may  die  from  the  reac- 
tion, from  hypostatic  pneumonia,  called  trophic  by  some  writers, 
from  pulmonary  oedema  or  hemorrhage,  acute  decubitus,  or  from  a 
second  brain  hemorrhage.  Reaction  is  over  in  one  to  six  weeks. 
If  the  patient  survives  the  insult  and  reaction,  there  is  always  some 
improvement,  depending  on  the  extent  and  localization  of  the  injury, 
which  can  be  determined  only  after  weeks  or  months.  If  movement 
appears  in  three  or  four  weeks,  the  outlook  is  good;  if  it  does  not 
return  in  three  or  four  months,  it  is  not  likely  to  develop  later.  Dis- 
appearance of  indirect  pressure  leads  to  bettering  (i)  of  damage  to 
the  sensory  nerves  and  those  of  special  sense,  (ii)  of  motility,  first  of 
the  trunk  and  face,  then  of  the  leg,  and  less  of  the  arm.  Absolute 
recovery  is  possible  but  improbable.  Hemichorea  and  hemiathefosis 
are  incurable.  Broken  neurones  never  unite,  and  secondary  degenera- 
tion, contractures  and  increased  reflexes  result.  Exaggerated  reflexes, 
developing  a  few  weeks  after  the  injury,  are  forerunners  of  contrac- 
tures and  ankle  clonus,  which  preclude  full  regression.  The  outlook 
is  fairlv  good  in  children  when  the  hemorrhao-e  is  not  due  to  blood 
disease,  because  compensation  is  likely  to  occur.  Recurrence  is  pos- 
sible in  decrepid  and  aged  subjects,  although  less  common  than 
usually  believed;   the  average  duration  of  life  is  five  years  (Dana). 

Treatment. — 1.  Prophylaxis. — Prophylaxis  regarding  worry,  hard 
work,  syphilis,  the  use  of  alcohol,  eating  and  excesses  is  necessary 
when  there  is  hereditary  tendency  toward  hemorrhage,  or  when  one 
hemorrhage  has  already  occurred. 

2.  The  Insult. — (a)  Absolute  quiet  is  indicated,  and  any  movement, 
transportation  or  extended  examination  should  be  avoided,  (b)  The 
head  should  be  slightly  elevated,  but  flexion  of  the  neck,  tight  clothes 
or  anything  hindering  the  return  venous  flow  should  be  avoided. 
Bowles  thinks  that  stertorous  breathing  is  due  to  the  position  of  the 
paralyzed  palate,  and  that  turning  the  patient  on  his  side  relieves  it 
more  effectively  than  does  venesection,  (c)  Venesection  is  seldom 
used,  since  being  discountenanced  by  Trousseau  and  Traube.  It  is 
certainly  indicated  only  in  robust  individuals  with  strong  hearts  and 
tense  vessels;  about  12  ounces  of  blood  should  be  withdrawn;  the 
chief  objection  to  venesection  is  the  difficulty  in  diagnosis  of  cerebral 
hemorrhage.  Any  physician  who  has  used  it  frequently  will  admit 
that  he  has  occasionally  bled  patients  with  thrombosis,  embolism, 
syphilis  or  tumor.  In  thrombosis  and  embolism  venesection  increases 
the  anpemia  of  the  brain,  which  at  present  holds  a  prominent  place  in 
the  pathology  of  hemorrhage.  Gushing  has  shown  that  the  high 
tension  is  a  \icarious  effort  to  keep  the  medulla  supplied  with  blood. 
The  same  objection   holds  to  compression   of  the  common   carotid. 


CEREBRAL  EMBOLISM  979 

id)  Leeches  and  sinapisms  are  harmless  but  useless,  (e)  The  ice-cap 
may  be  used,  but  cannot  influence  the  deep  circulation  in  the  brain. 
(/)  Evacuation  of  the  bladder  and  bowels  is  indicated.  Two  drops 
of  croton  oil  will  act  in  an  hour  or  two,  and  in  case  of  failure,  the  dose 
may  be  repeated.  Croton  oil  was  Hughlings  Jackson's  only  remedy. 
(g)  The  diet  should  be  fluid  and  should  be  administered  by  the  nasal 
catheter  or  by  rectum,  (h)  The  skin  should  receive  attention:  de- 
cubitus is  prevented  in  practically  all  cases  by  care  regarding  posture 
and  cleanliness.  Heat  and  sinapisms  must  be  used  with  greatest 
circumspection  because  the  hemiplegic  side  is  prone  to  necrosis  and 
inflammation,  (i)  Symptomatic  treatment  of  cardiac  and  of  respira- 
tory failure  is  by  champagne  or  ammonia,  but  this  should  not  be 
given  until  necessary;  treatment  of  restlessness  or  convulsions  is  by 
chloral  in  enema,  or  by  morphine  which  theoretically  congests  the 
brain,  but  really  quiets  it  without  detriment. 

3.  The  Reaction. — During  the  inflammatory  reaction  the  treatment 
is  wholly  expectant,  and  if  possible  should  be  conducted  without 
drugs. 

4.  The  Chronic  Stage. — (a)  Gentle  massage  of  the  muscles,  move- 
ment of  the  joints  and  alcoholic  rubs  are  instituted  as  soon  as  the 
coma  subsides.  (6)  Potassium  iodide  is  indicated  when  the  reaction 
subsides,  (c)  As  soon  as  the  leg  improves,  that  is,  in  four  to  eight 
weeks,  the  patient  should  be  encouraged  to  sit  up  and  walk,  (d) 
Application  of  the  faradic  current  to  the  limbs  is  certainly  valuable 
after  two  to  four  weeks,  and,  supplemented  with  massage  of  the 
paralyzed  groups  and  their  antagonists,  minimizes  the  contractures. 
(e)  Hydrotherapy  is  valuable;  cool  baths  or  rubs  are  efiicacious 
except  in  anaemic  or  poorly  nourished  individuals.  Warm  baths  are 
to  be  avoided  in  old  people  and  strychnia  in  all  cases. 


V.  Cerebral  Embolism. 

Embolism  and  thrombosis  of  a  brain  artery  result  in  brain  softening 
(encephalomalacia),  which  is  next  after  hemorrhage  in  importance 
and  frequency,  and  is  one  of  the  best  laiown  subjects  in  brain  pathology. 
Brain  softening  from  arterial  occlusion  is  not  the  "softening  of  the 
brain  "  known  to  the  laity,  who  give  that  name  to  progressive  paralysis 
of  the  insane.  Encephalomalacia  must  not  be  confused  with  inflam- 
matory softening  (encej)halitis) .  Softening  was  first  recognized  by 
Abercrombie  in  1818,  and  by  Rostan  in  1820,  while  those  coming, 
after  them  usually  considered  it  inflammatory.  Virchow's  researches 
on  embolism  confirmed  the  views  of  Rostan  and  Abercrombie,  while 
Cohnheim  elaborated  the  vascular  relations,  and  Panum,  Piltz,  Pre- 
vost,  Cotard  and  Cohn  worked  out  Virchow's  views. 

Etiology. — In  embolism,  Spierling  found  the  kidneys  involved  in 
77  per  cent.,  the  spleen  in  54  per  cent.,  and  the  brain  in  22  per  cent, 
of  cases,     (a)  About  90  per  cent,  is  due  to  heart  disease.    ^Nlost  com- 


980  DISEASES  OF  THE  NERVOUS  SYSTEM 

mon  is  acute  endocarditis  or  acute  exacerbations  of  chronic  valvular 
lesions,  in  which  the  embolism  is  benign  (mechanical)  or  malign 
(mechanical  and  septic).  Calcarious  fragments  from  the  valves,  or 
parts  of  torn  valves,  may  be  thrown  into  the  brain.  Of  valvular  dis- 
eases, mitral  stenosis  produces  embolism  most  frequently  because  of 
stasis  in  the  left  auricle.  Less  frequent  are  cardiac  clots  formed  in 
the  weak  hearts  of  decrepid,  cachectic  subjects,  in  myocarditis  or  in 
such  acute  diseases  as  typhoid.  Weakened  heart  action  and  slow 
circulation  are  never  the  only  cause.  (6)  Atheroma  of  the  arch  and 
aneurysm  are  far  less  frequent  causes,  as  are  (c)  lung  lesions,  as  tuber- 
culous cavities,  abscess,  gangrene  or  empyema  (after  irrigation), 
tumors,  echinococcus,  gumma  or  abscess  of  the  heart,  (d)  In  the 
rarest  instances,  lung  tissue  (Bottcher),  fat  embolism  from  fractures, 
pigment  embolism  (Frerichs)  in  malaria  or  liver  cells  in  acute  yellow 
atrophy,  may  produce  cerebral  embolism,  (e)  With  a  patent  foramen 
ovale,  thrombi  may  reach  the  brain  from  the  venous  system;  it  has 
been  observed  in  manual  expression  of  the  placenta.  (/)  Most  cases 
occur  in  youth  (and  middle  age)  when  acute  infections  are  most  fre- 
quent, as  chorea,  scarlatina,  or  endocarditis. 

Pathology. — (a)  The  embolus  in  fresh  cases  is  reddish,  or  gray-red, 
and  later  becomes  paler,  drier  and  more  friable.  There  are  often 
"riding  emboli,"  which  straddle  the  point  of  arterial  branching; 
they  may  in  rare  cases  soften  and  disappear,  or  by  slipping  produce 
another  embolism  further  on  (Laborde).  Secondary  thrombosis  may 
occur  at  the  infarction,  (b)  The  artery  beyond,  save  where  the  embolus 
retracts  or  softens,  becomes  a  thin,  hard,  impervious  cord.  Behind 
the  plug  an  aneurysm  may  form.  If  the  embolus  is  septic,  inflam- 
mation intervenes  in  and  around  the  vessel,  (c)  The  fate  of  the 
brain  tissue  depends  wholly  on  (i)  the  degree  of  occlusion,  and  (ii) 
the  collateral  circulation,  (i)  If  the  stoppage  is  partial,  only  stasis, 
oedema  and  swelling  occur;  if  total,  necrosis  results,  (ii)  The  brain 
arteries  are  "end  arteries,"  as  Cohnheim  pointed  out,  whence  complete 
collateral  circulation  is  unlikely,  although  the  necrosis  is  rarely  as 
extensive  as  the  distribution  of  the  artery  occluded,  even  where,  as  in 
the  basal  ganglia,  the  anastomoses  are  few.  There  is  more  chance 
of  collateral  compensation  at  the  cortex  than  at  the  base,  and  the 
least  collateral  compensation  occurs  in  the  deep  parts  of  the  centrum 
ovale  (Duret  and  Heubner).  The  brain  tissue  is  ischcemic,  or  its 
blood  is  venous  (Marchand).  The  collateral  vessels  (arteries  or 
venules)  allow  regurgitation  around  the  focus,  the  vessels  become 
more  pervious,  and  some  white  and  red  cells  often  escape;  this  col- 
lateral fluxion  saves  the  tissue  more  often  than  is  usually  admitted, 
especially  if  the  heart  is  strong.  With  a  weak  heart  or  diseased  col- 
lateral arteries,  ischsemic  necrosis  must  follow.  Some  pathologists 
hold  that  shutting  off  of  a  large  bloodvessel  raises  the  tension  in  the 
adjacent  (collateral)  vessels,  and  thus  causes  the  small  capillary 
hemorrhages  often  observed;  but  a  marked  hemorrhagic  infarct  is 
not  common,  for  it  is  prevented  by  swelling  of  the  nervous  tissue. 


CEREBRAL  EMBOLISM  981 

(Weigert).  Much  extravasation  follows  occlusion  of  a  large  vessel,  as 
the  internal  carotid.  Ischsemia  lasting  a  few  hours  probably  produces 
necrosis  (Brieger  and  Ehrlich)  but  microscopic  changes  are  seen  only 
after  one  or  two  days;  the  brain  substance  becomes  oedematous, 
gelatinous,  grayish,  marbled,  fusing  with  the  slightly  oedematous  brain 
tissue  surrounding  the  focus,  without  clear  demarkation;  necrosis 
develops  rapidly,  the  brain  becomes  fluid  and  pulpy,  although  its 
remarkable  cohesion  is  a  matter  of  frequent  comment.  The  gray 
matter  contains  yellow  plaques  {v.i.);  certain  convolutions  may  waste 
or  disappear;  the  gray  and  white  substance,  especially  after  plugging 
of  the  posterior  cerebral  artery,  may  wholly  disappear,  as  the  hippo- 
campus, lingual  and  fusiform  lobules.  The  white  matter  often  dis- 
appears, and  is  replaced  by  lax  cellular  tissue,  in  whose  meshes  are 
cystic  formations  with  turbid  fluid,  and  flocculi  of  brain  tissue.  The 
meninges  are  often  thickened.  Durand-Fardel  described  three  forms 
of  softening:  (a)  The  red  sojtening  is  usually  fresh  and  is  found  most 
often  in  embolism;  there  is  capillary  extravasation,  which  lends  it 
the  red  color;  it  is  irregularly  oval,  or  wedge-shaped  in  basilar  lesions; 
it  usually  measures  but  a  centimeter  or  two ;  it  is  prominent  on  section 
from  blood  and  serum;  it  is  soft,  but  not  fluid  in  the  centre;  is  mostly 
located  in  the  cortex  or  central  ganglia,  lasts  one  or  two  weeks,  and 
then  passes  into  the  second  form.  (6)  Yellow  sojtening  follows  the 
red;  the  yellow  color  is  due  to  old  blood  pigment  or  to  fatty  change; 
it  is  sunken  on  section,  from  atrophy  of  the  brain  substance;  is  fairly 
demarked  and  may  contain  fluid,  hydrops  ex  vacuo;  it  may  last  years 
and  is  found  especially  in  the  cortex,  (c)  White  sojtening  may  rep- 
resent (i)  a  jresh  lesion  about  tumors  (Bouveret)  or  abscesses,  or  in 
various  cachexias,  is  sunken  below  the  cut  surface  and  occurs  where 
few  vessels  are  involved  and  little  regurgitation  from  adjacent  vessels 
occurs;  (ii)  lesions  which  are  several  years  old,  occurring  when  the 
blood  and  fat  are  absorbed,  whence  their  snow-white  appearance; 
demarkation  is  often  slight,  and  if  diffuse,  gives  rise  to  the  spongy 
etat  crible. 

Demarkation  may  occur  after  weeks,  producing  a  "cyst"  of  spongy 
structure  and  milky  contents.  More  rarely  neurogliar  increase  may 
lead  to  shrinking,  and  a  scar  may  result.  Microscopically  myelin  and 
fat  drops,  leukocytes  laden  with  granules  and  fat,  collapsed  vessels, 
relics  of  necrotic  nervous  tissue  and  some  increase  in  neuroglia  are 
observed.  Location  of  embolism  will  be  considered  under  Symptoms. 
Secondary  degeneration  occurs  when  the  pyramidal  tracts  are  involved 
(see  Hemorrhage). 

Sjnnptoms. — As  in  apoplexy,  we  consider  (1)  the  insult,  and  (2) 
the  permanent  symptoms,  to  which  might  be  added  the  symptoms  of 
the  causal  disease,  e.g.,  those  of  mitral  stenosis,  etc. 

1.  The  insult  is  almost  always  (a)  sudden  and  without  prodromes 
(save  when  the  embolism  does  not  wholly  occlude  the  vessel,  and 
symptoms  appear  only  when  secondary  thrombosis  develops).  Em- 
bolism in  small  vessels  may  occur  without  symptoms.     The  patient 


982 


DISEASES  OF  THE  NERVOUS  SYSTEM 


may  be  stricken  without  coma,  and  sit  "astonished"  at  the  stroke, 
without  a  cry  or  even  vertigo.  The  insult  is  caused  by  brain  ancBmia, 
negative  pressure  and  shock  (the  etonnement  cerebrale  of  Trousseau  and 
Jaccoud);  Geigel's  idea  that  the  rest  of  the  brain  is  collaterally  con- 
gested is  less  plausible.  In  some  cases  (6)  coma  occurs  (generally 
less  profound  and  less  protracted  than  in  hemorrhage);  irritative 
symptoms,  as  (c)  convulsions,  tonic  spasms  and  conjugate  deviation 
are  more  common;  convulsions  are  often  unilateral,  corresponding 
with  the  hemiplegia,  (d)  All  possible  intermediate  types  of  focal  dis- 
ease are  observed;  for  instance,  cases  with  vertigo;  tendency  to  fall 
to  one  side;  hemianopsia,  alexia,  hemiansesthesia,  motor  or  sensory 
aphasia,  or  only  confusion,  delirium  and  aphasia  (Fagge).  (e)  The 
pulse  is  full  but  not  slow.  (/)  The  temperature  rarely  suffers  initial 
depression,  and  later  may  rise. 

2.  The  permanent  symptoms  and  secondary  degeneration  are  the 
same  as  in  hemorrhage. 

Localization  of  Embolism. ^ — 1.  The  artery  of  the  fossa  of  Sylvius  is 
most  frequently  involved  (80  per  cent.)  because  it  is  the  largest  and 

Fig.  58. 


Embolism  of  artery  of  the  fossa  of  Sylvius 

IC,  internal  carotid;  PC,  post,  communicating;  AC,  anterior  cerebral  artery;  AS,  art.  fossse  Sylvii 
and  1,  2,  3,  4  and  5,  its  main  branches.  CR,  corona  radiata  from,  cortex  to  internal  capsule. 
(See  text  for  explanation  of  lesions  at  A,  B,  C,  D,  E,  F  or  G.) 


CEREBRAL  EMBOLISM  983 

most  direct  branch  of  the  middle  cerebral  which  is  practically  a  con- 
tinuation of  the  internal  carotid.  Convulsions  occur  in  33  per  cent., 
with  or  without  loss  of  consciousness,  and  are  most  frequent  when  the 
smaller  branches  are  embolized.  High  temperature  is  common.  The 
clinical  picture  varies  with  the  site  of  infarction :  embolism  at  A 
(Fig.  58)  where  the  perforating  branches  (P.  P.)  are  given  off  to 
the  internal  capusle,  corpus  striatum  and  anterior  part  of  the  thalamus, 
must  involve  (a)  these  structures,  and  (6)  the  motor  and  sensory 
cortex,  with  hemiplegia,  fairly  complete  hemia7i(Bsthesia,  motor  aphasia 
(alexia),  deafness  and  tvord  deafness  (if  it  occurs  on  the  left  side). 
Convulsions  are  absent,  because  the  injured  internal  capsule  cannot 
convey  the  cortical  irritation  to  the  extremities;  the  large  areas  at 
the  base  and  cortex  thus  rendered  anaemic,  may  cause  marked  reaction 
(Huguenin),  sometimes  resulting  in  death.  In  rare  cases  only  the 
central  perforating  branches  are  involved  and  the  cortex  obtains  the 
blood  by  anastomoses  with  the  posterior  and  anterior  cerebrals.  The 
left  Sylvian  artery  is  more  frequently  involved,  because  the  left  carotid 
comes  directly  from  the  arch;  59  per  cent,  are  left-sided  (Gelpkel),  or 
51  per  cent.  (Thenevet).  If  the  lesion  is  at  (B),  (Fig.  58),  the  motor 
speech  area,  F3,  which  produces  motor  aphasia,  the  anterior  and 
posterior  motor  convolutions  (A.C.C.  and  A.P.C.)  which  produce 
hemiplegia  or  hemiparesis,  the  parietal  convolutions,  gyrus  angularis 
and  gyrus  supramarginalis  (P2)  which  produce  alexia,  and  the  tem- 
poral convolutions  (Tl  and  T2)  which  produce  deafness  or  word 
deafness,  are  involved.  Somnolence  and  delirium  are  common;  con- 
vulsions almost  invariably  occur,  because  the  internal  capsule  escapes. 
Convulsions  and  pain  are  most  frequent  in  embolism  of  the  smaller 
vessels.  Little  hemiansesthesia  is  observed  (see  Cortical  Localiza- 
tion). A  lesion  at  (C)  is  the  most  frequent  site.  It  affects  the  island 
of  Reil  (LR.)  in  part;  cortical  convulsions,  hemiplegia,  monoplegia, 
sensory  aphasia  (Tl,  T2),  alexia  (P2)  and,  sometimes  sensory  dis- 
turbance occur.  It  is  easily  seen  how  an  isolated  lesion  at  (D)  could 
produce  motor  aphasia;  at  (E)  a  monoplegia;  at  (F)  alexia;  or  at 
(G)  word  deafness. 

2.  Embolism  of  the  posterior  cerebral  (in  2  per  cent.)  comes  from 
the  vertebral  artery,  and  often  occurs  with  embolism  of  the  Sylvian 
artery.  It  supplies  (a)  all  the  ventricles,  the  thalamus,  ant.  corp. 
cjuadrigemina,  the  geniculate  body  and  the  peduncle  by  its  central 
branches,  and  (6)  the  mesial  aspect  of  the  occipital,  part  of  the  parietal, 
and  most  of  the  temporosphenoidal  lobes.  The  most  common  general 
symptoms  are  convulsions,  coma,  vertigo,  conjugate  deviation  and 
nystagmus;  while  the  most  important  focal  symptoms  are  sensory 
hemianesthesia,  sensory  aphasia  and  bilateral  homonymous  hemi- 
anopsia.   The  lesions  are  sometimes  symmetrical. 

3.  Embolism  of  the  anterior  cerebral  artery:  Few  clear  cases  are 
recorded,  since  the  artery  originates  at  a  right  angle  to  the  carotid. 

4.  In  embolism  of  the  internal  carotid  (in  4  per  cent.),  the  plug  must 
be  large  to  produce  much  damage,  for  if  the  vessels  of  the  circle  of 


984  DISEASES  OF  THE  NERVOUS  SYSTEM 

Willis  are  normal,  only  transient  hemiplegia  results.  Disease  of  these 
vessels,  or  abnormalities  in  size,  may  produce  permanent,  alarming  or 
fatal  results.  Secondary  thrombosis  is  especially  dangerous.  Sepsis 
is  a  frequent  factor. 

5.  Embolism  of  the  basilar  artery  occurs  in  6  per  cent.;  the  clot 
never  fills  the  vessel,  because  it  first  passes  the  smaller  vertebral 
artery;  symptoms  occur  less  frequently  at  the  time  of  embolism  than 
later  when  secondary  thrombosis  occurs.  They  are  convulsions, 
trismus,  paralysis  of  the  third,  fifth,  and  seventh  nerves,  crossed 
hemiplegia,  diplegia,  narrow  pupils  and  conjugate  deviation.  The 
temperature  often  falls  low  and  then  rapidly  rises.  Death  may  follow 
in  two  to  five  days  from  respiratory  failure. 

6.  In  embolism  of  the  vertebral  artery,  involvement  of  the  tongue, 
larynx,  lips,  pharynx,  spinal  branch  of  the  fifth  nerve,  result  in  anaes- 
thesia, dysphagia  or  other  signs  of  acute  bulbar  palsy.  Hemianses- 
thesia,  hemiplegia,  and  hemiataxia  may  develop.    It  is  often  fatal. 

7.  Embolism  of  the  cerebellar  arteries  is  the  rarest  of  all  embolisms. 
Diagnosis. — The   main   points   are    (a)   recognition   of  the   cause, 

which  is  usually  cardiac;  (b)  absence  of  prodromes;  (c)  sudden  insult, 
frequent  convulsions,  and  infrequent  coma.  (For  details  and  differen- 
tiation, see  table  under  Thrombosis.) 

Prognosis. — The  outlook  depends  (a)  on  the  'primary  disease,  being 
most  favorable  after  acute  infections,  and  in  youth;  (6)  on  the  intensity 
of  the  onset  itself,  during  which  death  may  occur;  (c)  on  the  localiza- 
tion; the  initial  symptoms  may  improve;  the  outlook  is  more  favorable 
than  in  hemorrhage.  Psychical  symptoms  are  cortical  in  origin, 
while  the  vegetative  or  trophic  are  due  to  lesion  in  the  basal  ganglia; 
basilar  and  vertebral  embolism  are  most  unfavorable  prognostics. 
{d)  Recurrence  is  possible,  although  it  is  less  likely  than  is  usually 
stated,  (e)  The  condition  of  other  organs,  as  the  vessels  of  the  circle 
of  Willis,  the  strength  of  the  heart  muscle,  etc.,  determine  the  prognosis. 

Treatment. — (a)  The  insult  is  treated  as  in  hemorrhage,  in  regard 
to  diet,  keeping  the  patient  quiet,  and  general  measures.  (&)  All 
derivative  measures,  as  drastics  and  venesection,  are  absolutely  to 
he  avoided,  (c)  The  heart  must  be  steadied  and  stimulated,  if  hemor- 
rhage is  clearly  excluded,  with  a  view  first,  of  relieving  the  brain 
ischsemia  by  a  strong  collateral  circulation,  and  second,  of  strength- 
ening the  heart  to  avoid  recurrence.  Digitalis  acts  too  slowly,  and 
camphor,  strychnine  and  ammonia  are  preferable,  {d)  Convulsions 
should  be  treated  by  chloral  given  by  rectum,  avoiding  alcohol  and 
supporting  the  heart.  The  administration  of  more  than  a  dram  of 
chloral  in  three  hours  is  very  dangerous;  gr.  x  to  xv  should  be  given 
forty-five  to  sixty  minutes  apart,  {e)  The  after  treatment  is  unsatis- 
factory, but  should  be  followed  out  as  in  the  corresponding  stage  of 
apoplexy. 


CEREBRAL  (ARTERIAL)  THROMBOSIS  985 


VI,  Cerebral  (Arterial)  Thrombosis. 

Thrombosis  is  more  common  than  emboHsm.  Three  decades  ago 
it  was  thought  that  fibrin  was  thrown  out  of  the  circulating  blood  by 
a  ferment.  Virchow  held  that  slowing  of  the  current  was  the  chief 
cause,  while  Zahn,  Weigert  and  others  attributed  great  importance 
to  coagulation  necrosis  of  the  leukocytes.  Bizzozero,  later  also  Ebert, 
and  Schimmelbusch  held  that  the  blood  plaques  played  a  large  part 
in  coagulation.  Briicke  taught  that  the  living  healthy  vessel  prevented 
coagulation. 

Etiology  and  Pathology. — 1.  Changes  in  the  Vessel  Wall. — (a) 
Arteriosclerosis  (q.v.)  is  the  chief  cause  of  this  most  important  group. 
It  affects  the  basal  arteries  especially  and  usually  several  vessels. 
Blood  plaques  are  deposited  on  the  rough  intima  (Aschoff,  Sahu),  and 
in  the  tortuous,  inelastic,  calcarious,  fatty  vessels,  with  their  unequal 
calibre;  layer  after  layer  of  fibrin  is  deposited,  aided  by  local  slowing 
of  the  blood  stream,  and  by  weakening  of  the  heart.  Thrombosis 
may  be  local  or  extensive.  Tumors,  abscesses,  and  traumatic  menin- 
gitis may  initiate  thrombosis.  Brain  atheroma  usually  occurs  with 
general  atheroma  (see  Arteriosclerosis).  The  vessels  most  involved 
are,  in  order  of  frequency,  the  carotid,  middle  cerebral  and  its  Sylvian 
branch,  basilar,  vertebral  and  posterior  cerebral.  (6)  Syphilitic  end- 
arteritis occurs  in  young  subjects,  84  per  cent,  being  found  in  persons 
between  the  twentieth  and  fortieth  years.  The  initial  proliferation 
may  of  itself,  without  thrombosis,  obliterate  the  vessel  lumen  (see 
Brain  Syphilis).  The  pathological  sequence  is  the  same  as  in 
embolism;  ischsemia,  necrosis  (softening)  and  loss  of  function  occur, 
save  that  in  gradual  thrombosis  the  focus  is  necessarily  less  homoge- 
neous than  in  the  sudden  lesion  of  embolism.  The  foci  are  more 
often  multiple,  for  example,  in  the  Sylvian  artery  and  in  the  posterior 
cerebral  vessel  of  the  opposite  side. 

2.  Changes  in  the  Heart. — Sudden  cardiac  insufiiciency  in  arterio- 
sclerosis may  precipitate  thrombosis,  as  brought  out  especially  by 
Kolisko.  An  acute  infection  in  the  aged,  low  arterial  tension  from 
exhaustion,  grief  and  similar  causes  may  produce  it  when  the  arteries 
are  ripe  for  encephalomalacia. 

3.  Changes  of  the  Blood. — This  constitutes  the  smallest  class  of 
cases.  Burns,  poisoning  by  carbon  monoxide  and  illuminating  gas, 
gout,  chlorosis,  pregnancy,  leukaemia,  metallic  poisons,  jaundice  and 
marasmus  in  very  young  children  or  in  extreme  old  age  may  cause 
thrombosis.  Mechanical  factors,  acute  infections  and  heart  weakness 
are  frequent  factors  in  this  class.  Malarial  thrombosis  might  possibly 
be  included.  Thrombosis  affects  the  smaller  vessels  and  is  usually 
multiple. 

Sjmaptoms. — In  some  cases  thrombosis  is  found  at  necropsy  without 
previous  symptoms  ("latency"). 


986  DISEASES  OF  THE  XERYOUS  SYSTEM 

1.  Prodromes. — These  are  frequent,  and  may  appear  hours,  days, 
and  even  weeks  or  months  before  focal  symptoms  develop.  The  most 
common  are  headache,  which  is  severe  in  the  syphilitic  variety,  vertigo, 
tingling,  numbness  and  weakness  in  a  limb  or  in  one-half  of  the 
body,  disturbance  in  sight,  mental  changes,  defective  memory,  poor 
articulation,  irritability,  loss  of  appetite  for  work,  change  in  character, 
and  sometimes  a  tense  pulse  with  weak  heart. 

2.  The  onset  varies;  (a)  an  acute  onset  with  insult  is  not  frequent. 
If  consciousness  is  lost,  the  coma  is  less  severe  and  protracted  than 
in  hemorrhage;  a  "stroke"  indicates  thrombosis  in  one  large  or  in 
several  vessels.  Conjugate  deviation,  flaccidity  and  paralysis  are 
frequent  during  the  coma.  Consciousness  is  usually  preserved  in 
the  syphilitic  type.  With  acute  onset  the  later  course  is  usually  slow. 
(6)  The  onset  may  be  gradual.  Layer  after  layer  is  added  to  the 
clot  in  this  most  frequent  type,  and  strengthened  heart  action  may  for 
a  time  help  the  collateral  circulation.  When  the  heart  weakens  the 
clot  increases  and  the  collateral  blood  supply  decreases,  so  that,  after 
a  step-like  course  of  advance  and  regression,  the  final  thrombosis 
with  irreparable  ischsemia  and  softening  results.  The  cardiac  strength, 
the  number  and  size  of  the  vessels  involved  determine  the  acuity  or 
chronicity  of  the  course.  Reaction  may  be  marked,  especially  in  the 
aged,  (c)  In  the  chronic  or  long  latent  variety,  prodromes  are  absent, 
psychic  alteration  is  apparent  and  focal  symptoms  are  usually  de- 
veloped. 

3.  In  the  chronic  stage,  whatever  the  onset,  focal  symptoms  as 
monoplegia,  hemiplegia,  hemianopsia  or  aphasia  are  common.  Apo- 
plectiform seizures  mark  the  advance  of  the  process  in  new  vascular 
areas.  The  motor  or  sensory  paralysis,  at  first  transitory,  is  prone  to 
recur,  and  presents  much  the  same  picture  as  hemorrhage  or  embolism 
in  their  chronic  stage. 

Localization. — It  is  impossible  to  determine  the  localization  when 
multiple  foci  exist,  as  in  the  Sylvian  artery  of  one  side,  and  the  posterior 
cerebral  artery  of  the  other;  to  the  few  reported  cases.  Senator  adds 
one  in  which  left-sided  hemiplegia  was  associated  with  aphasia.  The 
favorite  sites  are  the  cortical  branches  of  the  Sylvian  artery  and  the 
branches  of  the  posterior  cerebral  vessels. 

1.  Sylvian  Artery. — The  most  common  cause  of  this  localization  is 
syphilis  or  atheroma.  When  the  main  trunk  is  involved,  the  same 
symptoms  appear  as  in  embolism,  mz.:  hemiplegia,  aphasia,  hemi- 
ansesthesia,  and  hemianopsia  with  this  modification;  the  local  symp- 
toms are  more  severe  in  thrombosis,  because  other  vessels  are  somewhat 
diseased;  the  general  symptoms  are  less  severe.  Prodromes  appear 
first  as  vasomotor  changes  and  tingling,  then  hemiplegia  possibly 
with  delirium  or  loss  of  consciousness;  the  symptoms  may  improve, 
then  there  may  be  recurrence  with  aphasia,  and  coma.  The  course 
is  a  "step-like"  progression  and  regression.  Monoplegia  is  more 
common  than  in  embolism,  because  thrombosis  seeks  the  cortical 
vessels,  whence  the  face  and  arm  may  be  affected,  aphasia  may  exist 


CEREBRAL  (ARTERIAL)  THROMBOSIS  987 

alone,  or  alexia,  mind  blindness  or  deafness.  When  the  basal  arteries 
are  diseased,  the  vegetative  functions  are  involved,  that  is,  trophic 
changes  with  involuntary  evacuations  occur  (gdtisme). 

2.  Anterior  Cerebral  Artery. — This  artery  is  rarely  totally  occluded. 
A  clot  beyond  the  anterior  communicating  vessel  often  produces  crural 
monoplegia  with  some  paresis  of  the  arm.  Very  gradual  ancBmia 
produces  wasting  without  softening;  sudden  ansemia  produces  soften- 
ing. The  brain  may  atrophy  three  to  seven  ounces,  with  senile 
dementia,  mania  or  hypochondriasis  and  though  not  strictly  softening, 
its  close  arterial  connection  is  obvious.  The  frontal  lobes,  especially 
below,  present  the  "worm  eaten"  atrophy,  with  abundant  hydrops 
ex  vacuo. 

3.  Posterior  Cerebral  Artery. — Thrombosis  in  this  artery  is  fairly 
common  and  may  result  in  hemiplegia  alternans  oculomotoria,  hcmi- 
hypsesthesia,  and  hemianopsia  with  irregular  defects  in  the  crossed 
fields;  optic  changes  vary  accordingly  as  the  optic  radiation,  cuneus 
or  other  parts  are  affected. 

4.  Basilar  Artery. — If  the  thrombosis  is  acute,  the  symptoms  are 
like  those  of  embolism.  If  slow,  ophthalmoplegia  may  develop  which 
is  rarely  lasting,  or  other  motor  paralyses,  hemiplegia  with  alternating 
palsy  of  the  fifth,  sixth,  and  seventh  nerves. 

5.  Vertebral  Artery. — (a)  Acute  bulbar  palsy,  w^ith  stormy  symp- 
toms, which  cannot  be  distinguished  from  embolism;  or  (6)  subacute 
bulbar  palsy,  with  respiratory  difficulty,  dysphagia,  paralysis  of  the 
larynx,  disturbed  articulation,  hemiansesthesia  or  hemiplegia  mth 
crossed  paralysis  of  the  tongue  may  result  from  this  localization. 

Diagnosis  and  Differentiation. — The  prodromes,  gradual  onset  and 
cortical  location  are  most  distinctive,  although  the  analysis  may  be 
greatly  confused  and  differentiation  of  complicating  conditions  in  the 
heart,  and  kidneys  may  be  wholly  theoretical  or  impossible.  (See 
Table,  page  988.)  Thrombosis  maybe  confused  with  brain  tumor,  in 
which  the  course  is  slower,  stabile  focal  symptoms  less  frequent,  irritative 
symptoms  (headache,  vomiting  and  convulsions)  more  frequent  than 
permanent  paralysis ;  and  choked  disk,  Jacksonian  epilepsy  and  periodic 
psychical  manifestations  are  frequent.  In  this  connection,  we  may 
consider  hemiplegia  in  the  aged  and  Marie's  les  lacunes  de  desintegra- 
tion  cerebrale;  degeneration  clefts  occur,  chiefly  in  the  large  basal 
ganglia,  sometimes  in  the  internal  capsule  or  pons  (25  per  cent.), 
and  but  seldom  in  the  centrum  ovale  (13  per  cent.);  there  are  usually 
several  foci.  Marie  holds  that  the  lesion  is  a  rarefication  (cavity 
formation)  of  the  brain  tissue  due  to  chronic  sclerosing  encephalitis, 
without  vessel  occlusion.  It  is  said  to  cause  90  per  cent,  of  "insults" 
in  the  aged,  which  occur  usually  with  partial  paralysis;  sometimes 
with  aphasia,  dysarthria  or  dysphagia;  rarely  with  loss  of  conscious- 
ness; and  never  with  sensory  disturbance  or  contractures.  The 
gait  is  the  demarche  d  petits  pas.  The  prognosis  is  fairly  good;  great 
improvement  may  occur  and  the  patient  may  live  eight  to  ten  years 
though  hemorrhage  may  intervene. 


988 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Hemorrhage. 


Thrombosis. 


(1).  Predisposing  etiology.  Before 
third  year  (glioma) ;  80  per  cent, 
after  fortieth  year. 


Miliary  aneurysms;  atheroma,  and 
cardiac  hj^pertrophy. 


After  eightieth  year  more  frequent 
than  hemorrhage.  Twentieth  to 
fortieth  year  syphilis  (of  which 
84  per  cent,  occurs  between 
these  years). 

Weak  irregular  heart;  fevers, 
cachexia.  Atheroma,  especially 
syphilis,  alcoholism,  plumbism. 


Heredity.    Nephritis:    cause  in  33  Rare, 

per  cent,  "granular  kidney."       jRare, 
(2).  Attack  precipitated  by  heavy; Low    arterial    tension;    by    sleep, 

meal,    acute    alcoholism,     highi     grief,  exhaustion,  fatigue. 

art.  tension   (excitement,  effort,! 

shock).  I 

(3).  Prodromes     unusual,     unless  Very   common,    mental    irritabil- 

from  causal  arteriosclerosis.  ity,    weak   memory,    headache, 

vertigo,      numbness,     tingling, 
weakness  in  extremities. 
(4).  Insult:  Usually  sudden;  with- 1  Rarely  acute  onset,    (unless  in  a 

out  prodromata;   long  duration:      large  vessel);     usually  gradual 

(fatal  if  more  than  two  days); 

Cause:  positive  pressure  produc- 
ing brain  anaemia. 


especially  in  senile  softening. 
If  an  insult,  focal  and  general 
symptoms  usually  appear  during 
the  coma 


(5).  Intra-cranial  pressure:  "Pres-'None. 

sure  symptoms"  present,  poly-|Pulse  soft,  weak. 

uria,    albimiinuria,     glycosuria, 

red  face,beating  arteries, Cheyne-' 

Stokes    breathing;    slow,    hard, 

pulse  is  the  fundamental  differ-i 

ence  (Brissaud);  bruit  de  gallop' 

speaks  strongly  for  hemorrhage.! 

Irregularity,   if   combined  with 

strength  not  against  hemorrhage. 

Pulse  may  be  fast  (Brissaud).      ] 
(6).   Temperature:  Rectal  temper- 'initial  depression,  usually  lasting 

ature  usuallj^  depressed  at  first,:     Seldom  temperature   unless   le- 


may  fall  till  death.  May  rise 
later  (inflammatory  reaction). 
Early  rise  (pons,  medulla,  gang- 
lia). Sudden  rise  of  bad  omen; 
rises  before  death. 


Embolism. 


Youth:  hemorrhage    practi- 
cally never  in  youth. 


Endocarditis  (rheumatism, 
sepsis)  especially  mitral. 
Weak,  fatty  dilated  heart. 
In  heart  disease  Eichhorst 
found  in  60  per  cent,  hem- 
orrhage and  in  40  per  cent, 
embolism. 

Rare. 

Rare. 

By  exertion,  dislodging  clot. 


Absolutely  none. 


Sudden,  shorter  and  less 
severe  than  in  hemorrhage. 
Cause:  negative  pressure. 
Slow  insult  only  with  sec- 
ondary thrombosis. 

None  (pallor  rather  than  con- 
gestion). 


sion  m  pons.  More  probably 
early  reaction.  Especially  in  the 
aged. 


(7).  Coma;  More  frequent,  greater 
in  degree,  longer  in  duration, 
usually  complete.  If  lesion  seems 
small,  coma  speaks  for  hemor- 
rhage. Deep  and  prolonged 
speaks  for  hemorrhage  and  usu- 
ally fatal  if  over  twenty-four 
hours. 

<8).  Paralysis,  sudden,  complete, ;Gradual,  incomplete,  monoplegia, 
hemiplegic, non-progressive  after;     hemianopsia;     repeated,     often 
first  seizure.     Foot  gains  more      symmetrical  paralysis, 
rapidly  than    hand.    Persistent  Converse. 

aphasia  exceptional.  Spasmodic.  Aphasia  common.  Absence  of  focal 
laughing  and  weeping  common,  j  symptoms  rather  more  com- 
mon (central  ganglia).     Laugh 


Less  frequent  and  shorter.  Re- 
covery possible  after  several 
days  of  coma.  None  in  syphilitic 
thrombosis.  If  lesion  seems 
large  consciousness  speaks  for 
softening.  If  coma,  usually  focal 
symptoms  are  then  seen.  Coma 
in  large  bilateral  lesions. 


Temperature  may  rise  high 
at  once  without  bad  omen. 
Temperature  no  absolute 
guide;  occurs  especially 
when  large  trunk  embolized. 


No  coma  usually. 


More  like  hemorrhage.  Mono- 
plegia rare.  In  63  per  cent, 
it  is  in  the  left  side  of  the 
brain. 

Fairly  common. 


(9).  Convulsions:  Usually  general- 
ized; very  rare  from  cortical  irri- 
tation or  in  corpus  striatum; 
post  hemiplegic  are  rare. 

(10).  Sensation:  Anaesthesia  usu- 
ally transient. 

Postplegic  chorea,  trembling, 
athetosis,   common. 

(11).  Atheroma  retinal  arteries, 
hence  retinal  hemorrhage  (not 
significant  unless  large).  Aneu- 
rysms very  rare  but  speak 
strongly  for  hemorrhage.  Ret- 
initis albuminurica. 

(12).  Secondary  reaction;  not  much. 
Psychical  symptoms;  far  less. 


ing  and  weeping  exceptional. 

Less    than    in    embolism.       More  More  common  (33  per  cent.) 
localized,   Jacksonian    epilepsy 
speaks  for   softening.     May  re- 
cur.   Postplegic  frequent. 

Paraesthesia    persists     and     more 

marked.    Cerebral  pains  (hyper-  Ditto. 


than     in     hemorrhage 
thrombosis     (lesion    corti- 
cal). 


aesthesia  dolorosa). 
Less  common. 


Arteriosclerosis. 


Greater  secondary  reaction. 
Often  greater:  intelligence,  mem- 
ory aphasia,  word  deafness,  etc. 


Less  common. 

Optic  retinitis  sometimes 
from  endocarditis  (Broad- 
bent  and  Mackenzie). 

Occasionally  embolism  in  re- 
tinae. 


Very    seldom ;    after    attack 
may  be  some  delirium. 


INTRACRANIAL  ANEURYSMS  989 

Prognosis. — The  prognosis  depends  on  (a)  the  cause.  It  is  unfavor- 
able in  arteriosclerosis ,  because  collateral  vessels  are  probably  diseased 
and  the  cause  is  progressive.  If  the  other  vessels  are  sound,  enormous 
disease  may  be  compensated,  as  in  Kussmaul's  case  of  occlusion  of 
both  the  subclavian  and  carotid.  In  cases  of  recent  syphilis  the  prog- 
nosis is  more  favorable,  though  old  specific  thrombosis  is  incurable. 
The  younger  the  patient,  the  better  is  the  outlook,  (b)  It  also  depends 
on  the  onset.  A  brusque  beginning  is  unfavorable,  because  most  cases 
of  this  class  die  (Durand-Fardel).  Coma  indicates  thrombosis  in 
large  vessels  or  in  both  hemispheres,  and  is  therefore  ominous.  If 
there  is  no  insult,  the  focal  symptoms  are  usually  irreparable,  i.e., 
there  are  no  indirect  symptoms.  The  first  seizure  does  not  usually 
threaten  life,  (c)  The  location  and  extent  of  the  lesion.  The  number 
of  vessels  involved  is  obviously  important.  In  Sylvian  thrombosis 
involving  the  branches  to  the  central  ganglia,  cachexia  and  more 
trophic  disturbance  occur  and  the  patient  dies  in  four  to  six  weeks, 
with  involuntary  evacuations  and  bed-sores  (Marie).  Cortical  lesions, 
on  the  other  hand,  are  more  prone  to  produce  psychical  alteration. 
Basilar  or  vertebral  thrombosis  are  directly  dangerous,  (d)  The  focal 
symptoms  are  likely  to  persist  and  recur.  Ophthalmoplegia  may  regress. 
(e)  The  condition  of  other  organs,  above  all  that  of  the  heart,  is  of 
prognostic  import. 

Treatment. — (a)  The  general  treatment  is  the  same  as  in  hemor- 
rhage and  embolism.  (6)  The  causal  treatment  relates  to  the  iodides, 
which  are  of  value  in  atheroma  (lessening  the  viscosity  of  the  blood) 
and  are  specific  in  early  syphilis,  (e)  The  heart  must  be  stimulated 
with  strychnine,  digitalis  and  strophanthus ;  absolute  quiet  in  the 
prone  position,  and  free  administration  of  food  and  fluid  by  rectum 
and  by  nasal  catheter,  are  indicated.  Drastics  and  all  depleting 
measures  must  be  avoided.  On  the  heart  devolves  the  entire  pos- 
sibility of  collateral  compensation,  {d)  In  the  period  of  reaction, 
alcohol  should  be  avoided,  for  it  accentuates  the  inflammatory  reac- 
tion. For  delirium  and  headache,  bromides  are  most  useful; 
no  cardiac  depressants,  chloral  or  coal-tar  products  may  be  used. 
(e)  The  chronic  stage  is  treated  as  in  hemorrhage.  At  all  times 
catheterization  must  be  conducted  antiseptically  and  great  care  exer- 
cised against  bed-sores.  In  the  use  of  baths,  massage  and  electricity, 
treatments  short  of  producing  fatigue  are  indicated. 


VII.  Intracranial  Aneurysms. 

Etiology. — Aside  from  miliary  aneurysms,  aneurysms  may  occur  in 
the  large  brain  vessels.  They  are  seen  in  0.2  to  1  per  cent,  of  autopsies. 
They  are  more  frequent  in  males  (60  per  cent.)  and  in  middle  age, 
although  they  may  visit  either  extreme  of  life  and  a  few  more  (53  per 
cent.)  occur  before  than  after  the  fortieth  year.  The  causes  are  those 
of  aneurysm  elsewhere  (q.v.);   they  are  (a)  atlirroma  in  whose  causa- 


990  DISEASES  OF  THE  NERVOUS  SYSTEM 

tion  alcohol  is  particularly  important;  (b)  irawma,  initiating  arteritis, 
especially  in  the  internal  carotid,  as  after  basal  fracture  (Killian); 
(c)  syphilis  especially  productive  of  basilar  aneurysm,  which  often 
occurs  within  a  year  after  infection;  (d)  embolism,  the  most  frequent 
cause  in  early  life.  Endocarditis  is  the  usual  cause  when  trauma  and 
syphilis  are  excluded  (Lebert  and  Church),  The  embolus  produces 
arteritis  from  which  the  vessel  dilates.  The  clot  may  later  disappear. 
The  Sylvian  vessel  is  most  frequently  involved. 

Pathology. — Location. — The  statistics  of  Lebert,  Durand,  Bartholon 
(collected  by  Gowers),  and  Osier  combined  show  the  following  fre- 
quency: middle  cerebral,  29  per  cent.;  basilar,  26  per  cent.;  internal 
carotid,  14  per  cent.;  anterior  cerebral,  8  per  cent.;  anterior  com- 
municating, 6  per  cent.  They  are  somewhat  more  frequent  on  the 
left  side,  in  20  per  cent,  are  multiple,  are  usually  sacculated,  of  the 
size  of  a  pea  or  walnut  (rarely  large  as  an  egg),  and  are  genuine  aneur- 
ysms involving  all  coats. 

Symptoms. — Symptoms  may  be  absent  until  rupture  occurs.  They 
are  (a)  general,  as  headache,  which  is  the  most  common  sign,  or  con- 
vulsions, which  result  from  aneurysm  of  the  Sylvian  branch;  optic 
neuritis  is  rare;  a  systolic  murmur,  neuralgia  or  epileptiform  seizures 
may  be  noted.  (6)  They  may  be  local;  according  to  their  location, 
hemianopsia,  paralysis  of  the  ocular  nerves,  impairment  of  smell, 
hemiplegia,  optic  neuritis  (extension  of  inflammation  from  the  sac), 
aphasia,  and  symptoms  referable  to  the  pons  or  medulla  may  be  noted. 
Rupture  occurs  in  75  per  cent,  of  cases;  (i)  into  the  meninges  or  (ii) 
into  the  brain  substance  or  ventricles,  from  which  death  results  in  a 
few  hours  or  days;   healing  has  been  observed. 

Diagnosis. — Rupture  is  often  the  first  symptom,  and  differentiation 
from  hemorrhage  is  therefore  necessary.  A  general  cerebral  hemor- 
rhage in  a  young  individual,  with  a  history  of  trauma,  heart  disease 
or  syphilis,  is  rather  suggestive  of  aneurysm,  especially  when  the  loca- 
tion is  basilar.  If  symptoms  have  been  present,  they  are  often  those 
of  a  basal  tumor;  syphilis  (q.v..  Cerebral  Syphilis)  and  trauma  are 
causes  of  tumor  and  aneurysm,  but  iodides  and  mercury  usually  are 
not  beneficial  in  aneurysm.  The  murmur  is  suggestive  but  is  rare 
and  may  be  found  in  tumors  which  compress  vessels  or  in  very  vas- 
cular brain  tumors.  The  location  of  the  aneurysm  is  important; 
they  are  most  often  embolic  in  the  Sylvian,  and  specific  in  the  basilar 
artery.  Loss  of  sight  in  an  eye,  sometimes  with  impairment  of  smell' 
rather  indicates  aneurysm  of  the  anterior  cerebral  or,  if  the  eye  muscles 
are  paralyzed,  of  the  internal  carotid  artery.  Oculomotor  paralysis 
without  loss  of  vision  suggests  aneurysm  of  the  posterior  communi- 
cating artery.     Sonie  cases  closely  resemble  arterial  thrombosis. 

Treatment. — The  indications  are  the  same  as  in  aortic  aneurysm 
(q.v.)  viz.,  rest  and  iodides.  Surgical  intervention  is  occasionally 
opportune,  as  ligation  of  the  carotid. 


SINUS  THROMBOSIS  ■  991 


VIII.  Sinus  Thrombosis. 

The  marantic  form  was  known  to  the  oldest  authors,  while  Aber- 
crombie,  von  Dusch  and  Bright  described  the  pysemic  form.  Lebert 
(1854)  diagnosticated  the  first  case  and  with  Tonnele  built  up  its 
clinical  recognition. 

Etiology  and  Pathology. — There  are  two  varieties,  in  which  prac- 
tically all  cases  can  be  placed,  (1)  the  marantic  and  (2)  the  inflam- 
matory types. 

1.  Marantic  thrombosis  of  the  sinuses  and  veins  is  the  primary  non- 
inflammatory type,  due  to  altered  blood  states  and  weakened  circu- 
lation. It  occurs  (a)  in  children  mostly,  especially  in  the  first  six 
months  of  life,  and  after  acute  infections,  but  particularly  after  infective 
diarrhoeas;  (6)  less  frequently  in  the  aged  from  weak  heart  and  venous 
stasis;  (c)  in  cachexia,  from  cancer,  gout  and  tuberculosis;  {d)  in 
the  anaemia  of  pregnancy  and  in  chlorosis  (SoUier,  Bollinger,  Konig, 
Bucklers  and  Kochel) ;  (e)  compression  of  veins  or  sinuses  as  by  tumor, 
is  rare.  Its  most  frequent  site  is  the  superior  longitudinal  sinus, 
especially  in  children,  because  the  sinus  is  fixed,  its  lumen  is  triangular 
and  irregular,  crossed  by  trabeculae  and  compressed  by  the  Pac- 
chyonian  granulations;  the  tributary  veins  empty  against  the  current 
of  the  sinus,  the  veins  ascend  and  their  stream  is  very  weak.  Gowers 
believes  that  thrombosis  in  veins  entering  the  superior  longitudinal 
sinus  may  cause  hemiplegia  in  children.  Experimentation  seems  to 
show  that  simple  slowing  of  the  current  is  not  sufficient  for  coagulation, 
and  that  the  vessel  wall  must  be  altered;  Bollinger  holds  that  in  chlo- 
rosis there  is  fatty  degeneration  of  the  endothelium.  In  the  aged, 
marantic  thrombosis  rather  elects  the  cavernous  or  transverse  sinus. 
The  older  the  antemortem  clot,  the  lighter  is  its  color,  and  the  more 
laminated  and  adherent  it  is  to  the  sinus  wall,  wherein  it  differs  from 
the  reddish,  loose  and  separable  postmortem  clot.  The  marantic 
clot  may  be  total,  occluding  the  vessel,  or  may  be  partial.  It  may  be 
short,  or  may  fill  the  whole  sinus  and  enter  the  tributary  veins  which 
are  then  seen  as  firm  cords  over  the  hemispheres. 

2.  The  inflammatory  thrombosis ,  thrombophlebitis,  is  secondary  to 
disease  near  the  sinus;  as  (a)  ear  disease,  chiefly  chronic,  sometimes 
acute,  suppurative  otitis  media,  caries  of  the  bone  (Fuchs),  sometimes 
syphilis,  tuberculosis  or  cholesteatoma.  Infection  from  the  ear  reaches 
the  sinus  by  (i)  infecting  the  mastoid  cells,  which  infect  the  transverse 
sinus;  (ii)  by  the  passage  of  the  virus  from  the  middle  ear  to  the 
sinus  by  infecting  small  communicating  veins  (Politzer)  or  (iii)  its 
passage  along  the  petromastoid  canal  (Voltolini).  In  81,648  ear 
cases  reported  by  Hessler,  116  fatalities  occurred,  of  which  34  per 
cent,  was  meningitis.  It  may  be  secondary;  (6)  to  acute  injections, 
with  otitis  media;  (c)  to  sepsis,  puerperal  fever,  pyaemia;  {d)  to  trauma, 
tuberculous  meningitis,  erysipelas,  disease  of  the  orbit,  nose,  gums, 
and  face.     The  most  common  sites  are  the  transverse,  petrosal  and 


992 


DISEASES  OF  THE  NERVOUS  SYSTEM 


cavernous  sinuses,  whence  it  may  extend  to  their  branches.  The  clot 
is  puriform,  foetid,  soft,  discolored  and  contains  pyogenic  organisms; 
the  process  is  frequently  associated  with  meningitis  and  brain  abscess. 

In  both  types,  braiii  changes  may  result,  as  oedema,  swelling  or 
softening  of  the  cortex.  Most  frequently  the  thrombosis  is  bilateral; 
suggillations  in  the  pia,  bloody  imbibition  of  the  brain  or  reddening 
of  the  cerebrospinal  or  ventricular  fluid  may  occur.  Pulmonary 
infarcts  occur  in  50  per  cent.,  and  are  simple  or  septic  according  to 
the  type  of  thrombosis. 

Symptoms  and  Diagnosis. — Clinical  signs  may  be  absent  or  ob- 
scured by  the  primary  affection.  Diagnosis  depends  upon  signs  of 
(1)  extra-  and  (2)  intracranial  venous  stasis. 


Fig.  59. 


COMMUNICANS  WITH  THE  NECK 

Diagram  showing  the  connections*  of  the  transverse  and  cavernous  sinuses  (Leube). 

1.  Extracranial  Stasis.— (a)  In  thrombosis  of  the  superior  longi- 
tudinal sinv^,  stasis  in  the  nasal  veins  is  often  shown  by  epistaxis 
(connection  through  the  foramen  csecum) :  this  was  first  observed  by 
von  Dusch.  It  is  an  effort  of  nature  to  deplete  the  cerebral  congestion. 
Gerhardt  observed  cyanosis  in  the  anterior  frontal  veins  and  ocdetna. 


SINUS    THROMBOSIS 


993 


especially  in  children,  in  the  temples  between  the  great  fontanelle 
and  ear  (by  way  of  the  emissaria  Santorini  through  the  foramen 
parietale).  -  Oedema  is  often  absent  in  chlorotic  thrombosis.  Sweats 
over  the  forehead,  head  and  neck  (Fritz)  are  of  uncertain  diagnostic 
value,  (b)  In  thrombosis  of  the  cavernous  sinus,  stasis  develops  in  its 
tributaries,  producing  exophthalmos,  oedema  of  the  lids  and  conjunctiva 
(vena  ophthalmica) ;  retinal  stasis,  more  rarely  choked  disk  (Milligan) 
or  retinal  thrombosis  (Bouchut),  results  from  congestion  of  the  vena 
centralis  retinae.  Sometimes  oedema  of  the  forehead  results  from 
stasis  in  the  vena  facialis  ant.  Epistaxis  is  rare  (Stager),  (c)  In 
thrombosis  of  the  lateral  sinu^,  a  hard,  tender  oedema  hehind  the 
ear  (Griesinger)  and  in  the  neck  (communicating  with  the  posterior 
auricular  vein)  occurs  in  over  50  per  cent,  of  cases.  Occasionally 
the  swollen  thrombotic  internal  jugular  vein  may  be  felt.    The  external 


Fig.  60. 


VEINS  COMMUNICATING  THROUGH 
THE  PARIETAL  FORAMEN  WITH 
THE  EXTERNAL  SKULL  VEINS. 


CONFLUENS 
SIN. 


VENA  JUGULARIS  EXT. 


VENA  JUGUL.INT. 


Leul)e's  iliagraia  showiniEt  tlie'connections  of  the  superior  longitudinal  sinus  with  the 

external  veins. 


jugular  jrequently  collapses,  or  if  the  internal  jugular  is  thrombosed, 
it  becomes  overfilled  (Gerhardt).  In  33  per  cent,  the  disk  is  hyper- 
?emic,  and  in  another  33  per  cent,  there  is  choked  disk  (Jansen) 
from  complicating  abscess  or  meningitis,  {d)  In  thrombosis  of  the 
sinus  petrosus,  the  signs  are  conflicting  and  Gowers  questions  whether 
any  are  distinctive. 

2.  Intracranial  Stasis. — Progressive  clouding  of  the  mind,  delirium 
in  adults,  convulsions  in  children,  conjugate  deviation  of  the  eyes  and 
head,  stiff  neck,  vomiting,  headache,  irregular  pupils,  nystagmus  or 

63 


994  DISEASES  OF  THE  XERVOUS  SYSTEM 

strabismus  are  noted.  Hemiplegia  and  sensory  symptoms  are  occa- 
sional. Bilateral  symptoms,  as  paraplegia,  are  due  to  the  involvement 
of  the  veins  in  both  hemispheres  or  more  often  to  meningitis.  Bouchut 
thought  that  antemortem  convulsions  in  children  were  often  throm- 
botic in  origin.  It  will  be  seen  that  many  of  these  symptoms  resemble 
the  hydrencephaloid  (Marshall  Hall)  of  brain  anaemia.  The  fontaiielles, 
sunken  at  first  in  infantile  diarrhoea,  may  later  become  prominent 
(increased  cerebrospinal  fluid).  Sometimes  in  chlorotic  thrombosis  the 
process  may  extend  to  the  vena  Galeni  magna,  producing  hydro- 
cephalus internus  and  resulting  in  early  stupor,  coma  and  death. 
Irritation  or  paralysis  of  the  third,  fourth,  and  sixth  nerves  may  occur 
because  of  their  intimate  relation  to  the  cavernous  sinus;  involvement 
of  the  first  branch  of  the  fifth  nerve  may  result  in  ophthalmia  neuro- 
paralytica.  Rarely  is  there  paralysis  of  the  hypoglossus  and  spinal 
accessory. 

Other  symptoms  are  those  of  the  causal  affection.  The  temperature 
is  often  normal  in  the  simple  variety,  or  high  in  the  death  agony.  The 
pulse  is  slow  at  first  and  rapid  later.  The  thrombophlebitic  variety 
is  usually  attended  by  fever,  chills,  sweats,  diarrhoea  and  other  septic 
manifestations. 

Differentiation  from  meningitis  (q.v.)  and  brain  abscess  (q.v.)  is 
often  impossible;  the  cause,  the  extracranial  stasis,  and  evidences  of 
sepsis  are  of  diagnostic  importance.  Korner  held  that  metastases 
occur  in  the  lungs  from  sinus  thrombosis  and  in  the  bones  and  joints 
from  mastoid  caries. 

Prognosis. ^ — The  prognosis  is  almost  always  unfavorable;  death 
occurs  in  the  second  week,  or  possibly  later.  A  few  recoveries  from 
both  types  are  on  record.  Local  atrophy  of  the  brain  has  resulted 
after  recovery  from  the  marantic  type. 

Treatment. — Prophylaxis  relates  chiefly  to  the  otitic  variety,  because 
discharges  from  the  ear  are  much  too  lightly  regarded  by  the  laity. 
In  marantic  thrombosis  stimulation  and  avoidance  of  constriction  of 
the  neck  are  the  chief  indications.  In  septic  types  operation  is  indi- 
cated; recovery  is  most  likely  when  there  is  early  diagnosis  and  early 
operation.  Opening  and  packing  the  lateral  sinus  was  first  performed 
by  Zaufal  in  1884.  He  also  recommended  ligature  of  the  jugular 
vein,  which  was  first  performed  by  Thersley  and  Lane  in  1888.  Re- 
covery occurs  in  50  per  cent,  of  operated  cases  and  in  72  per  cent,  of 
Macewen's  series.  Recovery  has  occurred  even  with  complicating 
lung  abscess  (Ballance).  Gravitating  pharyngeal  abscess  and  extra- 
dural foci  also  necessitate  sursfical  interference. 


IX.  Infantile  Cerebral  Paralysis. 

Cerebral  infantile  palsy  is  classed  under  circulatory  diseases  because 
of  the  frequent  etiological  hemorrhage,  embolism  and  thrombosis. 
Pathologically  it  is  sometimes  described  under  encephalitis,  sclerosis 


INFANTILE   CEREBRAL    PARALYSIS  995 

or  porencephalia.  Clinically  it  is  variously  classed  according  to  the 
dominant  syndrome,  hemiplegia,  diplegia,  Little's  disease,  paraplegia, 
hemiathetosig,  and  athetosis.  The  disease  is  a  clinical  picture,  but 
with  varying  etiology  and  pathology.  Osier,  Sachs,  Striimpell,  Freud 
and  Rie  have  contributed  most  valuable  monographs. 

The  Hemiplegic  Form. — Etiology. — It  is  equally  frequent  in  either 
sex.  Most  cases  occur  in  the  first  year.  Gowers  finds  60  per  cent, 
in  the  first  two  years,  75  per  cent,  in  the  first  three  and  88  per  cent,  in 
the  first  five  years  of  life.  Infections,  as  scarlatina,  measles,  less  fre- 
quently variola,  pertussis,  or  diphtheria  are  apparent,  and  heredity, 
maternal  syphilis  or  trauma  are  doubtful,  causes.  The  causes  may 
operate  before,  during,  or  after  birth.  The  pathology  is  considered 
under  the  next  type. 

Symptoms. — (a)  Initial  symptoms,  present  in  66  per  cent.,  are 
severe  in  character,  consist  of  fever,  vomiting,  convulsions,  delirium 
and  coma,  and  last  from  a  few  hours  to  several  days,  sometimes  longer. 
Convulsions,  present  in  50  per  cent.,  are  often  unilateral  and  are  usually 
followed  by  coma.  In  33  per  cent,  of  cases  the  onset  is  insidious,  (b) 
The  -paralysis  (hemiplegia)  usually  develops  when  consciousness  re- 
turns. It  is  more  frequently  right-  then  left-sided.  The  lower  face 
is  involved,  but  usually  soon  improves,  the  leg  improves  more  than 
the  arm  and  hand,  and  the  paralysis,  at  first  flaccid,  soon  becomes 
spastic  and  is  usually  permanent.  In  general  it  resembles  adult  hemi- 
plegia (See  Next  Stage).  Sometimes  the  eye  muscles  are  involved, 
and  hemianopsia  may  be  noted.  Although  the  tactile  and  stereognostic 
sense  may  be  somewhat  reduced,  sensation  is  but  slightly  implicated, 
because  the  other  hemisphere  compensates,  (c)  The  residual  symp- 
toms are  the  same  as  in  adults,  with  some  exceptions;  the  paralysis 
is  spastic  (spastic  infantile  hemiplegia,  Heine)  but  also  atactic  and 
athetotic.  Because  is  occurs  in  the  young  growing  body  and  brain, 
marked  trophic  changes  or,  at  puberty,  retarded  development  appear, 
intellection  is  retarded  or  actual  idiocy  results,  and  epileptiform  seizures 
are  common.  Contractures  are  frequent,  the  reflexes  are  increased, 
and  the  gait  is  somewhat  impaired,  the  foot  dragging.  In  rudimentary 
(formes  frustes)  or  benign  cases,  the  paralysis  may  almost  disappear 
and,  after  months  or  years  may  be  so  replaced  by  epileptic  seizures, 
hemiathetosis,  hemichorea,  hemitremor  (described  under  hemorrhage) 
or  hemihypertonia  (rigidity  with  but  little  paralysis)  that  the  paresis 
readily  escapes  recognition.  Aphasia  is  rarely  lasting.  It  must  be 
recalled  (a)  that  reflex  aphasia  is  very  common  in  childhood  from 
fever  or  digestive  difficulties;  (6)  that  the  brain  readily  compensates 
in  childhood;  (c)  that  permanent  aphasia  indicates  great  or  total  loss 
of  intelligence.  Trophic  changes  are  in  part  a  moderate  atrophy  and 
in  part  lack  of  later  development,  though  seldom  so  marked  as  in  the 
spinal  type  of  paralysis.  They  are  noted  in  the  extremities,  body, 
sometimes  the  face  and  in  the  skull  which  often  thickens;  they  are 
most  common  in  porencephalia  (v.i.).  Epilepsy  increases  in  fre- 
quency after  the  paralysis,  and  is  rated  at  from  13  per  cent,  to  even 


996 


DISEASES  OF  THE  NERVOUS  SYSTEM 


66  per  cent.;  it  occurs  (a)  at  the  onset,  (6)  with  the  paralysis,  or  (c) 
a  year  or  two  later;  it  is  not  commensurate  with  the  degree  of 
paralysis  but  is  more  marked  in  rudimentary  palsy;  it  may  be  slight 
like  a  vertigo;  it  is  most  often  hke  the  Jacksonian  type,  but  may  end 
in  total  loss  of  consciousness.  In  infantile  cerebral  paralysis  there  is 
less  violence,  initial  cry,  trauma,  foaming  at  the  mouth,  and  fewer 
involuntary  evacuations  than  in  ordinary  epilepsy.  After  a  decade 
or  more  it  often  becomes  very  marked,  although  it  has  been  known 
to  disappear  between  the  fortieth  and  fiftieth  years. 

Diagnosis. — The  chief  differential  interest  centres  in  its  separation 
from  the  spinal  type  (poliomyelitis) : 


Cerebral  Type. 

Spinal  Type. 

Tendon  reflexes. 

Increased. 

Decreased  or  abolished. 

Muscular  atrophy. 

Only  after  a  long  time. 

Rapid. 

Electrical  reaction 

Normal,  or  little  quantita- 
tive decrease. 

Partial  or  total  reaction  of 
degeneration. 

Distribution  of  para 

ysis. 

Hemiplegic — diplegic. 

Chiefly  monoplegic. 

Intelligence. 

Often  involved. 

Usually  not. 

Epilepsy  and  hemichorea. 

Conimon. 

Rare. 

The  Double  Hemiplegic  or  Diplegic  Form. — Etiology. — (a)  Pre- 
natal causes  are  apparent  in  7  to  31  per  cent,  and  include  fright, 
trauma,  malnutrition  or  syphilis  of  the  mother.  These  causes  seem 
most  common  in  cases  which  develop  athetosis.  (6)  Anomalies  of 
labor,  suggested  by  Little  and  proven  to  be  as  a  factor  by  Sarah 
McNutt,  include  difficult  or  long  labor,  malpresentations,  resistant 
maternal  tissues,  twin  pregnancy,  version,  cord  prolapse  and  instru- 
mentation, although  delivery  by  forceps  is  less  important  than  the 
causes  calling  for  their  use.  Asphyxia  is  an  important  etiological 
factor.  Premature  delivery  is  also  causal,  possibly  because  the  soft 
skull  is  injured  (Gowers)  or  because  venous  stasis  occurs  from  pre- 
cipitate delivery,  (c)  Extra-uterine  causes  are  indefinite,  and  include 
trauma  and  acute  infections. 

Pathology.— The  pathology  presents  many  obscure  points.  The 
initial  lesion  cannot  always  be  determined,  (a)  In  the  traumatic 
class,  meningeal  hemorrhage  causes  66  per  cent,  of  the  diplegic  cases; 
Sarah  jMcNutt  found  hemorrhage  spreading  over  the  motor  cortex 
on  both  sides.  It  is  promoted  by  asphyxia  and  the  sliding  of  the  skull 
bones  of  one  side  under  or  over  those  of  the  other  side;  hemorrhage 
is  often  basal  in  head  presentations,  and  on  the  convexity  in  the  after- 
coming  head.  The  blood  is  absorbed  slowly,  especially  if  the  brain 
is  lacerated,  resulting  in  atrophy  of  the  motor  areas  of  both  sides; 


IXFAXTILE  CEREBRAL   PARALYSIS  997 

hemorrhage  rarely  results  from  hereditary  syphilis.  (6)  Vessel  disease 
(18  per  cent.)  may  be  arterial  (thrombosis,  embolism  or  hemorrhage) 
or  venous  (in-the  cortical  veins,  Gowers).  (c)  Striimpell  advanced  the 
views  of  Vizioli  and  Marie  that  acute  encephalitis  in  the  motor  cortex 
(poliencephalitis)  causes  the  acute  onset,  an  argument  largely  based 
on  analogy  (poliomyelitis  in  children),  though  seldom  verified. 

Chronic  Lesions. — The  most  important  are  diffuse  lobar  sclerosis, 
and  porencephalia,  which  are  peculiar  to  infantile  brain  palsies:  (a) 
Diffuse  lobar  sclerosis  and  atrophy  of  the  brain  occur  in  55  per  cent. 
(Osier).  The  meninges  are  normal  or  somewhat  thickened.  About 
the  atropine  areas  and  in  the  ventricles  the  cerebrospinal  fluid  is 
increased.  One  or  both  hemispheres  may  be  involved  but  usually 
unequally.  The  lobe  affected  is  shrunken,  hardened,  leathery  and  the 
white  matter  is  decreased,  while  the  gray  seems  increased.  The 
convolutions  are  much  wasted  and  are  smooth  or  "worm  eaten." 
The  nervous  tissue  is  wasted,  the  neuroglia  increased,  and  the  blood- 
vessels tortuous,  somewhat  thickened  and  their  perivascular  lymph 
spaces  widened  five-  or  six-fold.  The  nature  of  the  initial  lesion  is 
disputed;  it  is  thought  to  be  encephalitis  (Bourneville),  poliencephal- 
itis (Striimpell)  and  embolism,  (b)  Porencephalia  (Heschl,  1859)  con- 
sists of  loss  of  brain  substance,  and  ca^'ity  formation.  It  occurred  in 
26  per  cent,  of  Osier's  cases.  The  nature  of  the  initial  lesion  causing 
porencephaly  is  a  matter  of  doubt;  it  is  ascribed  to  anomaly  of  de- 
velopment (agenesis),  inflammation  (encephalitis  or  meningo-enceph- 
alitis),  trauma  (during  labor  or  to  the  uterus  during  pregnancy)  or 
anoemic  necrosis  (Kundrat);  the  latter  is  the  most  widely  accepted 
view.  It  is  most  frequent  in  the  distribution  of  the  Sylvian  or  occipital 
vessels.  Most  often  it  is  congenital  and  then  the  convolutions  radiate 
from  the  defect,  while  in  those  cases  resulting  post  natuin,  the  con- 
volutions stop  short  of  the  defect  "as  though  cut  off."  Bourne\alle 
and  Sollier  hold  that  the  congenital  type  communicates  with  the 
lateral  ventricle,  while  the  acquired  form  does  not.  Sixty-six  per  cent, 
is  bilateral  and  somewhat  symmetrical,  (c)  The  hypertrophic  nodular 
sclerosis  described  by  Bourneville  consists  of  multiple  discrete  prom- 
inent, often  umbilicated  nodes,  the  size  of  a  quarter  or  half-dollar. 
They  are  overgrowths  of  the  neuroglia. 

Symptoms. — Diplegic  cases  are  half  as  frequent  as  the  hemiplegic. 
Freud  describes  the  following  forms:  (a)  General  rigidity,  or  Little's 
disease,  33  per  cent,  of  which  is  caused  by  asphyxia.  The  main 
characteristics  are  (i)  predominance  of  the  rigidity  over  the  paresis, 
and  (ii)  predominance  of  the  leg  paresis  over  that  of  the  arms,  the. 
converse  of  adult  cerebral  paralysis  (hemorrhage  occurs  most  often 
over  the  leg  centres).  Convulsions  often  usher  in  the  symptoms, 
which  appear  after  birth  or  a  few  months  later.  The  rigidity  is  general 
but  most  conspicuous  in  the  flexors  and  adductors,  leading  to  unusual 
postures.  The  face  is  slightly  involved,  the  maximum  manifestation 
being  spasm  of  the  mouth;  in  rare  cases  the  child  cannot  nurse  or 
swallow.     Speech  is  slow  in  development  and  stuttering  is  common. 


998 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Fig.  61. 


In  33  per  cent,  the  head  cannot  be  hfted  or  the  trunk  flexed;  this  i.s 
due  to  involvement  also  of  the  uncrossed  pyramidal  tracts.  The 
arms  may  be  but  slightly  paretic,  but  the  legs  suffer  extensor  spasm 
on  movement,  and  the  toes  turn  down   (talipes  equinus  or  equino- 

varus).  The  child  learns  to  walk  late, 
if  at  all,  because  of  the  adductor  rigid- 
ity, which  may  even  cause  crossing  of 
the  legs.  The  reflexes  are  greatly  in- 
creased. The  intellect  is  somewhat 
affected  in  66  per  cent.,  but  nutrition 
in  the  paretic  members  is  usually 
intact.  Later  epilepsy  is  uncommon. 
The  paresis  may  regress  and  the 
mind  improve,  but  the  legs  remain 
spastic.  (b)  Para])legic  rigidity  re- 
sembles type  (a)  except  that  the  arms 
are  but  little  or  not  at  all  affected  and 
the  legs  alone  are  rigid.  The  name 
Little's  disease  is  also  given  to  this 
form.  Strabismus  is  common  (40  per 
cent.).  Premature  delivery  is  a  factor 
in  50  per  cent,  of  cases,  (c)  Paraplegia 
is  rare  and  is  referred  to  extra-uterine 
causes  or  to  infantile  infections.  The 
legs  are  rigid  and  paralyzed.  In 
severe  types  there  may  be  strabismus 
and  imbecility,  (d)  While  bilateral 
spastic  hemiplegia  (spastic  diplegia) 
exists,  the  symptoms  may  vary  on  the 
two  sides.  IMental  degeneration  is  fre- 
quent; nystagmus,  convergent  strab- 
ismus (25  per  cent.),  bulbar  symp- 
toms (Oppenheim)  and  speech  in- 
volvement (60  per  cent.)  are  frequent,  (e)  General  infantile  chorea 
is  also  called  "choreatic  diplegia";  asphyxia  is  a  factor  in  25 
per  cent.  Its  clinical  characters  are  (i)  paralysis,  (ii)  rigidity,  (iii) 
chorea-like  movements  which  are  irregular,  usually  slight  in  degree 
and  wide  in  distribution.  (/)  In  bilateral  athetosis,  the  mind  is  less 
involved  than  in  the  preceding  types.  The  paralysis  may  precede  it 
or  it  may  be  primary. 

Forms  resulting  from  premature  delivery  are  less  subject  to  con- 
vulsions, athetosis  or  mental  changes,  and  are  more  regressive  than 
those  due  to  birth  trauma  or  later  acquired  lesions.  (See  Diseases 
of  the  Spinal  Cord  for  the  allied  Family  or  Hereditary  Forms,  as 
Hereditary  [Friedreich's]  Ataxia).  In  all  forms  epilepsy  may  (i) 
replace  the  regressing  paralysis;  (ii)  remain  so  prominent  that  the  paral- 
ysis is  overlooked ;  (iii)  paralysis  may  appear  only  after  years  of  epilepsy, 
or  (iv)  may  not  appear  at  all,  "cerebral  paralysis  without  paralysis." 


Spastic  paraplegia,  cross-legged  progression 
(Dercum.) 


BRAIN    TUMORS  999 

Diagnosis. — The  diagnosis  cannot  always  be  made  at  once,  although 
later,  characteristic  symptoms  develop  and  leave  little  diagnostic 
difficulty.  Reparation  from  the  family  spastic  paralysis  (q.  v.)  may  be 
difficult  or  impossible.  As  a  rule,  aside  from  disease  of  the  spine 
which  compresses  the  cord,  confusing  spinal  cord  disease  is  very 
rare  in  children. 

Treatment. — Therapy  is  most  unsatisfactory.  In  the  initial  stage, 
convulsions  may  be  treated  by  chloral  or  inhalation  of  chloroform. 
Some  regression  in  the  paralysis  is  frequent,  but  the  hemiplegia,  mental 
changes,  and  epilepsy  are  incurable.  Marked  improvement  can  be 
expected  in  the  syphilitic  cases  alone.  Orthopedic  devices  are  valuable. 
The  resulting  epilepsy  is  usually  intractable,  and  bromides  are  of 
little  avail.  Flechsig  advises  their  use,  in  combination  with  opium. 
Operative  interference  has  been  suggested.  Twenty-five  per  cent,  die 
from  the  operation,  but  the  surviving  cases  seem  to  improve,  especially 
in  regard  to  the  convulsions. 


(C).  BRAIN  TUMORS. 

Etiology  and  Pathology. — Eichhorst  found  brain  tumors  in  ^  of  1  per 
cent,  of  his  cases.  Sixty-six  per  cent,  of  tumors  occurs  in  the  male  sex, 
especially  glioma  and  tubercle,  while  sarcoma  occurs  equally  in  the  two 
sexes.  Age.  In  the  first  decade,  18.5  percent,  of  cases  is  observed;  in  the 
second,  14  per  cent.;  third,  20  per  cent.;  fourth,  18.5  per  cent.,  and 
in  the  fifth,  14  per  cent.  (Gowers).  The  causation  is  that  of  neoplasms 
in  general,  as  developmental  errors,  granulomata,  metastatic  growths, 
and  parasites.  Trauma  is  a  certain  but  infrequent  cause;  it  may  clearly 
cause  gro^\i;hs, especial  y  glioma,  but  may  act  as  the" agent  provocateur" 
in  gumma,  sarcoma,  osteoma,  tubercle  or  aneurysm.  The  author  has 
seen  endothelioma  of  the  dura  develop  years  after  and  directly  at  the 
seat  of  an  unhealed  skull  fracture.    Syphilis  may  induce  sarcoma. 

Classification. — Classification  is  difficult. 

1.  The  Infectious  Granulomata. — (a)  Tubercle  constitutes  50  per 
cent,  of  cerebral  tumors,  50  per  cent,  being  found  in  the  first,  and  75 
per  cent,  in  the  first  and  second  decades  (Gowers).  The  subject  is 
usually  poorly  nourished,  and  often  exhibits  lung  changes;  33  per 
cent,  occurs  in  the  cerebellum,  33  per  cent,  in  the  cerebrum  and  the 
remainder  in  the  pons,  central  ganglia,  crus,  medulla  and  corpora 
quadrigemina.  With  equal  frequency  they  are  single  or  multiple,  and 
may  number  even  20  or  80.  They  originate  from  the  meninges  or 
vessels  of  the  brain  substance,  and  are  firm,  rather  rounded  tumors, 
with  grayish-red  periphery  and  yellow  caseated  centre.  Tubercles 
range  from  the  size  of  a  pea  or  walnut  to  that  of  an  egg  or  of  the  fist, 
from  fusion  of  many  small  growths.  They  grow  along  the  lymph 
vessels,  cause  vascular  thrombosis,  present  the  degeneration  of  tubercle 
of  other  tissues,  and  may  be  shelled  out  of  the  brain  tissue,  which  is 
compressed  and  atrophied,  but  neither  infiltrated  nor  softened,     ib) 


1000  DISEASES  OF  THE  XERVOUS  SYSTEM 

Gummata  (see  Brain  Syphilis)  occur  far  more  frequently  than 
statistics  indicate,  for  they  respond  to  treatment  and  often  disappear 
spontaneously.  In  the  adult  they  are  the  most  common  type  of 
tumor.  They  are  most  frequent  in  the  cerebral  hemispheres  and 
pons,  and  are  rare  in  the  cerebellum  and  central  ganglia.  Though  thev 
are  most  often  the  size  of  a  pea  or  hazelnut,  larger  dimensions  are 
observed.  Their  centre  is  yellow-gray,  and  their  periphery  is  reddish- 
gray,  gelatinous,  rich  in  cells  and  ultimately  cicatricial.  Gummata 
are  usually  multiple.  The  adjacent  brain  tissue  is  not  infiltrated,  but 
commonly  softened  and  compressed.  iMicroscopically  they  closely 
resemble  tubercle,  but  Virchow  described  them  as  more  nodose, 
angular,  irregular,  more  distinctly  connected  with  the  dura  even  when 
deeply  located,  more  gelatinous  and  less  caseated.  Tubercle  bacilli 
are  not  always  found  in  unmistakable  tubercles,  and  gummata  are 
sometimes  miliary  in  size.  Both  forms  have  been  confused  with  actino- 
mycosis. 

2.  Neuro-epithelial  Growths. — (a)  Glioma  constitutes  25  per  cent, 
of  brain  growths;  50  per  cent,  occurs  in  the  hemispheres,  especially 
the  cortex;  25  per  cent,  in  the  cerebellum,  and  the  balance  in  the  central 
ganglia,  pons,  medulla,  crus,  and  corpora  quadrigemina.  They  occur 
more  frequently  in  the  brain  than  in  the  cord  or  retina,  to  which  three 
structures  they  are  peculiar.  Gliomata  are  usually  (90  per  cent.) 
single,  and  are  seen  most  frequently  in  adults  (first  to  twentieth  year, 
20  per  cent. ;  twentieth  to  fortieth  year,  50  per  cent. ;  fortieth  to  sixtieth 
year,  25  per  cent.,  Gowers).  Some  classify  glioma  with  sarcoma. 
Gliomata  originate  largely  in  the  gray  substance,  which  they  so  closely 
resemble  in  tint  that  detection  is  difficult  at  operation,  or  indeed  at 
autopsy,  where  secondary  hemorrhage  or  softening  in  them  may  be 
confused  with  primary  hemorrhage.  Cases  formerly  called  brain  hyper- 
trophy were  probably  gliomata.  Their  size  varies  from  that  of  a  pea 
almost  to  that  of  a  hemisphere.  Glioma  infiltrates  without  sharp  de- 
markation  rather  than  compresses  the  brain  tissue,  and  does  not  form 
adhesions.  The  cells  resemble  the  neurogliar  structure  and  usually 
have  round  or  oval  nuclei,  although  Klebs  found  ganglionic  cells.  Their 
processes  are  fine;  numerous  and  branched  delicate  band-like  lines 
result  from  fiber  degeneration,  ih)  The  rare  cerebroma  of  Hayem  was 
held  by  Virchow  to  be  heterotopic  gray  matter  in  the  white  substance. 
(c)  Adenoma  of  the  pineal  gland  and  hypophysis  may  be  brought  under 
this  heading  as  also  may  {d)  growth^  from  the  plexuses,  and  (e)  neu- 
romata. 

3.  Connective  Tissue  Tumors. — (a)  Sarcoma  is  the  most  frequent, 
and  constitutes  20  per  cent,  of  brain  tumors;  it  may  develop  in 
the  meninges,  periosteum  or  vessels.  It  is  most  common  in  adults. 
Though  it  infiltrates  more  than  tubercles  or  gummata,  it  does  so  less 
than  would  be  expected.  ]Many  are  well  demarked,  and  cause  more 
softening  than  infiltration.  Its  structure  and  degenerations  are  those 
of  sarcoma  elsewhere.  Though  it  is  most  commonly  single,  diffuse  or 
multiple  sarcomatosis  is  sometimes  encountered.    Endothelioma  (Zieg- 


BRAIN  TUMORS  lOOi 

ler),  cylindroma  (Billroth),  angiosarcoma  and  melanosarcoma  are  but 
varieties.  The  sand  tumors  (psammomata)  of  the  pineal  gland,  Pac- 
chyonian  bodies  and  choroid  plexus  are  sometimes  described  as  angio- 
lithic  sarcomata.  The  "pearly  tumors"  (cholesteatomata)  are  formed 
of  flat  endothelial  cells.  (6)  Benign  connective  tissue  growths  (lipoma, 
fibroma,  and  osteoma)  are  very  infrequent. 

4.  Metastatic  Tumors. — Cancer  is  not  infrequent  (7  per  cent,  of 
brain  growths),  especially  from  mammary  or  lung  carcinoma,  just  as 
lung  suppuration  often  secondarily  involves  the  brain.  It  often  invades 
the  hemispheres  and  basal  ganglia,  and  may  attain  huge  dimensions. 
Like  sarcoma,  it  infiltrates.    Cancer  is  very  rarely  primary. 

5.  Cystic  Tumors. — Cysts  may  result  from  hemorrhage  or  softening, 
degeneration  in  neoplasms,  infantile  inflammations  or  defects  (poren- 
cephalia), trauma,  or  inflammation  in  the  choroid  plexus.  Dermoids 
and  teratomata  are  most  rare.  Parasitic  cysts  occur  largely  in  persons 
between  the  tenth  and  thirtieth  years;  echinococcus  cysts  may  be 
single  or  multiple;  they  occur  chiefly  on  the  surface  of  the  brain,  or 
in  the  meninges,  and  vary  much  in  size.  Cysticercus  cysts  develop 
mostly  on  the  pia  and  arachnoid  over  the  cortex  along  the  sulci,  or  in 
the  ventricles.  They  occur  in  /o  of  1  per  cent,  in  certain  autopsies, 
though  Diamond  (1899)  could  collect  but  8  cases  from  the  American 
literature;  they  vary  from  the  size  of  a  pea  to  that  of  a  hazelnut,  are 
usually  multiple  (200  in  Snell's  case),  and  contain  clear  fluid  with 
black  dots,  the  heads  of  the  parasites.  A  fibrous  capsule  frequently 
develops,  and  calcification  may  occur  later.  The  cysticercus  race- 
mosus  may  reach  a  great  size. 

6.  Aneurysms. — Aneurysms  have  been  considered  under  diseases 
of  the  brain  vessels. 

Location. — The  location  in  Gower's  figures  was: — cerebrum,  42 
per  cent.;  cerebellum,  25  per  cent.;  base,  11  per  cent.;  pons,  8  per 
cent.;  central  ganglia,  7  per  cent.;  medulla,  4  per  cent.;  corp.  quad- 
rigemina,  2  per  cent. ;  crus,  1  per  cent. 

Symptoms. — In  rare  instances,  tumor  is  found  at  autopsy  without 
clinical  symptoms  {latency).  This  is  due  to  location  of  the  tumor  in  a 
"silent"  or  tolerant  brain  area;  it  may  occur  in  tuberculous  menin- 
gitis, mental  disease,  aneurysm,  cysticercus,  psammoma,  cholesteatoma, 
or  meningeal  tumors,  which  slowly  compress  the  brain.  As  a  rule, 
symptoms  result  from  the  following  mechanisms:  (a)  Direct  'pressure 
exerted  on  the  brain,  which  may  flatten  the  convolutions,  obliterate 
the  sulci,  force  open  the  skull  fissures  in  children,  absorb  or  perforate 
the  cranium.  Pressure  is  conspicuous  in  growths  of  the  posterior  fossa 
closed  by  the  rigid  tentorium.  (6)  Internal  hydrocephalus ,  distention 
of  the  ventricles,  may  follow  closure  of  the  aqueduct  of  Sylvius,  or  com- 
pression of  the  veins,  particularly  of  the  choroid  plexus  and  the  vena 
Galeni  magna,  and  especially  by  tumors  of  the  cerebellum  and  corp. 
quadrigemina.  (c)  The  brain  may  be  softened  by  pressure  on  its  vessels 
(Bouveret),  inflamed,  or  hemorrhage  may  develop  (as  in  glioma),  (d) 
Infiltration  or  destruction  of  the  brain. matter  may  result,     (e)  Menin- 


1002  DISEASES  OF  THE  XERVOUS  SYSTEM 

gitis,  local  as  in  gumma,  or  general  as  in  tubercle,  may  develop.  (/) 
Auto-intoxication  from  the  growth  is  possible,  as  suggested  bvKlippel. 
(g)  Distortion  of  the  cerebral  or  spinal  nerves  (Dinkier,  Mayer),  may 
cause  their  degeneration,  or  changes  in  the  posterior  columns  of  the 
cord  and  its  posterior  roots. 

The  symptoms  produced  are  general  (diffuse),  and  focal  (local). 

The  general  symptoms  usually  come  first  in  the  evolution,  and 
include  the  following:- — (a)  Headache  is  present  in  almost  all  cases, 
is  usually  constant,  T^'ith  accessions  (especially  in  the  morning),  is 
general,  rarely  unilateral,  is  severe  and  obstinate  enough  to  keep  the 
patient  awake  at  night,  is  increased  by  alcohol,  exertion  and  coughing, 
and  rarely  corresponds  with  the  tumor's  site  except  when  the  pain  is 
persistently  local  and  the  tumor  near  the  surface.  (Frontal  headache 
often  results  from  tumor  in  the  white  substance  of  the  frontal  and 
parietal  areas,  but  sometimes  may  result  from  tumor  anywhere,  even 
in  the  cerebellum,'  which  more  often  is  attended  by  occipital  headache 
or  neck-ache.)  Headache  is  usually  referred  to  irritation  of  the  dural 
branches  of  the  fifth  nerve,  an  explanation  which  is  not  always  satisfac- 
tory. It  may  be  pulsating  in  aneurysm,  (b)  Choked  disk  is  the  most 
important  general  symptom,  and  occurs  in  80  to  90  per  cent.  It  consists 
of  a  grayish-red  swelling  of  the  disk,  to  even  two  or  three  times  its  nor- 
mal dimensions,  which  lessens  its  sharpness  of  outline  and  physio- 
logical cupping;  the  arteries  become  less  lustrous  and  smaller,  the 
veins  turgid  and  tortuous,  extravasations  of  blood  and  white  patches 
of  fatty  degeneration  or  exudation  appear.  (See  Plate  v,  fig.  3.).  It 
develops  in  weeks  to  months,  and  is  due  to  increased  intracranial  ten- 
sion, which  causes  mechanical  hydrops  of  the  optic  sheath  (Schmidt- 
Rimpler,  Matz,  Schwalbe),or  to  inflammation  from  choking  of  the  veins 
by  toxic  products  (Leber  and  Gowers).  It  is  bilateral  (90  per  cent.), 
although  more  marked  on  the  side  of  the  lesion,  is  not  an  early  symp- 
tom and  depends  neither  on  the  size  of  the  tumor  nor  on  its  location. 
It  is  almost  always  present  in  growths  of  the  cerebellum  and  corp. 
quadrigemina,  is  less  frequent  in  cortical  and  meningeal  localizations, 
and.  is  often  absent  or  appears  later  in  those  in  the  pons,  medulla,  and 
Corp.  callosum.  There  is  often,  but  not  always,  limitation  of  the 
field  of  vision  (scotoma  for  color  and  lessened  acuity  of  vision).  In 
many  cases  it  develops  into  atrophy,  oftener  still  into  stasis  and  blind- 
ness, while  in  some  it  may  regress  or  very  rarely  recur.  Transitory 
amaurosis  results  from  compression  of  the  optic  tract  or  chiasm  by 
the  distended  third  ventricle,  (c)  Convulsions  occur  in  50  per  cent., 
are  called  the  "signal  symptoms,"  by  Seguin,  and  may  be  general; 
general  tonic  precede  clonic  con^nilsions  in  no  special  order;  the  pupils 
react  poorly,  the  skin  reflexes  are  increased  unless  deep  coma  develops, 
the  tendon  reflexes  are  not  suspended,  respiration  is  labored  and  coma 
occurs.  Convulsions  are  more  frequently  late  than  early.  Slight  seizures, 
like  the  petit  mal  of  epilepsy,  may  occur.  Jacksonian  epilepsy  belongs 
to  the  focal  symptoms,  {d)  Vomiting  is  usually  an  early  general  symp- 
tom,  indicating  irritation  of  the  vomiting  centre   (it  is  sometimes  a 


BRAIN  TUMORS  1003 

focal  symptom).  It  is  of  the  cerebral  type,  occurring  without  effort, 
nausea,  or  pain,  often  on  an  empty  stomach,  as  in  the  morning,  or  at 
once  after  eating,  regardless  of  the  kind  of  food  ingested;  it  is  initiated 
by  sitting  up,  turning  of  the  head,  or  excitement.  Later  the  tongue  is 
often  coated.  Vomiting  is  closely  associated  with  headache  and  ver- 
tigo, and  is  due  to  intracranial  pressure  or  meningeal  irritation.  It  is 
rarely  absent  in  growths  of  the  cerebellum  or  medulla,  is  very  frequent 
in  disease  of  the  corp.  quadrigemina,  and  occurs  in  25  per  cent,  of 
tumors  in  the  hemispheres,  {e)  The  sensorium  is  often  involved. 
The  most  common,  and  sometimes  the  earliest,  change  is  dulness, 
which  often  deepens  into  stupor  and  coma.  It  is  not  surprising  that 
tumors  affecting  the  association  fibers  and  avoiding  the  motor  centres, 
may  cause  disturbance  of  intelligence,  judgment,  or  memory,  only; 
they  are  frequently  discovered  at  autopsy  in  the  frontal  or  temporo- 
sphenoidal  lobes  in  subjects  committed  to  asylums,  for  psychoses  or 
general  paralysis.  Hysteria  may  occur  in  subjects  of  organic  brain 
disease.  (/)  Fer^i^o  is  often  an  early  symptom ;  it  may  be  mere  "giddi- 
ness," or  it  may  affect  the  labyrinth,  pons,  or  cerebellum,  and  be  a 
sense  of  actual  rotation.  It  is  present  in  31  per  cent.  (Mills  and  Lloyd), 
occurs  especially  in  the  locations  mentioned  and  as  a  focal  symptom, 
when  the  middle  cerebellar  peduncle  is  implicated,  (g)  Slowed  pulse 
may  result  from  direct,  but  more  often  from  indirect,  pressure  on  the 
vagus  fibers  behind  and  lateral  to  the  hypoglossal  nucleus.  The  vagus 
fibers  become  accustomed  to  pressure  of  long  standing  and  the  heart 
rate  increases.  It  is  often  associated  with  yawning,  hiccough,  Cheyne- 
Stokes  breathing,  glycosuria,  or  polyuria.  Cardiac  disease,  cholaemia, 
and  anaemia  must  be  excluded. 

Focal  Symptoms. — Focal  symptoms  may  be  absent  when  the  disease 
is  limited  to  "silent,"  or  "tolerant"  areas,  when  the  tumor  does  not 
destroy  nerve  structures,  and  when  vicarious  compensation  by  other 
parts  is  possible.  Focal  symptoms  of  irritation  or  paralysis  may  result 
directly  from  actual  lesion  of  a  centre  or  its  fibers,  or  indirectly  from 
"distance  pressure"  upon  them.  (They  are,  therefore,  most  signif- 
icant when  no  particular  increase  of  intracranial  tension  exists.) 

1.  Frontal  Lobes. — The  reported  changes  in  mentality  are  much 
discussed;  early  observers,  as  Bernhardt,  claimed  that  mental  changes 
were  no  more  frequent  in  frontal  localization  than  in  localization  else- 
where. Many  cases  show  the  symptoms  indicated  above.  Jastrowitz 
describes  a  condition  designated  as  moria,  a  dementia  with  character- 
istic irritability  and  excitement.  A  tendency  to  make  jokes  (Witzel- 
sucht)  is  described  by  Oppenheim.  Psychical  changes,  especially 
those  developing  early,  justify  a  "probability"  diagnosis  only.  Allan 
Starr  records  the  first  case  in  which  diagnosis  was  confirmed  by  opera- 
tion. "The  two  prominent  characteristics  of  the  mental  state  are 
apathy  and  suffering,  which  may  be  associated  or  alternate"  (Church). 
Early  or  late  mental  alteration  sometimes  follows  other  localizations. 
Sometimes  tumors  in  the  frontal  lobes  are  thought  to  be  in  the  motor 
areas  from  indirect  pressure  upon  the  latter.    The  head  and  eyes  may 


1004  DISEASES  OF  THE  XERVOUS  SYSTEM 

deviate,  and  the  neck  and  back  are  sometimes  rigid.  Bruns  has  re- 
corded frontal  tumors  with  cerebellar  ataxia,  which  is  caused  hy 
unequal  innervation  with  disturbance  of  the  sensorium  (Oppenheim), 
or  involvement  of  the  trunk  centres  (Striimpell).  Some  would  asso- 
ciate with  frontal  lesions  a  lack  of  initiative.  The  motor  centres  in  the 
left  lower  frontal  convolution  may  be  directly  or  indirectly  involved. 
Bradyphasia  (slow  speech)  is  probably  psychical,  and  differs  from  the 
separation  of  syllables  sometimes  seen  in  tumor  of  the  pons.  Oppen- 
heim speaks  of  "laryngeal  aphasia,"  in  which  the  patient  moves  his 
lips  and  attempts  to  speak,  but  finds  the  voice  lacking. 

2.  Motor  Cortex. — (a)  Jacksonian  convulsions  are  often  (50  per 
cent.)  dissociated,  and  follow  a  given  sequence  (see  Cortex  Localiza- 
tion) ;  consciousness  is  often  preserved  unless  the  other  side  of  the 
body  is  involved.  The  convulsions  may  be  few,  with  long  intervals, 
or  may  run  into  the  hundreds  (17,000  in  eleven  months,  as  reported  by 
Gowers).  They  may  be  preceded  by  the  general  convulsions  described 
above.  When  the  conducting  fibers  are  destroyed,  they  cannot  occur, 
whence  they  may  be  observed  in  the  part  nearest  the  seat  of  greatest 
damage.  As  long  as  convulsions  are  present,  the  motor  centres  cannot 
be  wholly  destroyed.  Tapping  the  tendons  or  the  skull  may  initiate 
spasms,  and  it  has  long  been  recognized  that  convulsions  can  sometimes 
be  aborted  by  electricity,  by  grasping  the  arm,  etc.  (6)  Cortical  'paralysis 
or  paresis  is  usually  monoplegic,  and  is  associated  with  cortical  spasm. 
It  is  usually  slight  at  first,  for  a  weakness  from  exhaustion  follows  the 
spasms ;  later  it  becomes  more  marked.  In  some  cases  paresis  (or  total 
hemiplegia)  may  be  the  first  sign  of  tumor,  and  sometimes  may  be  most 
narrowly  localized,  as  in  the  thumb  alone,  the  four  fingers,  or  great 
toe;  paralysis  is  accompanied  by  increased  reflexes,  rigidity,  and  rarely 
by  muscular  atrophy.  Surgical  extirpation  has  relieved  both  spasms 
and  paralysis.  In  infrequent  cases  the  paralysis  may  be  bilateral,  as 
when  a  cortical  tumor  near  the  median  line  presses  on  the  opposite 
hemisphere,  or  when  there  are  bilateral  symmetrical  growths;  these, 
however,  are  still  rarer,  (c)  Sensory  changes  are  less  frequent,  because 
the  sensory  area  is  larger  than  the  motor  area,  and  extends  posterior 
to  it,  and  it  is  possible  that  sensory  representation  is  bilateral.  (The 
gyrus  fornicatus  is  thought  by  some  writers  to  be  the  seat  of  tactile  and 
muscular  sensibility.)  Hypsesthesia,  especially  for  tactile  and  mus- 
cular sensibility  and  paraesthesia,  are  not  rare.  Cortical  pains  are  rare. 
Vasomotor  symptoms,  tachycardia,  and  salivation  (also  in  tumors  of 
the  frontal  lobe),  are  observed,  but  are  not  localizing  signs. 

3.  Parietal  Lobes. — Some  sensory  disturbance  is  fairly  common. 
Incoordinate  movements,  ataxia,  and  athetosis  have  been  observed. 
Wernicke  observed  a  tumor  in  the  lower  parietal  lobe  with  conjugate 
eye  movements,  and  Weil  noted  incoordination  of  the  extremities  on 
the  opposite,  and  of  the  eyes  on  the  same  side  of  the  body.  Sensory 
aphasia,  hemianopsia,  deafness,  and  word  deafness  are  also  observed. 

4.  Temporal  Lobes. — Symptoms  are  likely  to  be  confused  with  those 
of  the  contiguous  occipital  lobes;    hemianopsia,  disturbance  of  eye 


BRAIX  TUMORS  1005 

movements,  chiefly  toward  the  opposite  side,  ptosis,  and  agraphia  are 
recorded. 

5.  Occipital  Lobes. — Hemianopsia  is  the  most  constant  finding; 
it  results  from  any  occipital  lesion  large  enough  to  compress  the  optic 
radiation  in  the  white  substance  (Henschen).  Optical  hallucinations 
are  thought  to  indicate  a  cortical  occipital  localization  rather  than  one 
in  the  optic  radiation.  Alexia,  optic  aphasia,  and  psychical  blindness 
are  seen. 

6.  Pons. — Focal  may  precede  the  general  symptoms;  they  have 
been  enumerated  under  cerebral  localization.  Hemiplegia  with  alter- 
nating paralysis  of  some  of  the  first  eight  cranial  nerves  is  the  most 
common  type  (in  50  per  cent.).  The  fifth  nerve  may  be  involved  in 
its  sensory  or  motor  branches.  Foci  in  the  substance  of  the  pons  involv- 
ing the  sixth  nerve  usually  also  involve  the  third  nerve  of  the  opposite 
side;  foci  near  the  surface  involving  the  sixth  nerve  do  not  involve  the 
third  nerve.  Sometimes  the  nerves  may  be  involved  without  hemi- 
plegia (25  per  cent.),  but  rarely  without  crossed  motor  irritation  or 
hemiansesthesia ;  hemiplegia  alone  occurs  in  25  per  cent.  Unilateral 
tumor  of  the  pons  may  also  compress  the  opposite  motor  tracts  (para- 
plegia or  diplegia)  and  cranial  nerves.  Motor  irritation  is  not  uncom- 
mon, as  trismus,  facial  spasm  (Kolish),  and  sometimes  trigeminal 
neuralgia,  convulsions  in  the  contralateral  limbs,  etc.  Tetanic  rigidity 
is  rare.  Sensory  disturbance  is  usual,  as  a  result  of  involvement  of  the 
lemniscus  and  formatio  reticularis,  and  occurs  as  hemianesthesia 
cruciata  (in  arm  and  leg  of  one  side,  and  in  the  face  of  the  opposite 
side  when  the  focus  is  low  in  the  pons),  hemiansesthesia  of  face,  arm, 
and  leg  of  the  same  side  (tumor  in  the  upper  pons),  and  anaesthesia  of 
one  or  perhaps  of  both  sides.  Dysarthria,  dysphagia,  diflficult  urination 
or  defecation  and  disturbed  respiration  on  change  of  posture  (Pichler) 
have  been  observed. 

7.  Medulla. — It  is  remarkable  that  not  only  cystic  but  also  solid 
tumors  may  produce  no  symptoms  or  only  such  that  localization  in 
the  pons  or  cord  is  first  suggested.  In  a  small  number  of  cases  only 
are  the  symptoms  not  ambiguous.  Bilateral  paralysis  of  the  ninth 
to  twelfth  nerves  with  degeneration  and  atrophy  of  the  lips,  tongue, 
palate,  pharynx,  or  larynx,  is  characteristic,  and  presents  a  picture  like 
progressive  bulbar  palsy.  Alternating  hemiplegia  is  rare,  but  has  been 
observed  in  cases  of  gliosis.  Sensory,  motor,  atactic,  and  nerve  involve- 
ments are  usually  bilateral.  Growths  outside  the  medulla  may  cause 
paralysis  of  the  neck  muscles  (spinal  accessory  nerve).  Slowed  or 
rapid  pulse,  singultus,  embarrassed  breathing,  glycosuria,  and  polyuria 
are  not  uncommon.  Laslett  recently  described  degeneration  in  the 
posterior  columns  of  the  cord  from  pulling  of  the  medulla  on  the  pos- 
terior cervical  roots,  or  from  toxsemia,  which  was  previously  found 
by  Batten  and  Collier  (1889.) 

8.  Cerebellum. — Cerebellar  ataxia,  referred  by  Nothnagel  and 
Gowers  to  lesions  of  the  vermis  in  80  to  90  per  cent,  of  the  cases,  occurs 
but   half   as    frequently   in    disease    of   the    cerebellar  hemispheres. 


1006  DISEASES  OF  THE  XERVOUS  SYSTEM 

Compression  of  the  pons,  medulla,  corpora  quadrigemina,  and  fifth  to 
twelfth  cranial  nerves  is  somewhat  characteristic.  Sachs  regards 
involvement  of  the  sixth  nerve  as  almost  pathognomonic.  Of  the 
general  symptoms,  choked  disk  is  severe  and  almost  invariable;  occi- 
pital headache  and  rigid  neck  are  very  frequent.  Convulsions  are 
common,  and  opisthotonos  with  tetanic  rigidity  of  the  body  and 
extremities  is  most  suggestive. 

9.  Optic  Thalamus. — In  most  cases  spastic  hemiplegia  results  from 
invasion  of  the  internal  capsule;  hemichorea,  hemiathetosis,  hemi- 
ansesthesia  and  Nothnagel's  mimetic  paralysis  are  not  infrequent. 
Less  common  are  unilateral  convulsions,  forced  movements  or  pos- 
tures, contralateral  hemianopsia,  paralysis  of  the  eye  muscles,  widen- 
ing of  the  opposite  pupil  and  monoplegia. 

10.  Corpus  Callosum. — Bristowe  and  others  believe  that  the  follow- 
ing symptoms  are  characteristic;  dementia  (in  90  per  cent.),  absence 
of  initiative  in  speech  and  action,  paraplegia,  dysarthria  and  but  slight 
general  symptoms,  as  choked  disk.  Oppenheim  holds  that  there  are 
no  distinctive  symptoms. 

11.  Corp.  Qu.adrigemina.- — Ocular  paralyses  (of  the  third  nerve) 
are  common,  and  are  sometimes  associated  as  double  ptosis,  and  bilat- 
eral paralysis  of  the  internal  recti.  The  pupils  are  usually  free  but 
may  be  unequal.  Oculomotor  paralysis  may  exist  ^^'ith  crossed  hemi- 
ataxia  from  involvement  of  the  tegmentum,  or  pressure  on  the  cere- 
bellum. Disturbed  hearing  from  destruction  of  the  upper  layer  of 
the  tegmentum,  amblyopia,  and  intention  tremor,  are  also  observed. 
No  paralysis,  except  of  the  third  nerve,  is  present,  unless  the  tuinor 
extends  beyond  the  corp.  quadrig.  (Oppenheim). 

12.  Pineal  Gland. — ^The  symptoms  are  the  same  as  when  the  corp. 
quadrigemina  are  affected,  save  that  the  fourth  and  sixth  nerves  are 
involved  more  than  the  third,  and  compression  of  the  pons  or  medulla 
is  more  common. 

13.  Tumors  at  the  Base. — These  include  bone  tumors,  aneurysms, 
hypophysis  growths,  and  those  from  the  nerves  or  meninges,  (a)  At 
the  anterior  fossa,  hypophysis  tumors  (see  Acromegaly)  disturb  vision, 
and  produce  bitemporal  hemianopsia  with  amblyopia  or  sometimes 
irregular  or  transverse  hemianopsia.  In  some  instances,  there  is  am- 
blyopia of  one  eye  and  hemianopsia  of  the  other.  Usually  there  is  no 
choked  disk,  but  simple  optic  atrophy  is  present.  The  third  nerve  is 
paralyzed  in  most  cases,  and  sometimes  other  ocular  trunks  are  also 
affected.  Exophthalmos  is  occasional  and  the  growth  may  perforate 
externally  into  the  eye,  pharynx,  or  nose.  Loss  of  smell  (anosmia),  and 
mental  symptoms  are  also  observed  in  tumors  of  the  anterior  fossa. 
(6)  When  they  occur  in  the  middle  fossa,  mental  symptoms  and  con- 
vulsions are  less  common.  The  Gasserian  ganglion  may  be  compressed 
and  result  in  neuroparalytic  ophthalmia.  Other  cerebral  nerves,  as 
the  third,  and  sixth,  sometimes  suffer.  It  must  be  recalled  that  a  tumor 
elsewhere  may  indirectly  compress  the  basal  structures.  Syphilis  and 
.sarcomatosis  may  he  diffusely  basal,     (c)  T^esions  in  the  posterior  fossa 


BRAIX  TUMORS  1007 

may  simulate  bulbar  palsy.  The  lower  eight  cranial  nerves  may  be 
affected  and  usually  suffer  more  readily  and  earlier  than  do  the  pyra- 
midal tracts;-  the  grouping  of  the  cranial  nerve  implication  is  different; 
thus  paralysis  of  the  sixth  nerve  is  rarely  associated  with  the  conjugate 
fourth  nerve,  as  occurs  when  the  lesion  is  central.  The  seventh  and 
eighth  nerves  are  often  conjointly  paralyzed  in  disease  of  the  posterior 
fossa,  and  but  rarely  so  in  central  tumors.  The  symptoms  often  re- 
semble those  of  lesions  of  the  pons,  medulla,  or  cerebellum. 

Diagnosis. — Diagnosis  depends  upon  the  combination  of  focal  and 
general  symptoms.  Four  general  groups  of  cases  are  encountered:— 
(1)  Absolute  clinical  latency;  (2)  general  and  focal  symptoms,  the 
typical  case;  (3)  general  but  no  focal  symptoms;  (4)  definite  symptoms 
of  some  brain  disease  but  of  equivocal  significance.  According  to 
Bruns,  80  per  cent,  of  cases  can  be  detected. 

Analysis  of  the  General  Symptoms. — (a)  Headache  is  suggestive 
when  it  is  severe,  keeps  the  patient  awake,  and  when  the  skull  is  tender 
to  percussion  or  pressure  (the  parietal  regions  are  normally  somewhat 
sensitive).  Its  associates,  as  choked  disk  or  vomiting,  are  equally 
important.  Organic  irritative  brain  disease,  as  abscess  or  inflamma- 
tion, may  cause  headache,  but  mere  increase  of  intracranial  tension, 
as  in  hydrocephalus,  need  not  do  so.  Functional  nervous  disease  may 
cause  headache,  as  migraine,  neurasthenia,  hypochondriasis,  hysteria; 
it  may  result  from  eye  disease,  morbid  conditions  of  the  blood  or  intoxi- 
cations (ursemia,  gastro-intestinal  disorder,  and  poisoning  by  nicotine, 
opium,  alcohol,  or  lead),  and  from  arteriosclerosis,  (b)  Choked  disk 
in  80  or  90  per  cent,  of  cases  indicates  brain  tumor  (Oppenheim),  and 
if  very  marked,  it  is  seldom  due  to  other  causes.  It  is  less  frequent  in 
abscess  and  meningitis,  in  which  neuritis  optica  is  more  frequent.  It 
is  most  rare  in  embolism,  softening,  hemorrhage,  hematoma  durse 
matris,  arteriosclerosis,  poliencephalitis,  encephalitis,  the  acute  fevers, 
lead  poisoning,  neuritis  multiplex  or  alcoholism  (in  which  central 
scotoma  is  present).  Urosmia  must  be  excluded;  although  the  two 
diseases  have  much  in  common,  as  headache,  epileptiform  or  apoplecti- 
form attacks,  hemiplegia,  aphasia,  and  slow  pulse,  neuroretinitis  is 
more  common  in  nephritis,  though  local  causes  back  of  the  orbit  may 
sometimes  produce  it.  The  choked  disk  of  chlorosis  is  rare,  but 
responds  readily  to  rest  and  treatment  by  iron.  Optic  atrophy  has  the 
same  significance  as  choked  disk,  (c)  General  epileptiform  convul- 
sions occur  in  meningitis,  pachymeningitis,  abscess,  vascular  disease, 
syphilis,  alcoholism,  plumbism,  multiple  sclerosis,  paretic  dementia, 
ursemia,  and  gastro-intestinal  disease  in  children. 


EPII.EPTIC  Convulsions.  Convulsions    Resulting    from 
_^     Organic  Brain  Disease. 

More   coarse;     more   biting  of   tongue;  Convulsions  more  orderly,  slow,  clonic, 

more  frequent  cry;  more  sudden,  and  broken  by  tonic  contractions;  often 

complete  loss  of   consciousness,   fre-  with  gradual  local  commencement, 

quently  a  visceral  (epigastric)  aura:  without    loss   of  consciousness,  and 

usually      longer     interval      between  with  paresis  in  the  Jacksonian  type, 
attacks. 


1008  DISEASES  OF  THE  XERVOUS  SYSTEM 

(d)  Vomiting  is  probably  cerebral  and  organic,  and  due  to  tumor, 
if  hysteria,  migraine,  anaemia,  toxaemia,  and  gastric  disease  can  be 
excluded.  It  occurs  on  getting  up  in  the  morning,  and  is  often  asso- 
ciated with  vertigo,  syncope,  and  irritability  of  the  nervous  centres. 

Combination  of  General  Symptoms. — Headache  and  choked  disk 
occur  in  chlorosis  {v.  s.),  inplumbism  (also  with  delirium,  convulsions, 
and  coma,  but  distinguished  by  the  lead  line  on  the  gums),  or  in  uraemia 
in  which  special  examination  for  albumin,  casts  and  cardiovascular 
changes  are  definitive.  The  same  combination  may  also  prevail  in 
hypermetropia  in  anaemic  girls,  in  amenorrhoea  (Broadbent),  and  in 
injuries  of  the  head,  but  care  usually  distinguishes  them  from  brain 
tumor,  which  is  characterized  by  its  slow  onset  and  usual  focal  signs. 

Focal  Symptoms  and  Topical  Diagnosis. — Focal  syiwptoins  usually 
follow  the  general,  whereas,  in  apoplexy,  for  example,  the  focal 
symptoms,  as  hemiplegia,  are  early.  In  tumor  with  hemiplegia,  con- 
tracture or  spasticity  accompanies  the  paralysis  rather  than  follows  it, 
as  usually  occurs  in  hemorrhage  or  embolism.  Hemiplegia  from  a 
tumor  is  less  pure,  less  circumscribed,  less  systematic  (Fournier).  A 
tumor  at  the  base  may  cause  hemiplegia,  not  from  direct  involvement  of 
the  internal  capsule  or  pons,  but  from  pressure  on  the  middle  cerebral 
artery  with  encephalomalacia.  Jacksonian  epilepsy  with  paresis  is, 
in  50  per  cent,  of  cases,  due  to  cortical  tumors.  It  is  also  produced  by 
hemorrhage,  softening  and  inflammation,  and  is  then  earlier,  is  not 
confined  to  as  small  an  area,  and  is  not  as  progressive  as  in  neoplasm. 
The  cortical  paralysis  and  epilepsy  observed  in  alcoholism,  paretic 
dementia,  plumbism,  uremia,  and  rarely  in  tuberculosis,  cancer,  and 
diabetes  (Senator),  are  not  dissociated  and  are  but  transitory. 

Nature  of  the  Growth. — (a)  This  may  be  determined  in  part  from 
its  location.  Cortical  growths  are  most  probably  gumma  or  tubercu- 
losis (possibly  glioma,  cysts,  cysticercus,  or  sarcoma);  subcortical, 
glioma,  or  sarcoma;  'pons,  tubercle,  gumma,  glioma;  cerebellum,  tu- 
bercle or  glioma;  extracerebral,  sarcoma;  multiple  occurrence,  tubercles 
or  gummata.  (6)  Its  nature  may  also  be  determined  from  its  course^ 
A  rapidly  growing  tumor  is  most  probably  glioma  or  sarcoma.  An 
apopleptic  attack  indicates  glioma  or  ruptured  aneurysm.  Growth 
with  remissions  is  characteristic  of  tubercle  or  glioma.  A  very  slow 
course  suggests  fibroma  or  osteoma.  Coincident  meningitis  indicates 
tubercle  or  syphilis. 

Differentiation. — Tumors  must  be  distinguished  from  brain  abscess; 
abscess  and  tumor  have  much  in  common,  as  their  general  symptoms; 
both  may  result  from  trauma,  but  brain  abscess  is  almost  always  sec- 
ondary to  trauma,  or  to  a  pus  focus  (otitic  or  metastatic) ;  unilateral 
optic  neuritis  is  a  much  more  common  symptom  than  choked  disk, 
and  abscess  (q.  v.)  when  once  "manifest"  is  more  apt  to  produce  fever, 
chills,  a  rapid  course  and  apopleptic  seizures  than  is  tumor,  while 
involvement  of  the  cranial  nerves  is  less  frequent.  It  must  be  borne  in 
mind  that  bulbar  tumors  may  cause  fever,  and  that  in  abscess,  for  a 
time  at  least,  there  is  a  normal  or  subnormal  temperature.    Differenti- 


BRAIX    TUMORS  1009 

ation  from  paretic  dementia,  pachymeningitis  hemorrhagica  interna, 
meningitis,  syphih's,  and  hydrocephalus,  will  be  considered  under  each 
disease. 

Chronic  meningitis  (syphilitic,  tuberculous  or  actinomycotic)  or 
meningo-encephalitis  may  be  confused  with  diffuse  tumors  at  the  base, 
but  lack  pressure  symptoms  and  progression. 

Multiple  sclerosis  must  be  differentiated.  In  both  affections  inten- 
tion tremor,  disturbance  of  speech,  mental  change,  vertigo,  nystag- 
mus, apoplectiform  or  epileptiform  attacks  and  tonic  spasms  of  the 
extremities  may  occur,  but  marked  brain  symptoms  rather  speak 
against  multiple  sclerosis  at  least  in  its  earlier  stages.  The  pressure 
symptoms  of  tumor  and  increase  of  cerebrospinal  fluid  are  absent 
and  in  the  disk  there  is  an  incomplete  optic  atrophy.  If  undue  stress 
be  placed  on  the  tremor,  it  may  be  confused  with  the  incoordination 
tremor  of  tumor  in  the  optic  thalamus,  pons  or  cerebellum. 

Course  and  Prognosis. — ^The  first  symptoms  are  usually  general, 
followed  by  the  focal  symptoms.  If  left  to  itself,  the  disease  runs  a 
fatal  course  in  one-half  to  two  years,  although  in  rare  cases  it  endures 
four  to  fourteen  years.  A  long  latent  tumor  may  appear  to  begin 
acutely.  Exacerbations  result  from  aneurysmal  rupture,  hemorrhage 
into  a  glioma,  cyst  formation,  ventricular  effusions,  meningitis,  or  local 
neuritis.  Remissions  are  not  uncommon;  healing  of  parasitic  and 
simple  cysts,  aneurysms,  tubercles  (in  the  young)  and  gummata  is 
possible.  It  was  thought  that  aneurysms  and  gliomata  may  be  cured 
with  iodide  treatment  (Wernicke).  Unfavorable  symptoms  are  pro- 
nounced mental  change,  incoercible  vomiting,  irregular  and  rapid 
pulse,  repeated  fits,  apoplectiform  seizures  or  festinating  neuritis  optica. 
The  mechanism  of  death  is  (a)  exhaustion  from  vomiting,  pain,  or 
•cachexia;  (6)  inhalation  pneumonia;  (c)  coma  with  disturbed  respira- 
tion, circulation,  or  other  bulbar  signs;  (d)  sudden  death  in  tumors  of 
the  base  (rarely  of  the  cortex);  (e)  meningitis  or  arterial  disease;  (/) 
intercurrent  infections. 

Treatment. — Medical  treatment  does  not  produce  encouragmg 
results,  save  in  cases  of  syphilis,  but  every  patient  should  be  given  a 
course  of  mercury  and  iodide  for  at  least  three  months.  Tubercle  may 
sometimes  be  arrested  by  increasing  the  physiological  resistance  by 
forced  feeding,  fresh  air,  and  administration  of  cod-liver  oil  and  arsenic. 
The  headache  is  often  relieved  by  iodide,  in  any  kind  of  tumor,  by  the 
ice-bag,  morphine,  atropine,  hyoscine,  the  coal  tar  products,  and  by 
trephining.  Convulsions  should  be  treated  by  chloral.  Brain  con- 
gestion resulting  from  alcoholism,  excitement,  exertion,  overeating,  or 
obstipation  should  be  avoided. 

Surgical  Interference. — Macewen,  Horsley,  Bennett,  Ferrier,  and 
Godlee  are  the  pioneers  in  brain  surgery,  (a)  In  radical  operation 
the  outlook  is  not  very  encouraging.  Allan  Starr  estimates  that  but  18 
per  cent,  of  tumors  are  accessible,  and  but  7  per  cent,  removable; 
Siedel  finds  only  3  per  cent,  are  operable.  Thirty-four  per  cent,  is 
Ijasal.    At  operation  the  tumor  is  found  in  64  per  cent,  of  cases.    The 


1010  DISEASES  OF  THE  NERVOUS  SYSTEM 

best  results  are  obtained  in  meningeal  and  the  next  best  in  cortical 
growths,  especially  of  the  motor  and  occipital  zones.  Duret  (1903) 
analyzed  344  operations;  18  per  cent,  died,  64  per  cent,  improved  and 
vision  was  completely  restored  in  60  per  cent.,  and  partially  in  18  per 
cent.  In  cerebellar  tumors,  sudden  death  is  frequent,  because  of 
manipulation  compression  of  the  medulla.  In  116  operations  for 
cerebellar  growth,  the  mortality,  once  70  per  cent.,  is  now  38  per  cent. 
(Frazier,  1905). 

All  varieties,  even  the  syphilitic  scar  or  tubercle,  may  be  removed, 
excepting  metastatic  growths.  Recovery  from  the  operation  is  fre- 
quent, although  the  mortality  ranges  from  20  to  50,  or  even  80  per 
cent.  But  few  ultimately  recover.  Recurrence  is  common.  Death 
occurs  from  hemorrhage,  sepsis,  dislocation  of  the  brain,  basal  com- 
pression, brain  oedema  and  shock.  Horsley  and  Macewen  have  sug- 
gested that  the  operation  be  performed  in  two  steps;  first  exposing 
the  tumor,  and  later  removing  it,  after  the  brain  has  accommodated 
itself  to  the  change  of  relations,  (b)  Palliative  operation  may  be  bene- 
ficial. Removal  of  a  button  of  bone  with  incision  of  the  dura  often 
greatly  relieves  the  headache  and  growing  blindness,  allows  fluid  to 
escape  and  permits  the  tumor  to  grow  outward  when  it  cannot  be 
removed.  Henschen  claims  that  the  palliative  procedure  hastens 
death  more  than  twice  as  frequently  as  it  relieves  the  symptoms,  (c) 
Ventricular  drainage  has  not  proven  helpful  and  lumbar  puncture  is 
dangerous;  17  cases  of  sudden  death  are  reported  to  have  resulted 
from  it. 


(D).  INFLAMMATION  OF  THE  BRAIN. 
I.  Encephalitis. 

Acute  encephalitis  is  not  "inflammation  of  the  brain"  (as  under- 
stood by  the  laity),  which  is  meningitis.  Encephalitis  does  not  include 
the  zone  of  inflammation  which  occurs  about  tumors,  foci  of  hemor- 
rhage, softening,  syphilis,  and  meningitis.  It  was  once  held  by  Durand- 
Fardel  that  all  softening  was  encephalitis  (cerebritis).  Gluge  (1837) 
suggested  that  some  cases  were  encephalomalacia;  Coswell  and  Hasse 
(1850)  definitely  distinguished  between  them;  and  Virchow  anatom- 
ically and  Hayem  clinically,  followed  by  v.  Leyden,  Erb,  Westphal, 
FoviUe,  and  Otto,  described  definite  cases.  The  work  of  Wernicke, 
Striimpell,  Leichtenstern,  and  Oppenheim  will  be  mentioned  later. 

Etiology. — There  are  three  main  etiological  factors;  they  are  (a) 
intoxications,  chiefly  from  alcohol,  and  far  less  often  poisoning  by  sul- 
phuric acid,  ptomaines  in  decayed  meat  and  fish,  nicotine,  and  sun- 
stroke. (6)  Infections,  especially  influenza,  then  scarlatina,  measles, 
hydrophobia,  ulcerative  endocarditis,  and  numerous  other  infections. 
In  such  cases,  microbes  may  invade  the  brain  alone.  Some  relation 
to  chlorosis,  sinus  thrombosis,  chorea  insaniens  or  maniacal  forms  of 


ENCEPHALITIS  1011 

exophthalmic  goitre  is  possible,  (c)  Trauma,  by  laceration  or  concus- 
sion, directly  or  indirectly  may  produce  a  locus  resistentioB  minoris 
for  secondary  microbic  invasion,  although  an  aseptic  form  is  said  to 
exist. 

Pathology. — Wherever  located  (v.  i.),  the  process  begins  as  mul- 
tiple disseminated  and  often  symmetrical  foci,  principally  in  the  gray 
matter;  these  grow  and  diffuse,  sometimes  most  widely.  They  vary 
in  size  from  microscopic  dots  to  a  diameter  of  several  inches,  but  usually 
are  the  small  "flea  bite"  areas  of  capillary  hemorrhage,  which 
glisten  and  stain  the  adjacent  tissues,  show  above  the  cut  section  and 
later  become  foci  of  softening.  Microscopically,  hypersemia,  perivas- 
cular exudation  of  red  and  white  cells,  serous  effusion  and  changes 
in  the  nervous  elements  are  observed.  Aggregations  of  mononuclear 
cells  are  seen,  somewhat  resembling  a  tubercle,  which  Popoff  claims 
may  actually  enter  the  ganglion  cells,  which  become  degenerated,  fatty, 
and  swollen;  the  medullary  sheaths  and  later  the  axis  cylinders  de- 
generate. Its  issues  are: — (a)  regression  (recovery);  (6)  necrobiosis 
with  softening;  (c)  cyst  formation;  {d)  cicatrix  formation  with  enclos- 
ure of  fatty  granules  or  htematoidin,  or  (e)  it  may  possibly  spread  as 
diffuse  brain  sclerosis  or  (/)  may  become  the  foci  of  multiple  sclerosis. 
Associated  nervous  changes  are  optic  neuritis,  multiple  neuritis,  and 
poliomyelitis,  and  general  changes  are  enlarged  spleen,  retinal  or  general 
hemorrhages  and  parenchymatous  degeneration  in  the  kidney,  etc. 

Special  Pathology  and  Symptomatology. — 1.  Poliencephalitis  Acuta 
Superior  Hemorrhagica  (or  Ophthalmoplegica). — This  was  said  by 
Wernicke  (1881),  and  also  by  Badeker,  to  occur  in  alcoholic  sub- 
jects, and  therefore  in  adults;  it  attacks  the  gray  matter  about  the 
third  and  fourth  ventricles,  and  aqueduct  of  Sylvius,  whence  it  may 
spread  upward  or  downward;  it  results  in  eye  paralysis,  and  is  anal- 
ogous to  acute  poliomyelitis.  The  general  symptoms  are  delirium 
tremens,  or  somnolence  in  non-alcoholics,  headache,  vomiting,  and 
rigid  neck.  The  local  symptoms  consist  of  an  early  extensive  ophthal- 
moplegia, which  involves  associated  eye  muscles,  as  the  two  internal 
recti,  or  the  internal  rectus  of  one  eye,  and  the  external  of  the  other, 
and  usually  leaves  the  pupil  and  the  levator  palpebrse  superior  free. 
The  gait  is  almost  invariably  atactic  and  unsteady  from  involvement 
of  the  corpora  quadrigemina.  Speech  is  frequently  difficult.  Neu- 
ritis is  observed  in  the  optic  disk,  and  sometimes  in  the  peripheral 
nerves,  as  evidenced  by  the  absent  patellars,  ataxia,  tender  muscles,  etc. 
Sometimes  there  is  hemiparesis  and  facial  paresis.  The  temperature 
is  usually  normal,  or  in  alcoholics  may  be  subnormal,  though  respira- 
tion and  pulse  are  increased.  Death  occurs  within  two  weeks  after 
these  violent  symptoms.  This  type  is  most  easily  recognized,  although 
syphilis,  tumors,  or  encephalomalacia  may  affect  the  same  nuclei. 
Some  cases  thought  to  be  nuclear  have  been  shown  by  Badecker, 
Thompson,  and  Jacobseus  to  be  polyneuritic,  and  others  have  shown 
no  pathological  alteration  at  autopsy.  The  diagnosis  is  easiest  in  this 
type. 


1012  DISEASES  OF  THE  NERVOUS  SYSTEM 

2.  Encephalitis  (or  Poliencephalitis)  Hemorrhagica. — Striimpell 
(1884)  described  primary  cases  of  infantile  paralysis  (q.  v.)  in  which 
he  referred  the  lesion  to  inflammation  of  the  motor  cortex;  though  his 
theory  in  explaining  all  such  cases  is  too  general,  some  anatomical 
confirmation  of  it  is  not  lacking  (Ganghofner).  In  1885-86,  Leich- 
tenstern  saw  cases  which  resulted  from  the  infections  named  under 
etiology.  Foci  are  found  in  the  cortex,  subcortex,  or  central  ganglia, 
containing  pus  cocci,  and  influenza  bacilli.  In  some  cases  the  autopsy 
showed  nothing,  and  intoxication  was  then  assumed.  The  disease 
occurs  mostly  between  the  fifteenth  and  thirtieth  years,  but  also  in 
children.  After  an  influenza,  there  may  be  (a)  general  symptoms,  as 
headache,  vomiting,  delirium,  mental  obscuration,  convulsions  (in  the 
young),  high  fever  without  chill,  slowed  pulse  becoming  rapid,  and 
irregular  breathing,  or  sometimes  stiff  neck  or  optic  neuritis;  (b)  focal 
symptoms  appear  after  a  few  days,  as  hemi-  or  monoplegia,  aphasia, 
conjugate  deviation,  focal  convulsions,  or  hemichorea  (Friedmann). 
The  reflexes  are  affected  as  in  apoplexy.  The  course  lasts  one-half  to 
three  weeks,  and  is  often  fatal,  but  recovery  is  not  rare.  This  form 
may  resemble  hemorrhage,  syphihs  or  softening,  but  occurs  in  the 
young  with  normal  arteries,  and  the  paralysis  is  preceded  by  signs  of 
infection,  fever,  enlarged  spleen,  somnolence  or  convulsions.  Sinus 
thrombosis  cannot  be  differentiated  but  meningitis  is  usually  differ- 
entiated with  ease. 

3.  Subtypes. — These  consist  of  the  following:  (a)  poliencephalitis 
inferior  acuta,  involving  the  pons  or  medulla,  and  giving  acute  bulbar 
symptoms;  there  is  paralysis  of  the  sixth,  seventh,  to  twelfth  nerves 
when  it  occurs  in  various  combinations,  or  with  types  (1)  and  (2). 
Some  of  the  cases  (chorea  insaniens,  Basedow's  disease  with  mania), 
may  show  nothing  at  autopsy,  whence  the  diagnosis  is  very  uncertain. 
Confusion  with  softening,  hemorrhage,  the  late  hemorrhage  of  trauma, 
or  tumors  is  possible.  (6)  Another  form  is  poliencephalomyelitis ,  acute 
(Kaiser),  subacute  (Kahsher),  or  chronic  (Rosenthal),  in  which  the 
type  of  Wernicke  or  of  Striimpell-Leichtenstern  may  descend  and 
co-exist  with  inflammation  and  paralysis,  frequently  symmetrical, 
of  the  anterior  spinal  roots.  Hutchinson's  facies  is  observed,  viz., 
fixed  eyes,  fallen  lids,  prominent  eyebrows,  obHterated  nasolabial 
folds,  and  atrophic  paralysis  of  the  arms.  Differentiation  from  mul- 
tiple neuritis  is  usually  possible,  and  Oppenheim's  criteria  are  well- 
estabhshed  in  its  separation  from  myasthenia  gravis,  in  which  there 
is  (i)  no  atrophy,  but  (ii)  remissions  in  the  paralysis,  (iii)  great  mus- 
cular adynamia,  (iv)  absence  of  reaction  of  degeneration,  and  (v)  nega- 
tive anatomical  findings. 

Prognosis. — The  prognosis  is  unfavorable,  as  a  rule.  The  peracute 
cases  may  die  in  two  days;  acute  cases  last  one-half  to  ihxee  weeks, 
and  death  is  most  frequent;  Oppenheim  has  shown  that  they  may 
recover.  Much  involvement  of  the  mind,  decubitus,  alcohoHc  delirium, 
chlorosis,  sinus  thrombosis,  and  weak  pulse  are  unfavorable  elements. 
In  children  recovery  is  common,  but  epilepsy,  paralysis,  mental  altera- 


ABSCESS  OF  THE  BRAIX  1013 

tion  and  possibly  multiple  sclerosis  are  sequences.     Even  the  bulbar 
type  may  recover. 

Treatment. — This  is  wholly  symptomatic,  (a)  The  causal  feature 
must  be  eliminated,  (6)  cerebral  congestion  avoided,  and  (c)  the  skin, 
bowels,  and  bladder,  the  delirium  and  convulsions,  the  diet,  and  the 
patient's  rest  must  be  cared  for  as  in  brain  hemorrhage,  softening,  or 
tumor,  (d)  Mercurial  inunctions,  iodoform  inunctions  and  potassium 
iodide  give  the  best  results,  '(e)  Electricity  is  indicated  in  the  chronic 
stage. 

II.  Abscess  of  the  Brain. 

Brain  abscess  (encephalitis  suppurativa  or  apostematosa)  is  not  a 
common  disease.  Eichhorst  found  but  three  among  13,563  medical 
cases. 

General  Etiology.— All  cases  are  caused  by  microorganisms,  of 
which  the  streptococcus  is  the  most  frequent,  the  staphylococcus  com- 
ing next  and  then  the  pneumococcus,  and  other  bacteria.  Mixed  infec- 
tions are  common,  and  old  abscesses  are  often  sterile.  Sixty-six  to  75 
per  cent,  occurs  in  men.  It  is  most  frequent  between  the  twelfth  and 
thirtieth  year.  Twenty  per  cent,  occurs  in  the  second,  and  33  per  cent, 
in  the  third  decade  (Gowers).  The  cerebrum  is  involved  in  about  75 
per  cent.,  and  the  cerebellum  in  25  per  cent.,  but  the  pons  and  medulla 
are  rarely  involved. 

General  Pathology. — The  focus  is  single  in  80  per  cent,  of  cases. 
The  average  size  is  from  one  to  two  inches,  but  may  be  almost  micro- 
scopic or  may  occupy  nearly  the  entire  hemisphere.  The  surrounding 
brain  may  be  inflamed.  Durand-Fardel  described  the  various  plaques 
mentioned  under  embolism  as  various  stages  of  inflammation.  It  is 
possible  that  the  red  softening  may  sometimes  be  the  first  stage  of 
inflammation,  although  far  more  often  due  to  ischsemia.  A  zone  of 
oedema  is  common.  The  right  side  of  the  brain  is  more  often  affected 
than  the  left.  Pressure  is  less  common  and  less  intense  than  in  tumor, 
though  large  abscesses  flatten  the  brain  and  may  produce  internal 
hydrocephalus.  The  abscess  consists  of  pus  of  variable  consistency, 
yellow  or  green,  acid,  sometimes  rancid,  foetid  or  putrid;  flocculi  of 
disorganized  brain  tissue  are  common.  The  pus  cells  are  often  indis- 
tinct and  fatty  needles,  cholestearin  crystals  and  sometimes  corpora 
amylacea  or  foreign  bodies  are  found.  Putridity  is  due  to  communica- 
tion with  the  nose  or  ear,  or  embolism  from  putrid  lung  foci.  Encap- 
sulation occurs  in  50  per  cent.,  chiefly  in  old,  slow  cases,  and  requires 
from  two  weeks  to  two  months.  The  capsule  rarely  completely  or 
permanently  limits  the  abscess  which  usually  grows  and  often  rup- 
tures, although  ultimate  quiescence  from  inspissation  and  successful 
demarkation  is  barely  possible. 

Special  Etiology  and  Pathology. — 1.  Foci  near  the  brain  are  its 
usual  causes,  and  for  this  reason  brain  abscess  is  seen  bv  internalists , 


1014  DISEASES  OF  THE  NERVOUS  SYSTEM 

neurologists,  surgeons  and  otiatrists.  (a)  Ear  disease  explains  at  least  25 
per  cent,  of  brain  abscess  (even  33  or  42  per  cent.).  Otitis  media  is  the 
most  frequent  cause  and  is  chronic  in  91  per  cent.  (Griinert).  Insur- 
ance companies  generally  recognize  the  risk  in  these  cases.  Jansen 
found  one  abscess  to  500  cases  of  chronic,  and  one  to  2,650  of  acute, 
otitis.  The  ear  disease  may  date  back  thirty  or  forty-five  years,  and 
is  especially  dangerous  when  it  recurs  and  when  granulations  and 
polypi  exist.  The  acute  infections  are  thus  indirectly  causative  of 
brain  abscess.  Infection  traverses  the  bone  (92  per  cent.,  Korner), 
to  the  dura  by  way  of  the  thin  tegmentum  tympani,  by  the  roof  of  the 
antrum,  sometimes  through  the  petrosquamous  suture  (in  children), 
by  the  mastoid  cells,  lateral  sinus,  labyrinth  or  aqueduct  along  the 
sheaths  of  the  seventh  and  eighth  nerves  (though  this  is  more  common 
in  meningitis),  and  rarely  by  the  external  canal.  Korner 's  figures 
show  that  in  42  per  cent,  there  is  a  fistule  between  the  abscess  and  the 
causal  focus;  in  15  per  cent,  the  dura  interposes  between  the  two  foci; 
in  15  per  cent,  there  are  dural  adhesions,  and  in  17  per  cent,  the  inter- 
vening substance  is  softened  brain  tissue.  Toynbee  (1885)  remarked 
that  (i)  disease  of  the  roof  caused  temporosphenoidal  abscess,  but 
(ii)  disease  of  the  mastoid  cells  chiefly  produced  cerebellar  abscess. 
Of  otitic  abscess,  temporosphenoidal  constitutes  67  per  cent.  (75  per 
cent,  in  children  under  ten  years),  and  cerebellar  abscess  33  per  cent. 
(Korner) ;  the  latter  is  most  rarely  due  to  any  other  cause  than  otitis, 
and  almost  invariably  occurs  in  the  anterior  part  of  its  hemispheres. 
Otitic  abscess  infrequently  involves  the  occipital,  frontal  (two  personal 
observations)  or  parietal  lobes.  The  abscess  is  single  (87  per  cent.), 
and  lies  in  the  white  substance  of  the  brain  just  beneath  the  cortex. 
The  smaller  the  abscess,  the  nearer  it  lies  to  the  cortex.  Cholestea- 
tomata  (pearly  tumors)  may  cause  some  cases,  (b)  Traumatism 
produces  25  per  cent,  of  the  cases.  Punctured  wounds  are  more  danger- 
ous than  open  compound  fractures.  Fractures  of  the  base  may  result 
in  abscess  by  infecting  the  middle  ear.  Splintering  of  the  inner  table, 
and  operations  on  the  brain  are  possible  causes;  abscess  may  occur 
without  skull  fracture,  for  contused  areas  may  be  infected  through  the 
blood.  The  injury  may  be  direct,  or  in  rare  cases,  on  the  opposite  side 
by  contre  coup.  Gowers  states  that  but  20  per  cent,  occurs  under  ten 
years  of  age.  Ninety-three  per  cent,  are  solitary  abscesses  (Oppenheim). 
Infection  travels  along  the  perivascular  (and  perineural)  lymph  sheaths 
(Biswanger),  but  may  pass  by  other  routes  (arterial  thrombosis,  or 
by  way  of  the  diploe  veins,  with  or  without  thrombosis,  for  "retro- 
grade infection"  is  possible  by  the  valveless  veins).  The  early  trau- 
matic abscess  is  usually  cortical;  the  late  variety  is  usually  subcortical. 
(c)  Other  contiguous  disease  is  much  rarer,  causing  but  3.5  per  cent,  of 
brain  abscess.  Disease  of  the  nose  and  communicating  sinuses  (frontal, 
antral,  sphenoidal,  ethmoidal),  may  cause  abscess  of  the  frontal  lobes 
near  the  diseased  bone,  and  in  antrum  disease,  sometimes  of  the 
parietal  lobes.  Disease  of  the  orbit,  as  phlegmon,  or  penetrating 
wounds,  and  still  more  rarely  cervical  cellulitis,  cranial  osteomyelitis. 


ABSCESS  OF  THE  BRAIX  1015 

ulcerative  tuberculosis,  syphilis  or  tumor  of  the  cranial  bones,  may 
cause  abscess  by  contiguity. 

2.  Distant  foci,  or  metastatic  abscesses  cause  25  per  cent,  of  brain 
abscess.  The  abscesses  may  number  from  2  to  over  100  (v.  Berg- 
mann);  they  are  multiple  in  50  to  75  per  cent.  In  location  they  are 
cortical  or  subcortical,  less  frequently  they  occur  in  the  central  ganglia, 
rarely  in  the  cerebellum,  and  almost  never  in  this  location  alone.  The 
embolus  is  almost  never  found,  (a)  Lung  lesions:  "pulmonal  cerebral 
abscesses"  are  due  to  empyema,  putrid  bronchitis,  and  bronchiectasis 
(45  per  cent.  Williamson),  gangrene,  abscess,  and  sometimes  tubercu- 
lous cavities.  This  form  rarely  encapsulates,  (b)  Ulcerative  endocar- 
ditis, pyaemia,  osteomyelitis,  etc.,  are  less  common  causes;  paradoxical 
embolism  may  occur  through  an  open  foramen  ovale,  whereby  the 
clot  escapes  the  lungs.  Actinomycosis,  suppurating  tubercle  (D'Es- 
pine,  Frankel),  and  oidium  albicans  (Zenker  and  Ribbert)  have  been 
described;  in  thrush  Wagner  directly  traced  the  growth  from  the 
throat  to  the  brain. 

3.  The  existence  of  idiopathic  brain  abscess  is  denied  by  some,  but 
Gowers  found  it  in  16  per  cent,  of  his  cases;  it  may  possibly  result  from 
a  forgotten  trauma  or  ear  abscess.  Martins  and  Striimpell  believe  the 
meningococcus  causes  some  cases  of  this  class. 

Symptomatology. — Symptoms  are  absent  in  5  to  10  per  cent,  of 
cases.  In  17  cases  of  Martins'  series,  brain  abscess  was  not  diagnos- 
ticated. Symptoms  of  the  causal  affection,  trauma,  otitis,  or  metas- 
tasis are  described  under  diagnosis. 

1 .  Symptoms  of  Sepsis. — (a)  Fever  is  frequent.  Oppenheim  considers 
it  the  most  important  general  symptom;  Eichhorst  describes  cases 
closely  resembling  typhoid;  it  is  present  in  acute  cases,  and  in  many 
during  the  last  stages  when  the  abscess  spreads  or  meningitis  or  sinus 
thrombosis  develops;  the  original  disease  may  cause  it.  Macewen's 
cases  showed  normal  or  subnormal  temperature.  Though  it  is  probably 
overlooked  in  some  cases,  it  is  again  totally  absent  in  others,  (b)  Chills 
are  not  frequent,  (c)  The  pulse  is  often  accelerated,  but  may  later 
become  slowed  to  30  or  40,  the  compression  pulse,  {d)  There  may  be 
other  septic  signs,  as  gastric  disturbance,  anaemia,  emaciation,  pepton- 
uria, or  leukocytosis, 

2.  General  (Diffuse)  Brain  Symptoms. — These  are  due  to  compres- 
sion, oedema,  inflammation,  meningitis,  or  internal  hydrocephalus,  and 
include  (a)  headache,  which  is  most  common,  and  usually  severe, 
though  less  so  than  in  brain  tumor;  it  is  due  to  increased  intracranial 
tension;  it  is  usually  localized,  but  even  then,  the  stiff,  painful  neck 
and  headache  are  general  rather  than  focal  symptoms.  It  is  frequently 
associated  with  (6)  vomiting,  and  (c)  vertigo,  wliich  also  occurs  in  simple 
ear  disease,  (d)  Mental  symptoms  are  like  those  of  tumor,  "slow  cere- 
bration, heavy  comprehension,  and  a  want  of  sustained  attention" 
(Macewen).  (e)  General  convulsions  are  frequent  only  in  the  last 
stages,  in  cases  of  extensive  abscess  or  rupture  into  the  ventricle.  (/) 
The  pulse  is  often  slowed,  even  with  co-existent  fever,  to  40  (even  16  or 


1016  DISEASES  OF  THE  NERVOUS  SYSTEM 

10),  and  sometimes  with  slow  or  irregular  respiration,  (g)  Optic  neu- 
ritis is  more  common  than  choked  disk;  it  occurs  in  33  to  40  per  cent., 
develops  rapidly,  and  may  produce  amaurosis  and  atrophy. 

3.  Focalizing  symptoms  are  often  absent,  and  when  present,  are  less 
conspicuous  than  in  tumor,  because  they  are  obscured  by  the  primary 
affection  or  the  general  symptoms  and  occur  in  areas  of  less  physio- 
logical dignity.  When  present,  they  usually  signalize  advance  of  the 
abscess,  increase  of  surrounding  oedema,  softening  or  increased  brain 
tension. 

Frontal  or  mental  symptoms  may  occur  (see  Tumor),  but  foci  as 
large  as  the  fist  may  remain  latent.  They  may  impinge  on  the  motor 
cortex.  The  symptoms  are  those  of  a  cortical  lesion  (dissociated 
paralysis),  which  extends  more  rapidly  than  tumor,  and  is  attended 
by  Jacksonian  fits,  rigidity  and  increased  tendon  and  decreased  skin 
reflexes  on  the  contralateral  side;  in  subcortical  lesions  from  traumatic 
and  metastatic  (pulmonal)  abscess,  hemiparesis  occurs  in  50  per 
cent.,  is  sometimes  progressive,  is  usually  incomplete  and  at  times  is 
apoplectiform  in  onset  (three  personal  observations),  even  when  not 
embolic.  If  hemiparesis  is  early,  it  rather  indicates  involvement  of  the 
internal  capsule,  which  also  causes  hemihypsesthesia.  Conjugate  devi- 
ation is  not  common.  Temporosphenoidal  lesions  are  largly  otitic, 
are  frequently  latent  and  are  less  frequently  cortical  than  subcortical, 
whence  the  centres  are  less  involved  than  the  deeper  association  fibers. 
The  left  side  is  more  important;  lesions  here  lead  (in  42  per  cent.)  to 
sensory  aphasia,  partial  word  deafness,  alexia,  agraphia,  amnestic  and 
optic  aphasia;  Korner  holds  that  aphasia  is  rare.  (The  right  side 
concerns  the  memory  for  letters  and  figures  [Oppenheim].)  Occipital 
lesions  or  those  in  the  contiguous  parietal,  or  temporal  lobes,  or  deeper 
in  Gratiolet's  optic  radiation,  produce  hemianopsia  (they  occur  more 
in  traumatic  or  metastatic  than  in  otitic  abscess).  Cerebellar  abscess 
results  almost  exclusively  from  ear  disease,  and  is  often  latent.  iVtaxia 
may  also  be  caused  by  the  ear  affection  or  abscess  elsewhere,  even  in 
the  frontal  lobes.  Occipital  headache  and  stiff  neck  occur;  there  may 
be  a  tendency  to  fall  forward  (Gravis)  or  backward  (Dupuy),  and 
hemiparesis,  or  yawning  may  result  from  compression;  cranial  nerve 
paralyses  are  not  frequent  and  result  from  coincident  meningitis. 
Paralyses  of  the  seventh  and  eighth  nerves  are  often  due  to  bone  dis- 
ease. Abscess  of  the  pons,  medulla  (of  which  Gassier,  in  1903,  found 
only  16  cases),  and  crus  is  exceptional.  (See  Cerebral  Local- 
ization.) 

Symptoms  by  Stages. — (a)  The  initial  stage  is  observed  mostly  in 
acute  traumatic  or  metastatic  abscess.  Pus  may  form  in  thirty-six 
hours  (Martius),  but  this  usually  requires  ten  to  thirty  days.  The 
causal  symptoms,  those  of  sepsis  and  general  brain  symptoms,  appear 
rapidly  but  focal  symptoms  usually  appear  only  after  one-half  to  three 
months;  death  may  occur  from  coma,  fever,  and  meningitis,  or  the  next 
stage  may  appear,  (b)  The  latent  stage  has  no  fever,  is  seen  in  chronic 
abscess,  probably  corresponds  with  demarkation  and   encapsulation, 


ABSCESS   OF   THE   BRAIX  1017 

lasts  for  months,  years,  or  even  decades,  and  is  either  complete  or  inter- 
rupted by  symptoms  of  the  third  stage,  (c)  In  the  "manifest"  stage, 
symptoms  of  sepsis  and  general  or  focal  brain  symptoms  appear  con- 
tinuously or  remittently,  with  evidence  of  extension.  Most  cases  are 
seen  in  this  stage.  Gowers  estimates  that  after  nervous  symptoms 
once  develop,  (d)  the  next,  the  fatal  or  terminal  stage,  appears  in  five  days 
(20  per  cent.),  in  ten  days  (33  per  cent.),  fourteen  days  (50  per  cent.), 
and  in  thirty  days  (75  per  cent.).  This  stage  may  immediately  follow 
the  latent  stage  when  rupture  into  the  lateral  ventricle  occurs. 

Diagnosis. — Recognition  is  impossible  in  latent  cases  affecting 
"silent"  areas,  whence  "no  brain  disease  of  equal  severity  so  often 
escapes  recognition."  When  focal  symptoms  are  absent,  various 
psychoses  may  be  thought  of.  The  diagnosis  is  often  made  only  in  the 
last  two  stages.  Few  cases  can  be  detected  without  consideration  of 
the  etiology,  which  is  definitive  in  75  per  cent.  (Gowers),  the  sepsis, 
general  and  focal  brain  symptoms. 

Otitic  abscess  may  be  confused  with  the  otitis  itself  especially  in 
children ;  otitis  may  produce  general  symptoms,  as  headache,  vomiting, 
convulsions  and  even  optic  neuritis  (probably  due  to  serous  meningitis), 
cranial  nerve  symptoms  (nystagmus,  diplopia)  but  all  symptoms  dis- 
appear when  the  middle  ear,  attic,  mastoid  or  subperiosteal  foci  are 
cared  for;  otitic  brain  abscess  runs  an  acute  rather  than  a  chronic 
course,  but  the  various  stages  may  be  observed;  the  period  of  latency 
rarely  exceeds  one  to  one  and  a  quarter  years  (Korner,  Pitt),  and 
usually  averages  two  months  or  less  (Pitt).  Temperature  is  often 
lower  than  in  other  forms,  the  headache  may  be  local  or  unilateral, 
and  local  oedema  may  be  seen  over  the  temporal  region,  with  tender- 
ness on  percussion  and  a  higher  percussion  note  (Macewen). 

Otitis  may  also  cause  suppurative  meningitis ,  extradural  abscess  or 
sinus  thrombosis,  either  with  or  without  brain  abscess,  from  which 
they  must  be  differentiated.  The  table  on  page  1018  is  borrowed 
from  Oppenheim's  classical  description. 

Serous  meningitis  (Billroth  and  Quincke)  is  often  mi,staken  for  the 
suppurative  form  and  is  very  important  in  ear  disease.  It  is  attended 
by  little  rise  of  temperature,  internal  hydrocephalus,  paralysis  of  the 
basal  nerves,  often  gives  a  serous  fluid  on  lumbar  puncture  and  is 
often  cured.  Extradural  abscess  (external  suppurative  pachymenin- 
gitis) was  found  in  78  per  cent,  of  184  cases  of  brain  suppuration 
(excluding  meningitis)  by  Jansen,  sinus  thrombosis  was  found  in  18 
per  cent.,  and  brain  abscess  in  barely  3  per  cent.  It  is  more  common 
(43  per  cent.)  in  acute  otitis  than  is  abscess  (9  per  cent.).  Local 
symptoms,  as  oedema  and  tenderness,  are  common,  but  diffuse  and 
focal  symptoms  are  not  frequent.  Sinu^  thrombosis  is  more  often 
attended  by  pysemic  symptoms,  high  fever,  chills,  sweats,  icterus  and 
foci  in  the  lungs,  rapid  pulse,  choked  disk,  general  convulsions  and 
external  symptoms  of  altered  brain  circulation  (see  Sinus  Thrombosis). 


1018 


DISEASES  OF  THE  XERVOUS  SYSTEM 


Brain  Abscess  (Otitic). 


Diffuse  Suppurative 
Meningitis. 


Etiology: 
Onset: 
Course : 

Fever : 

Pulse : 
Sensorium : 


Headache,     vomit- 
ing, vertigo: 

General  convul- 
sions: 

Retina: 


Meningitic  evi- 
dences: 


Focal  symptoms: 


Spinal  symptoms : 


Lumbar  puncture: 


Ear  disease. 


Acute  or  subacute,  but  often 
some  latency. 

Acute,  subacute,  chronic 
(latency  stage),  from  weeks 
to  seldom  over  one  year. 


Normal,   subnormal,   moder- 
ate. 

Slow. 

Simple  dulness,  merging  into 
coma. 


Headache   almost    constant; 
others  less  constant. 

Not  frequent. 


Optic  neuritis  common. 
Choked  disk  not  common. 

Less  by  far. 

Stiff  neck  rare  save  in  cere- 
bellar. 


Frequent,   especially   tempo- 
rosphenoidal,  internal  cap- 
sule and  sometimes  cerebel- 
lar;   paralysis  of  third 
nerve. 


Seldom.    Few  cases  of  absent 
patellars. 


Rather  dangerous. 


Same:     favored    by    imperforate 
tympanum  and  childhood. 

Acute,  stormy,  even  apoplectic. 


Acute,  stormy,  more  rapid  than 
abscess  (66  per  cent,  last  under 
one  week)  though  sometimes 
remissions  occur. 

High,  continuous  and  rarely  low 
or  absent. 

Usually  fast  and  irregular. 

Unrest,     irritability,     delirium; 
dulness  later;  sensorium  seldom 
normal. 

Headache  and  vomiting  almost 
invariable. 

Usual,  clonic  and  tonic. 


Usually  negative  because  of  rapid 
course. 

More  common  psychical  and  motor 
unrest,  jactitation,  hypersesthesia 
of  special  and  general  sensation, 
trismus;  retraction  of  abdomen; 
general  rigidity. 

Diplopia,  strabismus,  unequal 
pupils,  conjugate  deviation,  par- 
alysis seventh  and  eighth  nerves ; 
these  are  diffuse,  transitory  and 
variable;  rarely  hemi-  or  mono- 
plegia; very  rarely  aphasia, 
hemianopsia  (more  frequent  in 
meningitis  tuberculosa). 

Almost  always  stiffness  and  ten- 
derness of  neck,  back  and  general 
muscles,  Kernig's  sign;  parses- 
thesia  and  hypersesthesia,  dy- 
suria,  involuntary  evacuations, 
absent  patellars. 

Positive  findings  (see  meningitis). 


Differentiation  is  sometimes  impossible. 

Traumatic  abscess  develops  early,  is  associated  with  hsematoma,  con- 
cussion, contusion,  or  diffuse  meningitis,  from  which  differentiation  is 
often  impossible  or  difficult,  except  that  the  abscess  is  slow  in  evolution. 
Its  presence  is  often  suspected  because  of  delayed  healing  of  the  wound. 


ABSCESS   OF    THE   BRAIX  1019 

It  is  usually  cortical  (whence  its  focal  symptoms),  and  often  provokes 
fever  and  other  general  symptoms.  It  must  also  be  differentiated 
from  traumatic  hemorrhage,  which  occurs  days  or  weeks  after  the 
injury  and  often  in  the  corp.  quadrigemina,  pons  or  medulla;  from 
acute  encephahtis,  whose  course  is  more  rapid;  from  concussion,  in 
which  the  symptoms  are  more  diffuse  and  may  involve  the  brain 
nerves  or  arouse  fever,  though  cortical  symptoms  are  absent;  from 
traumatic  neuroses,  which  lack  focal  and  septic  symptoms  (Oppen- 
heim).  In  late  traumatic  abscess  latency  may  last  in  extreme  cases, 
even  thirty  years.  The  abscess  is  not  cortical  (affecting  the  centres), 
but  subcortical  (affecting  the  conduction  or  association  fibers).  Cere- 
bral tumor  iq.v.)  must  be  considered. 

Abscess  by  metastasis.  It  is  well  known  that  hmg  suppuration 
affects  the  brain  with  especial  frequency,  whence  the  chest  must  be 
examined;  localization  is  largely  in  the  hemispheres,  thus  obeying 
the  general  topography  of  simple  embolism.  The  Sylvian  district 
(and  occipital  lobes)  are  most  often  affected,  and  the  multiplicity  of 
localization  should  be  remembered.    The  course  is  usually  precipitate. 

A  diagnosis  of  idiopathic  abscess  without  proper  etiology  is  always 
unsafe  and  usually  impossible. 

Prognosis. — Spontaneous  recovery  by  demarkation,  inspissation  and 
calcification  (Fenman)  is  recorded  in  a  few  cases,  though  it  is  then 
probable  that  such  abscesses  are  healed  tubercles.  External  rupture 
may  exceptionally  occur.  Without  operation,  death  is  practically 
inevitable,  (a)  from  rupture  into  the  lateral  ventricles  (16  per  cent., 
chiefly  in  metastatic  and  otitic  abscess),  and  into  the  membranes  (28 
per  cent.,  in  cerebellar  abscess),  (6)  from  hydrocephalus  internus,  (c) 
from  sinus  thrombosis,  (d)  from  pressure  on  the  medulla,  (e)  from 
brain  oedema  or  rarely  hemorrhage.  Sudden  death  may  occur,  how- 
ever, as  in  tumor,  without  adequate  postmortem  explanation. 

Treatment. — (a)  Prophylactic  therapy  concerns  the  etiological  fac- 
tor. Adequate  drainage  is  always  necessary,  although  granulations 
in  the  middle  ear  are  protective  and  should  not  be  curretted  in  any 
routine  manner  (precisely  as  uterine  curettage  in  puerperal  sepsis  is 
now  discountenanced).  (6)  Palliative  treatment  is  that  of  brain  tumor 
and  meningitis.  Special  care  regarding  vomiting  is  indicated,  lest 
it  rupture  the  abscess,  (c)  Surgical  intervention  is  indicated.  Suc- 
cessful cases  were  those  of  Morand  1868,  Roux  1848,  and  Schede, 
1866,  as  well  as  those  of  Hitzig  and  Wernicke.  Macewen,  Barker, 
Greenfield,  Ferrier,  Horsley,  and  Schwartze  are  the  pioneers  in  its 
practical  treatment.  Von  Bergmann's  rule  was  that  operation  should 
never  be  performed  unless  the  diagnosis  was  certain,  but  adherence 
to  this  rule  would  have  cost  many  lives.  The  contra-indications  are 
(a)  metastatic  abscess,  (6)  a  fatal  etiological  disease,  (c)  inability  to 
stand  the  anaesthesia  or  shock,  (d)  ventricular  rupture  and  (e)  diffuse 
meningitis,  although  in  the  last  two  cases,  isolated  recoveries  are 
recorded.  Sinus  thrombosis,  circumscribed  meningitis  and  incipient 
pyaemia  do  not  contra-indicate  operation.     In  Korner's  cases"(otitic 


1020  DISEASES  OF  THE  XERVOUS  SYSTEM 

abscess),  51.6  per  cent,  recovered,  Oppenheim  (traumatic  cases)  re- 
ported recovery  in  45  per  cent.,  Wheeler's  series  gave  87.5  per  cent., 
and  Macewen's  series  showed  96  per  cent. 


III.  Dementia  Paralytica. 

It  is  also  known  as  paralytic  or  paretic  dementia,  general  or  pro- 
gressive paralysis  of  the  insane,  and  among  the  laity  as  softening  of 
the  brain.  Bayle,  1822,  and  Calmeil,  1826,  first  accurately  described 
the  affection.  It  is  often  classed  among  the  mental  rather  than  the 
brain  diseases,  but  it  is  so  important  in  everyday  practice  and  con- 
stitutes such  a  large  proportion  (10  to  25  per  cent.)  of  all  insanities, 
that  its  description  is  in  place. 

Definition.^ — Dementia  paralytica  is  a  chronic  inflammation  or 
degeneration  of  the  brain,  characterized  by  progressive  vasomotor, 
motor  and  psychical  disturbances,  and  ending  in  death  after  two  or 
three  years. 

Etiology. — (a)  Syphilis  is  the  cause  in  at  least  75  per  cent,  of 
cases  (Mendel  and  Striimpell).  That  it  is  not  the  sole  cause  is  shown 
by  its  rarity  in  Egypt  and  Japan  where  syphilis  is  endemic,  (h)  Other 
causes,  as  modern  life,  with  its  strenuousness,  competition,  hurry  and 
worry  must  aid  the  syphilitic  toxins  which  cause  degeneration  of  the 
brain  after  the  syphilis  is  apparently  spent  (a  parasyphilitic  affection, 
according  to  Fournier).  Short  sleep,  dissipation,  overwork,  city  life 
and  the  so-called  civilized  life  account  for  its  increasing  frequency. 
Krafft-Ebbing  summarized  the  etiology  as  "syphilization  and  civiliza- 
tion." These  causes  may  cooperate  with  (c)  hereditary  nervous  taint 
(15  to  20  per  cent.),  and  (d)  alcoholism  (20  per  cent.,  though  this  is 
denied  by  many),  (e)  Certain  occupations,  as  those  of  officers,  artists, 
and  actors,  are  predisposing  factors,  and  generally  speaking,  the  higher 
classes  are  more  subject  to  it.  Krafft-Ebbing  did  not  find  any  clergy- 
men among  his  2,000  patients.  (/)  It  occurs  between  the  thirtieth 
and  fiftieth  years,  and  (g)  is  7  to  10  times  as  frequent  in  men  as  in 
women.  Other  factors  are  less  prominent  as  exposure  to  heat,  trauma 
of  the  head,  plumbism  or  chronic  toxtemia. 

Pathogenesis. — The  causes  enumerated  probably  produce  (a)  vaso- 
motor paresis  in  the  fore-brain,  followed  by  (b)  lymph  stasis  in  the 
cortex  and  pia  mater,  (c)  degeneration  and  atrophy  of  the  brain  and 
cord,  and  (d)  interstitial  inflammation.  Though  all  cases  end  in 
brain  atrophy,  opinions  still  differ  regarding  the  role  of  the  inflam- 
mation; some  regard  encephalitis  interstitialis  (chronic  meningo- 
encephalitis) as  primary  (Mendel),  and  others  hold  that  it  is  secondary 
to  encephalitis  parenchymatosa  (Tiiczek  and  Wernicke),  just  as  in 
liver  cirrhosis  it  is  now  thought  that  the  connective  tissue  formation  is 
secondary  in  time  and  importance  to  cellular  alteration. 

Pathology. — (a)  The  calvarium  is  thickened  in  33  per  cent.  The 
Pacchyonian  granulations  are  often  enlarged.     (6)  The  dura  in  50  per  - 


DEMENTIA  PARALYTICA  1021 

cent,  is  thick,  opaque,  vascular  and  adherent  to  the  skull  {'pachy- 
meningitis, which  is  often  hemorrhagic).  In  attempting  to  strip  off 
the  pia,  it  is  found  granular  and  adherent  to  the  brain  cortex  (in  80 
per  cent.),  especially  over  the  frontal  and  motor  areas,  which  are 
supplied  by  the  internal  carotid  artery.  Later  the  adhesions  may  dis- 
appear, (c)  The  gross  brain  changes  are  constant.  There  is  less 
opportunity  to  inspect  the  brain  in  the  early  stages,  when  it  is  swollen, 
and  hypersemic  than  in  the  later  stages  when  it  is  wasted;  it  may 
weigh  but  a  third  or  quarter  of  the  normal  (40  ounces  or  1,260  gm.); 
atrophy  affects  largely,  if  not  wholly,  the  areas  supplied  by  the  internal 
carotid  artery,  especially  the  frontomotor  cortex  and  the  island  of 
Reil.  The  gray  matter  is  yellow-gray,  soft  and  wasted,  but  the  atro- 
phied white  substance  is  firm.  The  convolutions  are  greatly  narrowed 
and  the  sulci  are  widened,  for  the  degree  of  atrophy  corresponds  to 
the  6  or  8  ounces  of  serum  which  fills  the  deficit  (hydrops  ex  vacuo). 
In  80  per  cent,  of  cases  granulations  are  seen  on  the  ependyma  of  the 
lateral  ventricles,  resembling  the  back  of  a  "cat's  tongue,"  and  the 
ventricles  contain  excess  of  fluid  (hydrops  ex  vacuo).  Areas  of 
hemorrhage,  softening  and  cyst  formation  are  due  to  complicating 
vascular  disease,  (d)  The  minute  alterations  in  the  brain  are  as  follows : 
the  ganglion  cells  are  early  swollen  and  cloudy;  the  later  findings  are: 
vacuolated,  degenerated  and  atrophied  ganglion  cells;  wasting  of  the 
medullary  sheaths  and  of  the  axis  cylinders,  especially  in  the  association 
or  tangential  nerve  fibers  running  parallel  to  the  cortex  (Tiiczek), 
which  are  said  to  waste  before  any  inflammation  can  be  seen ;  corpora 
amylacea  represent  what  is  left  of  them;  the  same  changes  occur  in 
the  cranial  nerves;  the  bloodvessels  show  mural  proliferation,  exu- 
dation, colloid  or  hyaline  metamorphosis,  thickening  and  latet  atrophy 
or  obliteration;  the  lymph  vessels  show  proliferation,  transudation 
and  compression  of  the  cortex,  where  lymph  cysts,  from  snaring  off 
of  lymph  vessels,  sometimes  cause  cystic  degeneration  of  the  cortex; 
the  neuroglia  increases  even  sevenfold  (sclerosis),  (e)  Alteration  of 
the  spinal  cord,  described  first  by  Westphal,  is  present  in  90  per  cent.; 
the  lateral  columns  often  show  descending  degeneration,  but  most 
commonly  changes  like  those  of  tabes  are  found  in  the  posterior  columns 
(column  of  Goll)  and  in  the  posterior  roots.  Pachy-  and  leptomenin- 
gitis are  seen  in  40  per  cent.  As  in  tabes,  the  cerebrospinal  fluid  contains 
chiefly  mononuclear  cells.  (/)  Changes  in  the  cranial  nerves,  especially 
the  first  to  the  seventh,  may  result  from  syphilis  or  alcoholism. 

General  Symptomatology. — As  a  rule,  the  symptoms  are  first  vaso- 
motor, second  psychical,  and  third  motor,  in  the  order  of  their  usually 
slow  development.  It  is  possible  for  the  psychical  symptoms  to  appear 
first,  with  the  motor,  or  more  rarely  to  follow  them.  The  leading 
symptoms  are  referable  to  alteration  in  the  frontomotor  cortex.  Three 
stages  are  usually  distinguished:  1.  In  the  prodromal  stage,  recogni- 
tion is  often  difficult,  because  the  first  symptoms  are  equivocal  or 
point  to  (i)  neurasthenia  because  of  the  "irritable  weakness,"  ready 
fatigue  in  mental  processes,  headache  or  sense  of  cephalic  pressure. 


1022  DISEASES  OF  THE  NERVOUS  SYSTEM 

introspection  and  rheumatic  pains.  Again,  the  initial  symptoms  are 
(ii)  congestive,  as  headache,  migraine,  especially  significant  when  it 
has  not  occurred  before,  or  attacks  similar  to  minor  epilepsy  (petit 
mal).  (iii)  Most  important  are  mental  changes.  The  patient  is 
described  as  "not  himself"  but  "he  does  not  remark  his  own  altera- 
tion" (Schule).  Krafft-Ebbing  gives  a  lucid  picture  of  these  altera- 
tions. The  intellect  is  cloudy;  the  patient  is  confused  as  to  time,  and 
comes  too  early  to  work  or  remains  after  time;  he  confuses  places 
and  may  smoke  in  church;  his  observation  is  faulty  as  well  as  his 
judgment;  he  confuses  dreams  with  actualities,  and  his  memory  is 
confused,  for  he  forgets  entire  epochs,  especially  recent  impressions. 
iEsthetic  and  social  lapses  are  common;  the  subject  becomes  vulgar, 
careless,  neglects  duties,  disregards  amenities,  and  from  lack  of  will 
power  may  steal  or  dissipate  most  openly.  Emotional  outbreaks  occur, 
as  violent  or  brutal  conduct,  or  maudlin  sentiment  over  soon  forgotten 
incidents.  The  patient  is  often  perniciously  active,  (iv)  Focal  symp- 
toms, especially  amnestic  aphasia  may  appear,  (v)  General  findings 
are  noted  after  a  time,  as  small  and  unequal  pupils  or  other  tabes-like 
findings,  double  vision,  unequal  innervation  of  the  face,  fibrillary 
contractions  of  the  tongue,  tremor,  pains,  headache,  vertigo,  congest- 
ive attacks,  slow  pulse,  rough,  unmodulated  voice,  skipping  of  words 
in  reading  (paralexia),  and  irregular,  incorrect  writing  (paragraphia). 
This  stage  covers  months  or  years.  In  rare  instances  the  symptoms 
may  follow  tabes;  this  is  "the  ascending  form  of  general  paralysis." 
2.  At  the  height  of  the  disease,  (i)  the  psychical  symptoms  take  var- 
ious types,  as  maniacal  exaltation,  melancholia,  hypochondriasis,  or 
simple  progressive  dementia.  Psychical  blindness  or  deafness  occurs, 
(ii)  Congestive,  apoplectiform  attacks  are  frequent,  and  the  general 
findings  become  more  distinct,  as  immobile  and  unequal  pupils, 
hesitant  speech  with  elision  of  syllables,  altered  expression,  trembling 
or  paresis  of  the  face,  incoordination  of  the  hands  and  gait,  disturb- 
ances in  writing  and  reading,  and  retention  of  urine.  During  the 
not  uncommon  remissions,  some  of  these  symptoms  can  almost  always 
be  found.  3.  The  terminal  stage  is  characterized  by  complete  demen- 
tia (the  final  type  of  all  initial  varieties),  complete  disorder  of  speech, 
incoordination  so  extreme  as  to  necessitate  feeding  the  patient  and 
keeping  him  in  bed,  sensory  disturbances,  vasomotor  paralysis,  grind- 
ing of  the  teeth,  trophic  complications,  and  death  from  pyelonephritis, 
bed-sores,  complications  or  bulbar  symptoms. 

Symptoms  in  Detail. — Psychical  Symptoms. — The  weakness,  altera- 
tion in  character,  loss  of  memory  and  reason,  and  the  ethical,  esthetic, 
and  moral  loss  have  been  described.  During  the  height  of  the  dis- 
ease there  is  one  of  three  main  mental  manifestations :  (a)  megalomania, 
with  simple  exaltation  or  mania.  This  classical  expansive  type  occurs 
in  66  per  cent.,  is  associated  anatomically  with  the  characteristic 
meningo-encephalitis,  and  is  characterized  by  ideas  of  grandeur,  the 
patient  believing  he  is  a  king,  God,  a  millionaire,  an  athlete,  etc.  He 
makes  ridiculously  large  plans,  buys  extravagantly,  lacks  will  power, 


DEMENTIA  PARALYTICA  1023 

indulges  himself  excessively,  changes  with  great  "facility"  from  one 
thing  to  another,  is  optimistic,  friendly,  even  philanthropic,  and  rap- 
idly runs  through  his  capital.  He  loses  himself,  forgets  names,  and 
confuses  the  real  with  the  unreal.  Periods  of  acute  mania,  with  fever, 
and  grinding  of  the  teeth  are  expressions  of  brain  congestion;  com- 
plete dementia  is  the  final  outcome,  even  though  remissions  occur, 
during  which  some  mental  or  somatic  change  can  be  detected,  (b) 
The  melancholic  or  hypochondriacal  form  is  thought  to  occur  with 
cystic  degeneration  of  the  cortex.  It  may  be  of  the  dull  or  agitated 
type.  The  patient  dwells  on  the  condition  of  his  bowels;  one  subject 
thought  that  they  would  "burst  and  flood  the  world."  There  is  often 
micromania,  characterized  by  "self-belittlement,"  in  which  the  indi- 
vidual fears  everything  and  thinks  himself  a  "dot,  nothing,  or  denies 
his  existence."  These  cases  may  commit  suicide.  Dementia  is  the 
outcome,  (c)  Simple  primary  dementia  may  be  present  from  the 
beginning;  this  type  is  increasing  in  frequency,  while  the  first  classical 
form  is  decreasing.  It  is  thought  to  be  based  anatomically  on  simple 
cortical  atrophy  in  which  inflammation  is  absent  or  late  and  secondary. 
These  subjects  are  often  deceptive  in  the  early  stage,  being  quiet, 
urbane  and  optimistic.  In  the  ultimate  dementia  of  all  types,  mentality 
is  wholly  gone,  "there  is  no  sense  of  time,  place  or  identity,"  and  the 
patient  babbles  or  is  speechless. 

Motor  Disorder. — This  usually  occurs  with  mental  changes,  is  con- 
stant, though  variable  in  its  expression,  incomplete  in  degree,  extensive 
as  to  parts  involved,  and  progressive,  (a)  Speech  is  pathognomonically 
disturbed  as  a  result  of  mental  change,  wasting  of  association  fibers 
and  later  of  bulbar  atrophy.  It  is  incoordinate,  involving  letters 
("literal"  ataxia)  or  syllables.  In  pronouncing  such  words  as  "elec- 
tricity" the  patient  characteristically  stutters  over  syllables.  It  is 
worse  in  the  morning  and  after  resting.  Loss  of  word  rhemory  is  the 
primary  trouble;  the  patient  forgets  expressions,  speaks  ungram- 
matically and  "does  not  notice  it."  Speech  becomes  atactic,  there 
is  paraphasia,  the  voice  is  unmodulated,  gives  out  suddenly,  is  some- 
times hoarse,  nasal  or  slow,  but  never  scanning.  Later,  speech  is 
disturbed  from  bulbar  alteration,  causing  dysarthria  from  disease  of 
the  facial  and  hypoglossal  nuclei;  it  is  ultimately  unintelligible  (abso- 
lute aphasia).  Closely  associated  with  speech  disturbance  is  (6) 
disordered  reading  (paralexia),  which  is  rather  characteristic  and  occurs 
early,  (c)  Writing  is  disturbed  first  because  of  the  mental  alteration; 
the  patient  has  difficulty  in  collecting  his  thoughts,  although  he  does 
not  realize  the  cause  (the  ataxia  by  which  he  drops  syllables,  repeats 
words  or  sentences — paragraphia);  and  it  is  disturbed  secondly  be- 
cause of  tremor.  The  writing  is  uneven,  up  and  down  or  zig-zag. 
These  changes  are  diagnostic,  {d)  Paralysis  of  the  eye  muscles  (in 
6  per  cent.,  INIarie)  is  usually  partial  and  transitory.  When  total, 
syphilis  or  tabes  is  the  probable  cause,  (e)  The  pupils'.  Myosis  may 
occur,  often  just  before  maniacal  outbursts.  Mydriasis  is  frequently 
unilateral  and  results  from  irritation  of  the  sympathetic  nerve.     In 


1024  DISEASES  OF  THE  NERVOUS  SYSTEM 

60  per  cent,  of  cases,  the  pupils  are  now  large,  now  small,  and 
this  is  considered  as  especially  ominous.  They  are  often  irregular  or 
triangular.  The  Argyll-Robertson  pupil,  responding  to  accommo- 
dation but  not  to  light,  usually  appears  early,  is  marked  in  47  per 
cent.,  partial  in  20  per  cent,  and  absent  in  33  per  cent.  Reichert 
holds  that  it  is  always  due  to  degeneration  in  Bechterew's  column 
{i.e.,  between  that  of  Goll  and  Burdach).  (/)  The  facial  nerve: 
The  paresis  of  the  lips  is  cortical,  as  are  fibrillary  twitchings  in  speak- 
ing or  mimetic  movements,  automatic  chewing  movements,  and 
almost  constant  grinding  of  the  teeth.  The  "fatuous"  or  "masked" 
expression  is  psychical.  Salivation  results  from  cortical  irritation. 
There  may  be  difiiculty  in  swa,llowing.  {g)  The  limbs :  (i)  The 
cortical  changes  cause  the  small-waved,  rapid,  constant  tremor, 
the  ataxia,  loss  of  muscle  sense,  and  the  uncertain,  ungraceful, 
tripping,  paralytic  gait,  (ii)  The  gait  may  be  tabetic,  with  absent 
knee  jerks,  immobile  pupils  and  vesical  symptoms;  or  it  is  more 
often  spastic  with  increased  patellar  reflexes,  ankle  clonus,  contractures 
and  changes  in  the  joints.  The  patellars  are  usually  increased 
in  the  early  stages,  (iii)  Neuritic  atrophy  of  the  cranial  nerves 
may  occur  as  in  tabes,  (h)  Apoplectiform  and  epileptiform  attacks 
may  occur.  (i)  Apoplectiform  seizures  result  from  vasomotor 
paralysis  and  brain  oedema,  and  differ  from  apoplexy  in  their  incom- 
pleteness, evanescence,  increased  temperature  and  increased  reflexes. 
They  last  part  of  an  hour,  and  may  produce  temporary  hemiplegia, 
but  especially  aphasia  with  paresis  of  the  right  arm.  (ii)  Epileptiform 
attacks  occur  later,  result  directly  from  cortical  disease,  are  usually 
partial  (involving  the  face  or  arm),  and  are  either  Jacksonian  or  are 
attended  by  partial  loss  of  consciousness;  conjugate  deviation  of  the 
eyes  and  increased  temperature  are  also  observed.  They  are  not 
frequent  but,  once  initiated,  recur  and  aggravate  the  mental  alienation. 

Sensation  and  Special  Senses.— Coincident  neurasthenia,  tabes  and 
pachymeningitis  may  emphasize  the  sensory  manifestations,  as  the 
lancinating  pains  of  the  tabetic  form.  Sensation  is  often  dulled  and, 
like  the  analgesia,  is  cortical  in  origin.  It  is  thought  that  the  hypo- 
chondriacal complaint  that  certain  organs,  as  the  bowels,  are  absent, 
is  due  to  visceral  anaesthesia.  Attacks  of  migraine,  when  they  first 
appear  late  in  life,  may  indicate  an  organic  origin,  and  Charcot 
described  a  form  with  hemianopsia  and  symptoms  like  glaucoma. 
Migraine  is  cortical  when  associated  with  paresis  of  the  face,  tongue 
or  arm.  Alteration  of  the  special  senses  includes  optic  neuritis  and 
atrophy  (4  per  cent.),  optic  hallucinations  and  psychical  blindness. 

Other  Symptoms. — (a)  Vasomotor  changes  occur  in  the  skin  (livid- 
ity,  oedema  and  sweating)  and  in  the  brain,  lungs,  bladder,  intestines 
and  stomach  (resembling  the  so-called  bilious  attacks).  (6)  Trophic 
symptoms  are  sweating  of  blood,  rough  skin,  phosphaturia,  perforat- 
ing ulcer  of  the  foot  (3  per  cent.),  bed-sores  and  friabihty  of  the  bones, 
which  may  be  broken  without  the  patient  knowing  it.  The  "insane 
ear"  is  frequent.     ]\Iany  of  these  symptoms  are  spinal  and  neuritic. 


DEMENTIA  PARALYTICA  1025 

General  Symptoms. — The  pulse  is  often  slow  and  monocrotic,  the 
temperature  low,  although  the  heat  centres  may  be  involved  in  conges- 
tive seizures_  with  great  febrile  elevation,  and  the  body  weight  is  often 
reduced  in  the  early  and  late  stages,  though  at  the  height  of  the  dis- 
ease it  often  increases,  especially  before  the  congestive  seizures.  The 
sexual  instinct,  at  first  increased  and  sometimes  perverted,  later  de- 
clines. Insomnia  may  be  severe,  may  last  for  months,  and  sometimes 
is  absolute. 

Diagnosis. — The  diagnosis  depends  upon  (a)  the  etiology,  as  syphilis 
Avith  mental  strain,  head  trauma,  or  excesses;  (6)  the  grouping  of  the 
psychical  symptoms,  as  character,  aesthetic  or  ethical  changes  with 
(c)  motor  symptoms,  as  the  speech,  writing  or  tremor;  id)  vasomotor 
symptoms,  as  migraine  or  apoplectiform  insults,  and  (e)  the  progressive 
course. 

DifEerentiation. — 1.  Diffuse  Brain  Diseases. — (a)  Cerebral  syphilis 
may  be  confused  with  diffuse  meningo-encephalitis  of  the  convexity. 

Progressive  Paralysis vs. Syphilis. 

Headache  absent  or  vague  and  transi-         Headache  present  and  severe. 
tory. 

Psychical    alteration    characteristic;  Somnolence,  variability  in  mental  symp- 

mental  symptonis  are  coordinated.  toms.     Merely  coincident. 

Epileptiform  mono-  or  hemiplegic  seiz-         More  frequent, 
ures  rare. 

Focal  symptoms  very  rare.  Focal     symptoms     common,     together 

with  diffuse  symptoms. 

Greater  speech  disturbance,  literal  para-         Less  or  no  tremor;    speech  far  less  fre- 
phasia,  and  fibrillary  tremor  of  face  quently  disturbed;    no  literal  para- 

and  tongue.  phasia. 

Argyll-Robertson  pupil.  Absent:  oculomotor  affections  and  optic 

neuritis  much  commoner. 

ProgressiA'e,  slower.    No  therapeutic  re-         In  installments,  more  rapid  jumps,  re- 
sults, missions.   Therapy  helps  or  possibly 

cures. 

A  parasyphilitic  disease.  Active  syphilis 

ih)  Diffuse  cerebral  sclerosis  presents  no  clear  picture  and  cannot  be 
diagno-sticated;  though  it  leads  to  dementia  and  attacks  of  delirium, 
there  is  not  the  speech  and  mental  alteration  which  is  present  in  general 
paresis,  (c)  Senile  dementia  seldom  occurs  until  after  sixty  years  of 
age.  Its  course  is  longer,  the  symptoms  more  gradual  and  less  intense, 
memory  is  maintained  longer  and  there  is  less  megalomania  than  fear 
of  persecution  and  poisoning,  id)  Midtiple  sclerosis  occurs  earlier, 
has  no  syphilitic  etiology,  is  complicated  by  late  and  mild  mental 
symptoms  and  an  intention  tremor,  Avhich  is  wider  in  amplitude  and 
ceases  during  repose.  The  speech  is  scanning,  staccato,  and  there  is 
no  literal  ataxia.     Nystagmus  is  common,  while  it  is  rare  in  general 

65 


1026  DISEASES  OF  THE  XERVOUS  SYSTEM      ' 

paralysis.     Motor  symptoms  are  largely  referable  to  disease  of  the 
lateral  columns. 

2.  Focal  Brain  Diseases. — (a)  Although  migraine,  headaches,  apo- 
plectiform attacks  and  partial  sensory  or  motor  irritation  of  the  Jack- 
sonian  type  may  occur  in  brain  tumor,  it  does  not  cause  difficulty  in 
pronouncing  syllables,  peculiar  mental  alteration,  or  immobile  pupils; 
it  is  characterized  by  general  symptoms,  as  choked  disk,  or  vomiting 
and  focal  symptoms,  which  are  foreign  to  general  paralysis.  In  tumor 
there  is  simple  dulling  of  the  intellect  and  dementia  only  with  marked 
internal  hydrocephalus,  (b)  Hemorrhagic  pachymeningitis  compli- 
cates 20  per  cent,  of  cases  of  dementia  paralytica;  when  it  exists  as 
an  independent  affection,  it  often  leads  to  intense  local  headache, 
vomiting,  recurrent  hemiplegia  or  monoplegia,  cortical  irritation,  and 
more  rapid  course,     (c)  Softening  usually  produces  focal  symptoms. 

3.  Psychoses  and  Neuroses. — (a)  Mania  and  hypochondriasis  may 
require  differentiation.  Every  case  of  mania  between  the  twenty-fifth 
and  forty-fifth  year  not  due  to  alcoholism  or  to  acute  somatic  disease 
should  arouse  suspicion  of  general  paralysis  (Mendel).  The  same 
may  be  said  of  hypochondriasis,  (b)  Neurasthenia  may  be  confused 
with  dementia,  and  the  etiology  may  be  identical.  In  neurasthenia 
the  onset  is  more  acute;  headache  accompanies  the  lassitude  and 
"irritable  weakness,"  the  memory  is  fatigued  but  never  lost,  the 
patient  recognizes  his  incapacity;  and  oxalates  and  urates  abound  in 
the  urine.  In  dementia  paralytica,  however,  there  is  phosphaturia, 
hypochondriasis  with  absurd  conceptions,  changes  in  the  pupils,  disk 
and  field  of  vision,  alterations  in  character,  speech  and  intellect  which 
are  never  seen  in  neurasthenia. 

4.  Intoxications. — These  may  produce  many  of  the  symptoms  of 
dementia  paralytica  and  may  cause  many  of  the  forms  known  as 
general  pseudoparalysis  which  are  due  to  alcohol,  lead,  etc.  (a) 
Chronic  alcoholism  is  not  progressive,  recovery  is  frequent,  delirium 
tremens  and  convulsions  are  common,  the  course  is  acute  covering 
but  weeks  or  months,  and  the  alcoholic  tremor,  headache,  hallucina- 
tions, and  neuritis  are  found,  (b)  Chronic  plumbism  (saturnine  enceph- 
alopathy) is  often  progressive,  even  fatal,  and  in  its  last  stages  indis- 
tinguishable from  dementia  paralytica.  It  is  more  acute,  and  80  per 
cent,  of  the  cases  recover.  There  is  headache,  cardiac  distress,  anaemia, 
and  gingival  lead  line,  (c)  Chronic  bromism  is  distinguished  by  its 
stupor,  dementia,  bromide  acne,  foetid  breath,  coated  tongue,  pharyn- 
geal anaesthesia,  weak  heart  and  acute  course,  which  usually  ends  in 
recovery. 

Prognosis. — The  disease  is  fatal  within  three  years  and  in  66  per 
cent,  of  cases  within  two  years,  though  remissions  may  occur.  Krafft- 
Ebbing  saw  no  recoveries  in  2,500  cases;  if  recovery  occurs  the 
diagnosis  is  probably  incorrect  and  the  disease  is  considered  pseudo- 
paralysis generalis.  The  following  courses  are  distinguished:  (a) 
acute  or  galloping  form,  which  lasts  months  or  a  year;  (6)  classical, 
expansive  type,  which  lasts  three  to  four  years  and  in  which  the  prog- 


CHRONIC  PROGRESSIVE  SOFT  EX  I XG  1027 

nosis  is  the  most  favorable;  (c)  the  depressive  type,  which  lasts  two  to 
three  years;  (d)  dementia  forms,  which  last  four  to  five  years;  (e) 
circular  form,  in  which  depression  alternates  with  mania;  (/)  female 
variety  which  has  a  longer  course  than  in  males;  (g)  spinal  form,  with 
a  relatively  long  course;  (h)  juvenile  or  adolescent;  and  (i)  senile  form. 
Death  results  in  50  per  cent,  from  the  disease  itself,  by  apoplectiform 
seizures,  suicide,  inanition  or  bulbar  symptoms.  In  50  per  cent,  it 
results  from  complications,  tuberculosis  (18  per  cent.),  bed-sores,  with 
sepsis  (10  per  cent.),  lung  gangrene  (6  per  cent.),  pneumonia  (5  per 
cent.),  choking  (10  per  cent.),  and  cystitis. 

Treatment.^ — -(a)  Etiological  treatment.  Recovery  is  barely  pos- 
sible in  the  early  stages,  and  many  physicians  advise  that  mercurial 
inunctions  be  given.  It  must  be  recalled  that  the  disease  is  a 
meta-  or  parasyphilitic  disease,  not  active  syphilis,  and  that  some 
consider  mercury  distinctly  injurious.  Iodides  promote  resorption  and 
favor  a  milder  course.  (6)  Hygienic  treatment,  as  rest,  protection 
from  heat,  and  quiet  surroundings,  is  indicated,  (c)  The  patient 
should  be  put  in  an  asylum,  for  suicide  or  other  violence  is  always 
possible.  In  the  simple  dementia  form,  alone,  may  the  patient  be 
treated  at  home,  (d)  Hydrotherapy  is  valuable  within  limits.  Cold 
rubs  lessen  excitation,  although  full  cold  baths  are  contra-indicated. 
(e)  Medicinal  treatment  is  unsatisfactory.  Drugs  produce  dispropor- 
tionate effects  and  must  be  exhibited  with  caution.  For  delirium  and 
insomnia  bromides  are  most  efficacious,  but  chloral  and  opiates  should 
be  given  less  frequently  or  only  in  combination  with  hyoscine,  digitalis, 
and  bromides,  or  with  the  ice-cap.  Ergot  is  said  to  produce  remis- 
sions, but  is  valuable  chiefly  as  a  vascular  tonic  for  brain  congestion. 
(/)  The  skin,  bladder  and  rectum  should  receive  treatment  as  in 
apoplexy  and  spinal  diseases. 


(E).   DEGENERATIONS  OF   THE   BRAIN. 

I.  Cystic  Degeneration. 

Cystic  degeneration  occurs  mostly  in  the  shrunken  brain  of  aged 
persons,  and  largely  in  the  perivascular  spaces  of  the  cortical  and 
basal  white  substance.  No  essential  symptoms  result  from  the  fluid; 
they  are  those  only  of  the  causal  atrophy.  Possibly  the  vessels  are 
prone  to  dilate  and  rupture  from  shrinkage  of  the  brain  and  conse- 
quent lack  of  support. 

II.  Chronic  Progressive  Softening. 

Chronic  progressive  softening,  when  not  due  to  vascular  disease,  is 
a  rare  affection;  it  was  described  by  Wernicke.  It  affects  the  white 
matter  chiefly,  occurs  mostly  after  the  sixtieth  year,  its  pathogenesis 


1028  DISEASES  OF  THE  NERVOUS  SYSTEM 

is  obscure,  and  its  clinical  symptoms  are  weakness  on  one  side,  slight 
irritative  phenomena,  as  tingling  or  pain,  and  involvement  of  the 
intellect.  The  length  of  the  course  varies  from  a  month  to  a  few  years, 
and  remissions  are  uncommon.  . 


III.  Multiple  or  Insular  Sclerosis.— (See  Spinal  Cord.) 

IV.  Diffuse  Sclerosis. 

This  may  involve  one  or  both  hemispheres  of  the  brain  or  cere- 
bellum, (a)  It  is  often  secondary  to  meningeal  hemorrhages  at  birth, 
infantile  hemiplegia,  arrest  of  development,  and  trauma.  In  these 
cases  the  sclerosis  is  secondary  to  brain  atrophy.  (6)  In  other  cases 
there  is  sclerosis  without  atrophy.  The  causes  are  congenital  syphilis, 
chronic  alcoholism,  contracted  kidney  or  other  exhausting  diseases. 
The  symptoms  are  indefinite.  Hemiplegia,  impaired  mentality,  con- 
vulsions, contractures,  spontaneous  movements  (Striimpell),  vertigo, 
syncopal  attacks  and  slow  speech  have  been  noted.  Miliary  sclerosis 
is  very  rare  and  consists  of  minute  foci  in  the  cortex,  where  the  gray 
and  white  substance  join.  Many  reported  cases  are  due  to  artefacts 
in  hardening. 

V.  Atrophy  of  Brain. 

Genuine  atrophy  is  always  acquired.  It  is  often  associated  with 
microcephaly,  and  the  brain  is  usually  normal.  Unilateral  atrophy  is 
observed  in  some  cases  of  chronic  insanity.  Local  atrophy  may  occur 
anywhere,  is  usually  associated  with  sclerosis  (q.v.)  or  neuroglia  in- 
crease, is  usually  acquired  and  is  very  often  secondary  to  previous 
trauma,  tumor,  or  hydrocephalus.  Some  reported  cases  are  clearly 
agenesis  and  arrested  development.  The  symptoms  are  not  distinctive. 
Hemiplegia,  hemiathetosis  and  imbecility  may  accompany  the  infantile 
forms;  they  occur  bilaterally  when  both  hemispheres  are  diseased. 
Senile  atrophy  occurs  in  old  age,  when  the  brain  becomes  smaller  and 
firmer  and  hydrops  ex  vacuo  occurs  in  direct  proportion  to  the  shrink- 
age.    Mental  changes  are  not  as  common  as  is  usually  stated. 

VI.  Hypertrophy  of  the  Brain. 

This  is  most  infrequent.  Increase  of  the  neuroglia  is  sometimes 
present  and  so-called  local  hypertrophy  is  frequently  only  gliomatous 
infiltration.  Hypertrophy  occurs  at  birth,  in  the  first  year,  when  it  is 
often  associated  with  rickets,  and  sometimes  in  older  children  or  in 
adults.  A  family  tendency  is  said  to  exist.  The  skull  is  enlarged, 
the  ventricles  decreased,  and  the  convolutions  are  flattened.    Coincident 


CHROXIC    BULBAR    PARALYSIS  1029 

hypertrophy  of  the  lymphatic  glands,  thyroid  and  thymus  has  been 
observed.    The  symptoms  are  vague  and  diagnosis  is  impossible. 


VII.  Chronic  Bulbar  Paralysis. 

Although  mentioned  by  Robinson  (1815),  and  Dumesnil  (1859), 
this  affection  was  first  thoroughly  described  by  Duchenne  (1860),  as 
labioglossopharyngeal  (laryngeal)  paralysis,  and  his  observations 
were  confirmed  by  Trousseau,  who  made  the  first  autopsies.  Wachs- 
muth  (1864)  advanced  the  name,  progressive  bulbar  paralysis,  and 
Charcot  and  v.  Leyden  demonstrated  alteration  in  the  bulbar  nuclei. 

Etiology. — Most  cases  occur  in  persons  between  fifty  and  seventy 
years  of  age,  although  some  are  observed  in  children,  and  sometimes 
in  the  same  family.  Heredity  is  a  factor  only  when  the  disease  is 
associated  with  progressive  muscular  atrophy.  Sixty-four  per  cent, 
of  cases  occurs  in  males.  Trauma,  cold,  infections,  mental  or  physical 
exhaustion  and  toxaemias,  are  uncertain  factors.  Rheinhardt  holds 
that  it  may  follow  acute  inflammation  of  the  medulla. 

Pathology. — ^To  the  naked  eye  the  medulla  usually  appears  normal, 
though  sometimes  shrunken.  Microscopically,  (a)  the  motor  nuclei 
are  symmetrically  and  bilaterally  wasted,  their  cells  and  processes 
shrunken.  The  hypoglossal  nucleus  suffers  most,  and  few  normal 
cells  remain;  its  accessory  nucleus  is  usually  normal.  The  spinal 
accessory  nucleus  is  next  most  frequently  affected,  but  the  vagus 
nucleus  suffers  less.  Degenerative  atrophy  may  invade  the  glosso- 
pharyngeal or  exceptionally  the  facial  and  fifth  nuclei.  In  some  cases 
(Eisenlohr),  perivascular  exudation  occurs  within  the  nuclei,  and  the 
nerve  elements  are  degenerated  (the  parenchymatous  form),  but  in 
others  increase  of  connective  tissue  or  thickening  or  multiplication  of 
the  bloodvessels  may  be  seen,  (b)  The  respective  nerve  trunks  in 
their  course  or  in  their  terminal  intermuscular  endings,  are  soft,  gray 
and  show  parenchymatous  and  interstitial  change.  This  may  occur 
even  within  the  medulla,  and  the  posterior  longitudinal  fibers  waste 
in  direct  ratio  to  the  hypoglossal  nuclear  atrophy,  especially  those 
which  form  the  anterior  fundamental  fibers  of  the  spinal  cord.  Some- 
times the  loop  of  the  seventh  nerve  wastes,  although  the  cause  is  not 
clear,  (c)  The  muscles  supplied  by  the  above  nuclei  and  nerves 
waste,  as  those  of  the  lips,  tongue,  palate  and  larynx  (the  process 
sometimes  extends  to  the  neck  and  arms).  The  greatest  change  is 
in  the  tip  of  the  tongue.  The  changes  are  those  of  progressive  muscular 
atrophy,  i.  e.,  atrophy  which  is  unequal  in  its  distribution,  as  granular, 
fatty  or  waxy  alteration,  increased  nuclei  in  the  muscular  sheaths  and 
in  the  connective  tissue,  reddish  pigmentation,  and  sometimes  over- 
growth of  the  fatty  tissue.  The  nuclei  of  the  medulla  are  rarely  the 
sole  seat  of  the  disease,  and  when  they  are  alone  affected,  the  disease 
runs  a  rapid  course  of  a  few  months  to  a  year  (Remak),  suggesting 
that  other  structures  have  not  time  to   be   affected,      (d)   In   many 


1030  DISEASES  OF  THE  XERVOUS  SYSTEM 

cases  the  'pyramidal  tracts  show  degeneration,  which  may  be  traced 
down  into  the  cord  or  up  into  the  cms. 

S3anptoms.^Labioglossopharyngeal  paralysis,  the  name  proposed 
by  Duchenne,  designates  the  parts  paralyzed  by  the  wasting  of  the 
motor  nuclei.  It  is  almost  invariably  bilateral,  and  but  one  case 
showed  unilateral  disease.  It  is  slow  in  onset,  afebrile  and  painless. 
Initial  dyspnoea  and  headache  are  exceptional;  the  first  symptom  is 
usually  paresis  of  the  to?igue  (hypoglossus)  which  first  shows  fatigue 
and  much  later  actual  paralysis.  It  is  difficult  to  protrude  or  move 
up,  dowm  or  transversely.  The  linguals,  L,  N,  R,  and  S  are  formed 
with  difficulty  and  also  later  the  lingual  palatines,  as  T  and  D.  The 
tongue  is  sometimes  large  and  flabby,  but  more  often  wrinkled  and 
wasted.  The  lips  become  weak;  and  kissing,  whistling  and  formation 
of  the  labials  (O,  U,  P,  B,  M)  becomes  impossible.  At  first  sight  it 
seems  strange  that  paralysis  of  the  tongue  and  lips  should  be  so  closely 
associated,  yet  physiologically  they  are  more  closely  associated  than 
any  other  muscles  of  the  body;  anatomically  it  is  probable  that  the 
facial  fibers  for  the  orbicularis  oris  originate  in  the  hypoglossus  nucleus 
or  arise  very  close  to  it.  Forced  attention  may  for  a  while  overcome 
imperfect  enunciation,  but  later  the  paralysis  is  complete,  the  mouth 
cannot  be  closed,  the  lower  lip  sags  and  the  zygomatic  muscles  over- 
come the  weak  fibers  of  the  upper  lip,  and  accentuate  the  nasolabial 
furrow.  The  lips  are  frequently  thin,  but  may  appear  normal.  The 
expression  is  peculiar,  the  forehead  is  corrugated,  the  eyebrows  some- 
what lifted,  but  the  mouth  is  passive,  its  expression  is  "dead,"  and 
laughing  and  emotional  displays  produce  a  strange  effect,  which  Trous- 
seau compared  to  the  mask  of  the  Greek  actors.  The  original  descrip- 
tions graphically  picture  the  patient  constantly  holding  a  handkerchief 
before  the  lips  to  collect  the  free  flow  of  saliva  from  the  open  mouth; 
the  salivary  secretion  is  probably  also  increased  from  disease  of  its 
bulbar  centre.  The  chin  muscles  are  also  weak.  Sirallowing  becomes 
dijficult  from  the  inability  of  the  tongue  to  propel  the  food  to  the 
pharynx,  so  that  the  subject  must  push  the  food  back  with  the  finger,, 
and  again  the  palate  (which  is  controlled  by  the  spinal  accessory  and 
vagus  nerves)  is  weakened,  producing  a  nasal  voice  and  allowing  food 
to  regurgitate  into  the  nose.  The  pharynx  is  also  paretic  (it  is  supplied 
by  the  glossopharyngeal  and  vagus  nerves),  and  the  larynx  suffers 
(spinal  accessory  and  vagus  nerves).  Semi-solid  food  can  best  be 
swallowed,  because  fluid  more  easily  regurgitates  into  the  nose,  and 
solids  more  easily  reach  the  larynx.  The  larynx  is  often  involved. 
The  adductors  are  much  more  often  affected  than  the  abductors,  but 
the  palsy  is  usually  incomplete.  Talking  and  coughing  are  difficult 
or  impossible.  Fibrillary  twitchings  are  very  common,  sensation  is 
normal,  but  the  reflexes  of  the  skin  and  mucosa  are  usually  lost, 
which  may  possibly  be  the  first  sign  of  the  disease  (Krishaber).  The 
electrical  reactions  are  seldom  much  changed,  though  there  is  some- 
times a  partial  or  mixed  form  of  reaction  of  degeneration.  The  intel- 
lect is  normal.     The  patient  may  be  somewhat  emotional,  and  forced 


CHRONIC   BULBAR   PARALYSIS  1031 

laughing  and  weeping  are  not  uncommon.  The  general  nutrition 
suffers  from  the  dysphagia.  In  some  cases  the  process  extends  beyond 
the  nuclei  mentioned;  the  eyes  may  be  involved,  as  in  progressive 
nuclear  ophthalmoplegia  (which  is  an  identical  process  in  the  pons), 
chiefly  in  young  subjects  and  in  "family  forms";  occasionally  the 
cervical,  facial,  masseteric,  temporal  and  pterygoid  muscles  are  in- 
volved; affection  of  the  latter  was  considered  ominous  by  Duchenne. 
The  optic  nerve  is  very  rarely  implicated.  Bulbar  paralysis  frequently 
co-exists  with  progressive  muscular  atrophy  of  spinal  origin,  affecting 
the  limbs  or  trunk,  and  Kussmaul  first  pointed  out  that  the  two  pro- 
cesses are  identical  in  nature  and  differ  only  in  location.  The' spinal 
disease  may  progress  upward  to  the  medulla,  causing  secondary  bulbar 
palsy,  or  the  bulbar  palsy  may  be  primary,  followed  by  the  secondary 
and  analogous  spinal  atrophy.  In  the  typical  case  of  bulbar  paralysis 
there  is  wasting,  paralysis  and  absence  of  the  reflexes.  In  some 
atypical  forms  there  is  paralysis  but  no  wasting,  and  at  times  the  reflexes 
are  increased  (clonus  in  the  muscles  of  mastication);  in  these  cases 
it  is  probable  that  the  lesion  is  in  the  supranuclear  fibers,  and  this  is 
"the  bulbar  analogue  of  amyotrophic  lateral  sclerosis  of  the  cord," 
with  which  it  may  also  be  combined  later. 

In  the  progressive  course  of  the  malady,  the  pulse  becomes  rapid- 
(120  to  150),  and  irregular;  tachycardia  is  often  preceded  by  running 
together  of  the  heart  tones,  which  Duchenne  compared  to  the  "heart 
beating  in  water."    Respiration  is  difficult,  dyspnoea  develops  and  the 
expiration  is  weak. 

Diagnosis. — This  is  based  on  (a)  the  distribution  of  the  process  in 
the  motor  nuclei;  (b)  its  bilateral  symmetry;  (c)  gradual  onset,  and  (d) 
chronic  progression.  Neuritis  of  the  bulbar  nerves  is  very  rare;  the 
lips  escape,  because  the  nerve  fibers  to  the  orbicularis  oris,  arising  in 
or  near  the  hypoglossus  nuclei  run  to  the  pons  and  leave  it  by  the 
facial  nerve  fibers;  there  is  more  atrophy,  more  rapid  course,  more 
sensory  disturbance  and  the  reaction  of  degeneration  is  present.  It 
occurs  in  acute  infections,  in  leukaemia,  etc.  Brain  tumor  within  the 
medulla  occurs  most  often  in  young  subjects  and  gives  the  general 
and  local  signs  of  tumor;  growths,  exostoses,  dislocations,  caries  or 
aneurysms  without  the  medulla  but  rarely  produce  bilateral  or  exactly 
symmetrical  paralysis;  the  lips  escape,  dysphagia  is  the  leading  symp- 
tom and  other  symptoms  foreign  to  bulbar  palsy  develop,  as  motor 
irritation,  convulsions,  vomiting  or  hemiplegia  (see  Brain  Tumors, 
Medulla  page  1005).  The  bulbar  symptoms  of  multiple  sclerosis, 
and  syringomyelia  are  almost  never  symmetrical.  Pseudobulbar 
paralysis  may  be  confused.  Bilateral  disease  of  the  cerebral  hemi- 
spheres, sometimes  in  the  cortex,  but  more  often  in  or  near  the  internal 
capsule,  especially  when  due  to  arterial  lesions,  may  cause  dysarthria 
(Joffroy,  1872).  One  lesion  may  be  in  the  cortex  and  the  other  in  the 
lenticulostriate  area  (Halipre);  Jolly  found  this  condition  in  sym- 
metrical sclerosis  of  both  hemispheres.  Pseudobulbar  palsy  causes 
cerebral  symptoms,  as  mental  change,  aphasia,  hemiplegia,  double 


1032  DISEASES  OF  THE  XERYOUS  SYSTEM 

facial  paralysis,  and  hemianopsia;  one  side  is  involved  after  the  other 
and  it  is  attended  by  no  wasting,  no  loss  of  reflex  action  and  no  reaction 
of  degeneration. 

Prognosis. — The  disease  is  almost  invariably  fatal  in  one  to  three 
years  (or  seven),  especially  in  advanced  life  or  when  co-existent  with 
spinal  muscular  atrophy.  Remissions  are  possible,  and  in  the  rarest 
instances  the  disease  may  be  arrested  in  youth  or  middle  life.  Death 
results  from  inanition,  inhalation  pneumonia,  intercurrent  disease  or 
paralysis  of  the  cardiac  or  respiratory  centres. 

Treatment. — Treatment  is  discouraging.  Nutrition  must  be  main- 
tained by  feeding  with  the  nasal  catheter,  to  which  a  funnel  is  attached. 
Iron,  arsenic  and  strychnine  may  be  given.  Electrotherapy  is  of  little 
value.  Faradization  of  the  neck  and  tongue  may  help  deglutition; 
the  positive  pole  should  be  applied  to  the  spine  and  the  negative 
pole  to  the  throat.    The  disease  steadily  progresses  in  spite  of  treatment. 


Asthenic  Bulbar  Palsy;    Myasthenia  Gravis. 

Chronic  bulbar  palsy  without  anatomical  lesion  may  be  discussed 
in  this  connection.  It  was  first  described  by  Wilkes  (1877),  then  by 
Erb  (1879),  who  recognized  its  light  forms,  by  Goldflam  (1891),  who 
with  Oppenheim  published  reports  of  severe  and  fatal  cases.  It  is 
sometimes  known  as  the  Erb-Goldflam  syndrome.  E.  Bramwell  has 
collected  90  cases.  Its  etiology  is  unknown,  but  it  occurs  most  often 
in  persons  under  the  thirtieth  year,  and  in  25  per  cent,  a  neuropathic 
heredity  is  demonstrable.  The  cardinal  feature  is  extreme  exhaustion 
(myasthenia)  after  the  slightest  exertion.  Weakness  slowly  develops  in 
the  eyelids,  face,  palate,  masseters,  pharynx,  vocal  cords  and  the  tongue 
although  but  slightly  expressed  by  ptosis  (the  first  symptom  in  33  per 
cent,  of  cases),  dysphagia,  dysarthria,  and  difficult  mastication,  and 
disappears  after  rest,  to  return  anew  after  a  few  muscular  efforts. 
In  six  cases  myasthenia  was  confined  to  the  eyes.  From  these  bulbar 
symptoms  the  affection  is  also  called  asthenic  bulbar  paralysis.  In 
some  cases  the  arms,  legs  and  trunk  are  similarly  involved,  so  that 
walking,  or  arm  movements  become  impossible  after  short  exertion; 
this,  together  with  the  bulbar  symptoms,  is  known  by  the  term  myas- 
thenia gravis  pseudoparalytica.  The  symptoms  are  symmetrical. 
The  myasthenic  reaction  of  Jolly  consists  of  normal  tetanic  response 
to  faradic  stimulation,  but  becoming  weaker  with  each  repetition, 
until  at  last  no  reaction  is  elicited.  The  reflexes  are  normal  or  perhaps 
exaggerated  but  soon  also  become  exhausted.  Some  atonicity  of  the 
digestive  tract  is  fairly  common.  The  mind,  special  senses,  sensation, 
muscles  and  sphincters  are  normal,  although  Collins  noted  a  rapid 
exhaustion  of  the  special  senses.  Remissions  are  usual,  four  years 
being  the  maximum  clinical  duration.  About  40  per  cent,  of  cases  die, 
from  exhaiistion  of  the  cardiac  and  respiratory  centres  but  the  autopsy 
findings  are  negative  (in  66  per  cent)  or  doubtful.     Kalisher  found 


APOPLECTIFORM   BULBAR    PARALYSIS  1033 

hemorrhages  in  the  medulla,  and  C.  Mayer  found  vascular  and  nuclear 
alterations.  Lymphoid  cells  have  been  found  between  the  muscle 
bundles,  an-d  Hun  and  Blumer  describe  lymphoid  and  glandular 
hyperplasia  in  the  thymus  gland.  The  diagnosis  is  based  on  (a) 
absence  of  atrophy;  (b)  absence  of  reaction  of  degeneration;  (c) 
absence  of  twitchings  and  sensory  phenomena;  (d)  the  presence  of 
muscular  adynamia  occurring  with  (e)  remissions  in  the  course  of 
the  disease;  (/)  Jolly's  myasthenic  reaction;  (g)  the  slight  involve- 
ment of  the  hypoglossus. 

Treatment. — Rest  and  massage  are  helpful,  but  iodide  and  strych- 
nine are  less  useful.  Galvanization  of  the  head  and  neck  is  recom- 
mended by  Goldflam,  who  has  reported  recovery  from  its  use. 


Apoplectiform  Bulbar  Paralysis. 

Sudden  or  apoplectiform  bulbar  paralysis  does  not  properly  come 
under  degenerative  brain  disease,  but  deserves  discussion  in  this  place 
for  the  sake  of  topical  differentiation.  Its  usual  causes  are  hemorrhage, 
embolism,  thrombosis,  and  less  frequently  bulbar  encephalitis,  trauma 
or  compression,  bulbar  neuritis,  the  ascending  paralysis  of  Landry, 
and  paralysis  after  acute  infections.  Its  symptoms  are  as  follows: 
(a)  The  onset  is  apoplectiform  with  symptoms  (which  are  rarely  focal) 
as  vertigo,  vomiting,  dyspnoea,  yawning,  slowed  heart,  which  often 
occur  without  coma.  They  may  progress  or  regress,  (b)  Motor 
symptoms  are  frequent,  as  double  hemiplegia;  monoplegia  is  possible, 
or  if  the  lesion  occurs  at  the  pyramidal  decussation,  there  may  be 
hemiplegia  cruciata,  i.e.,  paralysis  of  one  arm  and  the  opposite  leg. 
A  unilateral  focus  may  produce  bilateral  symptoms,  which,  however, 
are  rarely  wholly  symmetrical.  The  pyramidal  tracts  in  the  medulla 
are  supplied  by  the  inferior  cerebellar  artery.  Descending  pyramidal 
degeneration  follows  severe  involvement  of  these  tracts,  (c)  Sensory 
symptoms  may  develop,  as  hemiataxia,  or  hemiansesthesia,  (possibly 
without  disturbance  of  muscle  sense),  (d)  The  bidbar  nerves  may  be 
affected;  paralysis  of  the  tongue,  pharynx,  masseters,  larynx,  and, 
because  of  the  vascular  supply,  frequently  of  the  eyes,  face  and  other 
pons  centres  may  result.  The  reflexes  of  these  parts  are  often  sus- 
pended, though  in  the  extremities  they  are  increased.  The  lesion 
may  be  at  the  level  of  the  nuclei,  or  supranuclear.  The  hypoglossal 
and  spinal  accessory  nerves  are  supplied  by  the  anterior  spinal  and 
vertebral  arteries;  the  vagus,  glossopharyngeal  and  auditory  nerves  by 
the  vertebral;  the  fifth,  seventh  and  eye-nerves  i third,  fourth  and 
sixth)  by  the  basilar  artery.  There  may  be  hemiplegia  with  paralysis 
of  the  opposite  side  of  the  tongue  if  the  lesion  is  in  the  anterior  part  of 
the  medulla. 

The  diagnosis  is  usually  easy  from  the  acuity  of  the  lesion  in  the 
medulla.  Chronic  bulbar  palsy  is  excluded  by  the  onset  and  the  asym- 
metry and  irregularity  of  the  bulbar  symptoms,  as  double  hemiplegia. 


1034  DISEASES  OF  THE  NERVOUS  SYSTEM 

which  is  unequal  on  the  two  sides,  or  dysphagia  without  paralysis 
of  the  tongue  or  lip.  Exact  differentiation  between  hemorrhage, 
embolism  and  thrombosis  is  frequently  impracticable.  Pseudobulbar 
paralysis  of  cerebral  origin  presents  the  characters  of  disease  of  the 
hemispheres  and  is  clearest  when  one  attack  is  followed  by  a  second. 
Differentiation  is  impossible  should  lesions  in  both  hemispheres  occur 
simultaneously. 

The  prognosis  is  most  grave  at  the  onset,  but  later  there  is  less 
danger  of  progression.  Improvement  and  even  recovery  are  possible. 
Treatment  concerns  chiefly  the  underlying  vascular  disease,  as  in 
hemorrhage,  or  embolism  (q.  v.). 

VIII.  Progressive  Nuclear  Ophthalmoplegia. 

This  is  a  degenerative  atrophy  of  the  oculomotor  nuclei,  similar 
pathologically  to  chronic  bulbar  paralysis.  It  is  more  conveniently 
considered  under  affections  of  the  third  nerve  (q.  v.). 

(F).  HYDROCEPHALUS. 

Acute  hydrocephalus  is  an  acute  accumulation  of  fluid  either  between 
the  dura  and  the  brain  (acute  external  hydrocephalus)  or  in  the  ven- 
tricles (acute  internal  hydrocephalus).  In  some  cases  the  fluid  is  a 
transudate,  being  part  of  a  general  oedema  resulting  from  cardiac  or 
renal  disease,  or  being  due  to  local  causes,  as  sinus  thrombosis.  In 
most  cases  it  is  an  exudate.  Acute  meningitis  is  the  only  certain  cause 
of  acute  hydrocephalus,  and  is  most  often  tuberculous  (80  per  cent.); 
it  is  less  often  the  serous  meningitis  of  Billroth  and  Quincke.  It  is 
difficult  to  distinguish  between  transudation  and  exudation,  and  diag- 
nosis is  uncertain.    Quincke  thinks  some  cases  are  angioneurotic. 

Chronic  Hydrocephalus. 

External  form  (fluid  between  the  dura  and  brain). — The  causes  are 
(a)  compensatory  hydrops  ex  vacuo,  occurring  where  brain  develop- 
ment is  arrested  (the  congenital  form)  or  when  the  brain  wastes  (paretic 
dementia,  softening,  hemorrhage,  sclerosis,  senile  atrophy,  poren- 
cephaly). The  hydrops  is  a  transudate  under  the  dura  in  the  arachnoid 
meshes,  or  between  the  pia  and  brain,  and  has  no  clinical  importance. 
(6)  Stasis,  as  in  sinus  thrombosis;  and  (c)  chronic  diseases,  as  cancer, 
nephritis  or  alcohoHsm  are  also  causes.  The  symptoms  are  indeter- 
minate. 

Chronic  Congenital  Internal  Hydrocephalus. 

The  etiology  is  uncertain.  It  has  been  thought  that  the  cause  was 
foetal  meningitis,  inflammation  in  or  obstruction  of  the  choroid  plexus. 


CHRONIC   COXGEXITAL   IXTERXAL  HYDROCEPHALUS      1035 

or  obstruction  in  the  branches  of  the  vena  Galeni,  in  the  lymphatics, 
in  the  lateral  apertures  of  the  fourth  ventricle  near  the  glossopharyn- 
geal roots,  in  the  aqueduct  of  Sylvius,  or  in  the  foramen  of  Magendie 
or  Luschka.  Hereditary  influences  and  syphilis  (10  per  cent.)  are 
sometimes  suggested;  parental  alcoholism  and  trauma  are  questionable 
causes. 

Sjmiptoms  and  Pathology. — The  head  is  large  and  may  be  an  obsta- 
cle to  labor.  It  may  measure  over  5  feet  (167  cm.)  in  circum- 
ference. If  it  appears  after  the  seventh  year,  the  head  is  not  enlarged, 
and  in  cretins  the  head  may  be  undersized.  Often  the  head  cannot  be 
held  upright.  The  skull  is  thin,  even  membranous  and  translucent 
to  the  candle  test.  If  the  disease  halts, the  bones  may  here  and  there 
thicken,  and  Wormian  bones  may  develop.  The  head  projects  beyond 
the  base,  the  sphenoid  is  luxated  forward  and  downward,  the  ear 
meatus  points  downward,  the  occiput  is  forced  back,  the  sella  turcica 
is  flattened  and  widened,  the  roof  of  the  orbit  may  be  pushed  down 
so  as  to  become  palpable,  the  fontanelles  are  large,  the  fissures  gape, 
and  fluctuation  may  be  felt.  The  hair  is  thin,  the  veins  are  large  and 
a  systolic  murmur  may  be  heard,  the  cause  of  which  is  doubtful.  The 
hrain  is  pale  and  may  be  flattened  almost  beyond  recognition.  The 
membranes  are  often  thickened,  and  the  ependyma  are  often  thick, 
granular  and  sclerotic.  The  average  amount  of  fluid  is  1  quart, 
the  maximum  13  quarts.  The  ventricles,  especially  the  lateral,  are 
enlarged;  sometimes  the  third  or  fourth  ventricle  escapes.  The 
enlarged  third  ventricle  easily  compresses  the  optic  chiasm.  The 
foramen  of  Monroe  is  often  very  large.  The  fluid  is  usually  clear, 
sometimes  slightly  yellow,  and  rarely  blood-stained.  It  may  contain 
epithelial  flocculi;  it  is  neutral  or  alkaline,  its  specific  gravity  is  1,001 
to  1,009,  the  albumin  is  0.2  to  2.0  pro  mille;  and  nuclein,  fibrin,  urea, 
cholestearin,  a  leucin-like  body,  and  sugar,  are  found.  More  than  2.5 
pro  mille  of  albumin  or  a  specific  gravity  higher  than  1,009  indicates 
inflammation,  according  to  Huguenin. 

The  face  is  small,  triangular,  and  the  eyes  are  prominent.  Much 
of  the  sclera  is  shown  and  the  upper  lid  is  small,  though  the  lower  lid 
may  cover  much  of  the  iris.  Nervous  symptoms  are  not  unexpected, 
for  the  brain  may  be  reduced  to  a  small  fraction  of  an  inch  in  thick- 
ness, and  is  a  mere  flask  for  the  fluid.  The  demarkation  between  grav 
and  white  matter  is  lost  and  in  marked  cases  the  convolutions  and 
sulci  are  obliterated,  the  basal  ganglia  flattened,  the  cerebellum  forced 
into  the  spinal  canal,  and  many  structures,  such  as  the  fornix  or  corpus 
callosum  have  disappeared.  Mentality,  as  a  rule,  is  impaired  or 
abolished,  speaking  is  learned  late  if  at  all,  will  power  is  lacking,  and 
irritability  is  common.  Patients  are  prone  to  psychoses.  Epilepti- 
form attacks,  headache  and  vomiting  are  fairly  common.  Eye  symp- 
toms are  frequent,  as  diminished  vision  or  blindness  from  initial  optic 
hyperemia  and  subsequent  atrophy,  strabismus,  nystagmus,  and  wide, 
possibly  reactionless,  pupils.  Other  special  senses  suffer.  All  the 
limbs,  or  the  legs  alone,  often  present  spasticity,  contractures,  paresis 


1036  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  increased  reflexes,  if  not  secondary  degeneration  in  the  pyramidal 
tracts.  The  face  may  be  similarly  afi^ected.  The  child  walks  late,  if 
at  all.  Sensation  is  practically  normal.  In  some  instances  there  is 
constipation,  which  may  be  followed  by  vomiting,  diarrhoea,  emacia- 
tion and  death.  Puberty  may  be  delayed  or  the  infantile  testes  may 
persist.  Lumbar  puncture  shows  increased  intraspinal  pressure, 
amounting  to  a  column  of  36  mm.  of  mercury. 

Complications  are  largely  anomalies  of  development,  as  syringo- 
myelia, hydromyelus,  meningocele,  microcephaly,  porencephaly,  an- 
encephaly,  and  encephalocele. 

Course. — The  course  varies  considerably.  Some  subjects  die  dur- 
ing or  after  birth.  Many  die  in  the  first  three  years  from  increase  of 
brain  pressure  with  coma,  from  intercurrent  disease  or  diarrhoea. 
In  some  cases  temporary  remissions  are  seen,  and  in  still  rarer  in- 
stances, permanent  arrest  of  the  process  occurs,  the  mind  improves 
with  partial  recovery,  the  speech  shows  some  defects  or  the  gait  remains 
paretic  and  spastic.  In  very  exceptional  cases,  rupture  externally  is 
observed  after  head  trauma,  or  spontaneous  breaking  into  the  ear  or 
nose  occurs,  as  in  Lebert's  case,  which  "leaked"  for  five  years.  Gall 
reported  a  case  which  lived  fifty  years,  and  Goelis  one  of  seventy-one 
years'  duration. 

Acquired  Chronic  Hydrocephalus. 

It  is  difficult  and  often  impossible  to  differentiate  between  the 
acquired  form  and  an  acute  exacerbation  of  the  congenital  variety. 

Etiology. — The  causes  are  (a)  stasis,  either  general  (cardiac  or 
pulmonary)  or  local  (brain  tumor  or  sinus  thrombosis);  (b)  cachectic 
transudation,  as  in  carcinoma  or  nephritis;  and  (c)  inflammation, 
beginning  as  acute  meningitis  of  the  sporadic  or  epidemic  type,  or  as 
slowly  beginning  chronic  basal  meningitis,  especially  in  young  children. 
The  same  points  of  obstruction  may  exist  as  in  the  chronic  variety. 
(d)  Rickets  is  possibly  a  cause  or  at  least  a  frequent  associate. 
Quincke's  idea  that  some  forms  are  angioneuritic  has  been  mentioned. 
Some  cases  show  nothing  at  autopsy. 

Sjrtnptoms. — Meningitic  symptoms  usher  in  some  cases  in  which 
after  weeks  or  months  new  evidences  of  brain  pressure  appear,  as 
alteration  in  the  pulse  and  breathing,  unequal  pupils  or  coma.  Head- 
ache, vomiting,  vertigo,  visual  disturbance,  spastic  paresis,  epilepsy, 
altered  mentality,  idiocy  or  involvement  of  the  cranial  nerves  are  seen, 
as  in  the  chronic  congenital  form.  The  shape  of  the  head,  however, 
is  not  altered. 

Diagnosis  of  the  chronic  congenital  and  acquired  forms. — Differen- 
tiation between  the  two  forms  is  usually  very  difficult,  unless  there  is 
an  accurate  history,  (a)  .From  rhachitis:  The  two  affections  are  often 
associated,  for  some  unknown  reason.  The  rhachitic  head  is  square 
rather  than  globular,  it  protrudes  more  in  front  and  laterally  than 
behind,  the  sutures  are  less  widely  separated,  the  fontanelles  are  wide 


PACHYMEXIXGITIS  1037 

but  do  not  bulge,  and  there  are  no  signs  of  brain  tension.  The  head 
should  be  measured,  because  the  rhachitic  head  often  seems  larger 
than  it  actually  is.  (b)  From  brain  tumor:  The  two  conditions  are 
sometimes  coincident.  In  each,  symptoms  of  brain  pressure,  both 
focal  and  general,  are  observed.  The  congenital  form  is  more  easily 
distinguished  by  means  of  the  history  of  the  disease  from  birth,  and 
its  slower  course,  but  focal  symptoms  are  less  common,  as  hemiplegia, 
monoplegia,  and  hemiansesthesia,  and  spinal  symptoms  are  more  com- 
mon than  in  tumor,  (c)  Hyperostosis  of  the  skull  (Paget's  disease), 
brain  hypertrophy  and  acromegaly  increase  the  size  of  the  head,  but 
they  are  rare  and  are  separable  by  the  same  methods  of  argument  as 
in  rhachitis. 

Treatment. — Few  therapeutic  results  can  be  obtained.  Bandaging 
the  head  is  sometimes  helpful,  but  must  be  carefully  done,  lest  it 
aggravate  the  brain  compression.  Puncture  of  the  lateral  ventricles 
dates  from  the  time  of  Hippocrates.  Isolated  recoveries  are  recorded, 
but  the  evacuation  must  be  slow.  Permanent  drainage  is  usually 
fatal,  but  occasionally  has  resulted  in  cure.  Attempts  to  obliterate  the 
ventricles  have  recently  been  made,  as  in  Mikulicz's,  Troje's  and  Leur's 
efforts  to  effect  anastomosis  between  the  ventricles  and  the  subdural 
space;  McArthur  was  successful  in  three  cases.  Lumbar  puncture 
in  acquired  forms  may  be  useful;  though  less  dangerous  than  radical 
measures,  death  may  result. 


DISEASES  OF  THE  CEREBRAL  MENINGES. 

Inflammation  of  the  dura  is  termed  pachymeningitis,  and  inflam- 
mation of  the  arachnoid  and  pia  is  known  as  leptomeningitis,  or  simply 
as  meningitis, 

PACHYMENINGITIS. 

External  pachymeningitis  is  essentially  a  surgical  disease  and  pos- 
sesses no  independent  significance,  being  secondary  to  skull  disease 
(syphilis,  trauma),  various  infections  and  atrophic  brain  affections. 
Its  symptoms  are  indefinite,  as  pain,  headache,  or  possibly  hemi- 
plegia, or  they  are  those  of  the  primary  lesion;  the  diagnosis  is  difficult. 
Surgical  treatment  in  Macewen's  22  cases  gave  100  per  cent,  recovery. 

Internal  pachymeningitis  is  divided  into  (a)  the  purulent  form,  which 
follows  bone  disease  or  leptomeningitis;  and  (b)  the  pseudomem- 
branous type,  sometimes  with  fluid  between  its  layers,  which  is  known 
as  serous  pachymeningitis  and  is  seen  chiefly  in  general  paralysis  or 
in  children  with  perisplenitis.    These  varieties  are  not  as  important  as 


1038  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  last  variety,  known  as  pachymeningitis  hemorrhagica  interna;  this 
form  was  described  by  Heschl  (1855),  and  a  year  later  Virchow  gave 
it  the  present  name;  he  regarded  the  inflammation  as  primary  and  the 
hemorrhage  as  secondary.  Kremiansky  (1868)  developed  the  etiology 
and  produced  the  disease  in  dogs  by  administration  of  alcohol. 

Etiology. — (a)  Most  cases  occur  in  middle  and  advanced  years, 
although  a  few  are  seen  in  marantic  children.  Fifty  per  cent,  occurs 
in  persons  over  fifty  years  of  age,  40  per  cent;  in  those  over  sixty,  and 
25  per  cent,  in  those  over  seventy  (Gowers).  (6)  Seventy-seven  per 
cent,  of  cases  occur  in  males,  (c)  Paretic  dementia  causes  19  per  cent. 
Pachymeningitis  is  common  in  other  dementias  and  chronic  psychoses, 
whence  its  far  greater  frequency  in  asylums  and  poorhouses  than  in 
private  or  hospital  practice.  It  also  occurs  in  senile  atrophy,  arterio- 
sclerosis, and  encephalomalacia.  {d)  Chronic  alcoholism,  frequently 
with  cardiac  and  renal  disease,  is  a  more  frequent  cause  than  the 
statistics  of  Konig  show,  viz.,  6  per  cent,  (e)  Trauma,  as  during 
birth,  from  forceps  delivery,  or  from  small  pelvis.  (/)  Hemorrhagic 
diathesis  (scurvy,  haemophilia,  leukaemia,  pernicious  anaemia),  chronic 
nephritis,  {g)  Infective  diseases,  as  typhoid,  scarlatina,  puerperal 
fever  (9  per  cent.),  heart  disease  (18  per  cent.),  hereditary  syphilis 
(11  per  cent.),  tuberculosis  (23  per  cent.),  bronchitis,  and  pertussis 
are  also  causes. 

Pathology  and  Pathogenesis. — 1.  Gross  Pathology. — In  slight  cases 
the  inner  surface  of  the  dura  is  cloudy,  yellow  or  brown  from 
punctate  hemorrhages  or  hsematoidin  deposits.  In  pronounced  cases 
the  dura  shows  membranous  laminae,  which  are  adherent  by  prolifer- 
ation of  bloodvessels  and  by  organization.  The  laminae  may  number 
even  20  and  may  be  a  quarter  of  an  inch  thick.  Those  layers  nearest 
the  brain  are  the  most  newly  formed.  Repeated  hemorrhage  into  the 
layers  of  the  newly  formed  tissue  or  between  them  is  very  frequent, 
and  may  be  an  inch  or  more  thick  or  may  reach  the  size  of  an  egg. 
The  free  hemorrhage  may  spread  over  the  entire  surface  of  the  brain, 
even  reaching  the  retina;  older  foci  are  apt  to  be  encapsulated.  Cyst 
formation  in  the  clot,  suppuration  and  calcification  are  rare  issues. 
The  leptomeninges  are  tinged  and  often  somewhat  inflamed.  Corres- 
ponding to  the  most  frequent  seat  of  pachymeningitis,  the  convexity 
of  the  brain  is  compressed,  especially  over  the  motor  areas.  The 
process  is  bilateral  in  56  per  cent,  of  cases,  and  the  basal  cranial 
nerves  are  seldom  implicated. 

2.  Minute  Examination. — The  normal  dura  is  vascularized  from  its 
external  aspect,  and  the  branches  spread  into  a  capillary  mesh  on  its 
inner  surface.  The  fresh  fibrin  of  the  earliest  hemorrhage  and  the 
exudation  contains  red  cells  with  large  nuclei,  and,  nearest  the  brain, 
a  covering  of  endothelial  cells.  Later  the  exuded  fibrin  develops 
capillaries,  organizes,  and  again  hemorrhage  occurs  from  the  newly 
formed  vessels.  This  organizes  in  turn,  so  that  successive  laminae 
develop.    The  older  layers  become  firm  and  fibrous. 

3.  Pathogenesis, — Virchow  viewed  the  affection  as  primary  pachy- 


PACHYMEXIXGiriS  ■  1039 

meningitis  with  secondary  hemorrhage,  but  Spierhng  and  Hueguenin 
held  that  the  hemorrhage  was  primary,  with  secondary  inflammation. 
Virchow's  views  still  hold  for  most  cases,  although  more  recently 
Jores  has  proven  that  two  classes  of  cases  exist,  (a)  In  traumatic 
cases,  the  hemorrhage  is  primary  and  a  simple  clot  forms  which  later 
organizes  into  firm  connective  tissue;  this  variety  is  called  regressive. 
The  same  sequence  is  thought  to  occur  in  cases  due  to  the  blood  dis- 
eases, acute  infections,  and  arteriosclerosis,  (b)  In  chronic  pachy- 
meningitis proper,  the  inflammation  is  primary,  the  process  is  pro- 
gressive, the  connective  tissue  formed  in  layers  is  looser,  more  vascular, 
and  its  inner,  successively  formed  layers,  are  the  seat  of  repeated 
hemorrhages. 

Symptoms. — In  most  cases  there  are  no  symptoms,  because  the 
membrane  is  small  and  the  hemorrhage  is  slight,  or  because  the  pachy- 
meningitic  symptoms  are  overshadowed  by  those  of  the  original  dis- 
ease. In  the  minority  of  cases,  symptoms  exist  depending  on  the 
intensity  of  the  process,  its  extent  and  localization. 

1.  General  Symptoms. — The  most  frequent  one  is  headache,  which 
is  per  se  of  little  differential  value.  It  is  diffuse  and  is  most  marked 
in  alcoholics.  Vertigo  is  also  of  no  diagnostic  value.  These  symp- 
toms increase  in  value  when  mental  dulness  or  irritation  and  coma 
develop  with  focal  signs  {v.  i.).  There  may  be  prodromal  delirium. 
The  pulse  is  sometimes  slow  and  irregular.  Choked  disk  is  not  rare. 
Moderate  albuminuria  sometimes  occurs.  The  temperature  is  vari- 
able, but  may  be  slightly  elevated. 

2.  Focal  Signs. — ^The  most  important  is  hemiplegia,  which  is  pre- 
ceded for  some  time  by  coma  (Fiirstner).  The  paralysis  is  contra- 
lateral, rarely  complete,  varies  with  increase  or  decrease  of  the  clot, 
often  involves  the  cortical  facial  and  hypoglossal  centres,  is  sometimes 
bilateral  and  is  associated  with  aphasia  (33  per  cent.),  hemihypsesthesia 
(especially  involving  the  muscle  sense  and  therefore  causing  hemi- 
ataxia),  hemiamblyopia,  contractures  in  the  paretic  members  and 
Jacksonian  epilepsy.  Conjugate  deviation  of  the  head  and  eyes, 
nystagmus  and  forced  postures  may  be  observed.  The  patient  may 
^rasp  at  his  clothes,  or  at  his  hair  or  beard  (Fiirstner).  The  pupil 
contralateral  to  the  lesion  is  usually  larger  (Griesinger) ;  the  pupils 
react  poorly,  and  later  both  are  wide.  The  tendon  reflexes  are  increased, 
but  the  skin  reflexes  are  decreased  or  abolished  during  the  coma.  The 
basal  nerves  are  very  rarely  involved ;  trismus  and  rigidity  of  the  neck 
are  uncommon.    Statistics  on  lumbar  puncture  are  as  yet  lacking. 

Course  and  Prognosis. — Death  may  occur  in  the  first  seizure,  or  the 
symptoms  may  subside  for  months,  years,  or  possibly  permanently. 
Residual  signs  are  common  and  include  headache,  ataxia,  psychical 
alteration,  paresis  and  aphasia.  Recurrence  is  frequent,  with  stupor, 
coma,  and  hemiplegia  until  death  occurs  (a)  from  the  fundamental 
disease,  (6)  from  the  hemorrhage,  or  (c)  from  intercurrent  affections. 
The  outlook  depends  on  the  etiology;  for  instance,  it  is  better  in 
alcoholism  than  in  dementia. 


1040  •  DISEASES  OF  THE  XERVOUS  SYSTEM 

Diagnosis. — A  correct  diagnosis  is  rare.  A  patient  with  paretic 
dementia  may  die  from  a  pseudo-apoplectic  shock,  or  from  pachy- 
meningitis, or  a  nephritic  subject  may  succumb  to  pachymeningitic 
hemorrhage,  ursemia,  brain  oedema  or  heart  failure.  A  presumptive 
diagnosis  can  be  made  from  (a)  the  age,  (b)  basal  disease  (paretic 
dementia,  alcoholism),  (c)  preceding  dulness  or  coma,  (d)  hemiplegia, 
or  (e)  irritative  phenomena  (small  pupils  and  convulsions),  (/)  from 
variability  and  (g)  recurrence  of  the  symptoms. 

Differentiation. — It  should  be  distinguished  from  localized  brain 
disease  as  (a)  paretic  dementia  (q.  v.),  and  (b)  cerebral  hemorrhage. 
Differentiation  may  be  impossible,  especially  when  pachymeningitic 
hemorrhage  is  very  large.  The  etiology  is  different,  and  in  pachy- 
meningitis there  is  more  cortical  irritation,  the  coma  and  paralysis  are 
more  variable,  and  temperature,  narrow  pupils  and  optic  neuritis  are 
more  common,  (c)  In  encephalomalacia,  the  hemiplegia  is  more  often 
attended  by  aphasia  and  hemianeesthesia,  and  there  is  less  cerebral 
irritation,  (d)  Brain  tumor  is  easily  distinguished.  Trauma,  apo- 
plectiform attacks  and  progression  with  remissions  occur  in  both  affec- 
tions. Tumor  usually  appears  earlier  in  life,  does  not  depend  on 
alcoholism,  and  focal  signs,  intense  headache,  and  choked  disk  are 
much  more  common. 

Diffuse  brain  disease  chiefly  concerns  meningitis,  whose  cardinal 
symptoms  (q.  v.)  and  course  are  usually  distinctive. 

Treatment. — Treatment  should  be  (a)  prophylactic  and  etiological  ; 
and  (b)  that  of  the  seizure.  The  use  of  the  ice-cap,  quiet,  elevation 
of  the  head,  application  of  leeches  back  of  the  ear,  and  possibly  vene- 
section are  indicated.  Nourishment  should  be  given  by  rectum. 
Morphine  and  chloral  relieve  the  headache,  excitement  or  convulsions. 
Lumbar  puncture  has  not  proven  beneficial  (Ricken).  Operation  was 
first  performed  by  Ceci  in  traumatic  cases  and  by  Annandale,  Jaboulai, 
Monroe,  and  Ballard  in  other  varieties.  In  the  future,  surgery  will 
probably  benefit  a  larger  number  of  cases. 

MENINGEAL  HEMORRHAGE. 

Meningeal  apoplexy  may  be  extradural,  subdural,  arachnoideal 
subarachnoideal,  and  subpial. 

Etiology  and  Pathology. — (a)  Trauma  may  rupture  the  anterior, 
middle  or  posterior  meningeal  arteries,  with  or  without  fracture  of  the 
skull.  Rupture  occurs  usually  at  the  site  of  trauma,  but  sometimes 
by  contre-coup.  The  corresponding  veins  may  rupture,  also  the 
sinuses,  or  the  pial  vessels  from  the  latter  of  which  blood  may  percolate 
to  the  base  of  the  brain,  affecting  the  basal  nerves,  or  may  reach  the 
spine.  The  internal  carotid  may  be  ruptured,  and  death  then  occurs 
precipitately.  External  hemorrhage  is  either  diffuse  or  circumscribed 
and  results  most  frequently  from  middle  meningeal  rupture.  The 
blood  clot  may  weigh  .3  to  17  ounces  or  may  reach  the  size  of  the 


MEXIXGITIS,  SUPPURATIVE,  EPIDEMIC,  TUBERCULOUS      1041 

fist,  compressing  the  brain,  and  dislocating  the  falx.  If  the  dura  is 
injured,  blood  may  be  found  in  its  substance.  During  birth  (see  In- 
fantile Cerebral  Paralysis)  trauma  may  be  a  factor,  and  hemor- 
rhage has  even  occurred  during  gestation  from  maternal  trauma 
(Teale),  but  asphyxia  and  precipitate  labor  are  more  important; 
large  symmetrical  hemorrhage  of  the  convexity  is  common.  (b) 
Arteriosclerosis  and  rupture  of  cerebral  aneurysms  may  cause  menin- 
geal hemorrhage,  (c)  Acute  infections,  hemorrhagic  diathesis,  sinus 
thrombosis  and  rarely,  heart  and  lung  disease,  may  produce  it.  id) 
Ten  per  cent,  of  cases  occur  under  ten  years  and  50  per  cent,  under 
forty  years  of  age  (Gowers).  Small  clots  may  be  absorbed  or  micro- 
gyria, porencephalia,  cysts  or  brain  sclerosis  may  result. 

Symptoms. — Clinical  latency  is  not  rare  in  the  new-born,  possibly 
because  of  the  poor  development  of  the  motor  centres.  Small  hemor- 
rhage may  in  the  adult  produce  no  symptoms.  Very  large  ones  result 
in  early  sudden  death.  In  rupture  of  the  middle  meningeal  artery  there 
are  (a)  symptoms  of  brain  pressure  with  those  of  brain  concussion  or 
contusion,  as  loss  of  consciousness,  irritative  symptoms,  increased 
breathing,  slowed  pulse,  pallor,  vomiting, and  slight  fever  (100°  to  101°). 
Either  death  or  improvement  may  result.  (6)  In  other  cases  improve- 
ment from  the  concussion  and  contusion  occurs;  there  may  be  an 
interval  of  hours  to  often  of  days  when  hemorrhage  occurs  or  recurs,  with 
coma,  pressure  symptoms,  mono-  or  hemiplegia  and  convulsions  as  in 
pachymeningitis.  Rigidity  is  rather  rare;  it  is  less  frequent  than  in 
meningitis,  but  Oppenheim  has  observed  rigidity  on  the  hemiplegic  side 
and  flaccidity  on  the  sound  side,  which  may  cause  error  in  localization. 
The  pupils  are  variable.  Hemorrhage  of  the  sinuses  and  pia  are  said 
to  cause  monoplegia  frequently;  the  brain  nerves  are  sometimes 
reached  by  infiltration  to  the  base.  In  the  new-born,  there  is  asphyxia, 
slow  then  rapid  pulse,  and  coma;  this  is  followed  later  by  epilepsy, 
idiocy  and  spastic  paralyses. 

Differentiation. — From  concussion:  an  exact  diagnosis  is  possible 
only  after  trephining,  or  by  the  clinical  evolution.  From  cerebral 
hemorrhage:  the  course  is  very  rapid.  Differentiation  from  slow, 
ingravescent  cerebral  hemorrhage  is  impossible. 

Prognosis  and  Treatment. — Ninety  per  cent,  of  cases  die  from 
expectant  treatment  (Wiesmann);  33  per  cent,  die  in  twenty-four 
hours,  and,  when  the  hemorrhage  is  due  to  aneurysmal  rupture,  30  per 
cent,  die  in  ten  hours  (Lebert).  Early  surgical  treatment  is  indicated; 
this  was  especially  described  by  Kronlein. 


ACUTE  LEPTOMENINGITIS;  SUPPURATIVE,  EPIDEMIC  AND 
TUBERCULOUS. 

In  1768,  Whytt,  of  Edinburg,  noted  the  acute  hydrocephalic  symp- 
toms of  meningitis  but  failed  to  recognize  the  meningitis,  which  Quinn 
(1779)  described.     In  1805,  Vieusseux,  of  Geneva,  described  the  epi- 

66 


1042  DISEASES  OF  THE  XERVOUS  SYSTEM 

demic  variety;  in  1806,  it  was  seen  by  Danielson  and  Mann  in  Xew 
England,  and  they  performed  the  first  autopsies  (Osier).  Coindet 
(1817)  described  the  cry,  cri  hydrencephaliqiie,  and  Senn  in  1825, 
coined  the  name  meningitis.^  In  1819,  Guibert  described  the  granula- 
tions and  Guersant  spoke  of  meningite  granuleuse  as  associated  with 
phthisis.  Parpavoine  (1830)  recognized  the  tuberculous  form  and 
Gerhardt  of  this  country  two  years  later  drew  the  profession's 
attention  to  the  role  of  tuberculosis.  In  1855,  Rilliet  and  Barthez 
distinguished  the  suppurative,  secondary,  tuberculous  and  other 
forms. 

Acute  leptomeningitis,  or  meningitis,  is  of  various  forms  which  may 
well  be  considered  together,  because  the  main  symptoms  are  common 
to  all,  though  epidemic  meningitis  might  be  classed  under  the  acute 
infections,  and  tuberculous  meningitis  is  usually  part  of  a  generalized 
tuberculosis.  Their  contrast  is  better  effected,  however,  under  the 
grouping  followed  below. 

General  Etiology. — 1.  Trauma. — The  microorganisms  of  the  ear  or 
nose  may  find  ready  access  to  the  brain,  when  its  resistance  is  lessened 
by  wounds,  concussion,  or  contusion. 

2.  Regional  Extension. — (a)  From  the  ear:  acute  or  chronic  disease 
of  the  middle  ear,  antrum  or  petrous  bone  may  invade  the  brain 
through  the  bone,  along  the  lymph  or  bloodvessels,  the  nerve  sheaths 
or  sinuses  (see  Brain  Abscess)  and  may  result  in  suppurative,  tuber- 
culous or  serous  inflammation.  (6)  From  the  nose:  extension  by  this 
route  is  generally  less  common,  but  may  be  frequent  in  the  epidemic 
form  (Weigert).  The  disease  may  be  acute  or  chronic,  spontaneous 
or  operative  (by  sounding  with  a  probe),  syphilitic,  tuberculous,  men- 
ingococcic,  neoplastic  or  suppurative,  of  the  nasal  mucosa  or  of  the 
ethmoidal,  sphenoidal  or  antral  cells.  Infection  may  travel  through 
the  bone,  along  the  veins  which  communicate  with  the  dura,  or  along 
the  olfactory  nerve  endings,  (c)  From  the  eye:  the  avenues  to  the 
brain  are  numerous,  and  yet  disease  of  the  eye  itself,  even  panophthal- 
mitis is  less  important  than  orbital  cellulitis  or  enucleation,  which 
exposes  the  sheath  of  the  optic  nerve,  id)  Extension  may  also  result 
from  other  less  frequent  sources,  as  ^parotitis,  carbuncles,  especially  of 
the  face,  whose  veins  communicate  with  the  cavernous  sinus;  scalp 
affections;  erysipelas;  bone  disease,  especially  abscess  and  tubercle; 
and  sinus  thrombosis. 

3.  Metastatic  or  Secondary  Extension. — (a)  Tuberculosis  is  the 
most  frequent  cause,  and  this  is  easily  understood  when  we  study  the 
statistics  of  Nageli,  who  found  tuberculosis  in  97  per  cent,  of  autopsies. 
(b)  Septic opycemia,  from  lung  suppuration,  empyema,  arthritis,  endo- 
carditis and  kindred  affections;  (c)  pneumonia  (about  0.5  per  cent, 
in  5,540  cases);  and  {d)  rarely  exanthemata  may  produce  it.  In  this 
group  there  is  probably  an  intermediate  link,  as  otitis  media  in  scar- 
latina and  empyema  or  lung  infarct  in  typhoid,  {e)  Syphilis,  generally 
subacute  or  subchronic  may  also  cause  it. 

4.  The  Epidemic  Form. — This  is  in  itself  an  etiological  entity. 


SUPPURATIVE   MEXIXGITIS  1043 

5.  Diseases  of  Metabolism. — Meningitis  may  rarely  occur  in  the 
course  of  diabetes,  nephritis,  gout,  arteriosclerosis  or  malnutrition,  but 
it  is  probably  only  a  terminal  infection. 

General  Bacteriology. — (a)  The  tubercle  bacillus  is  the  most  com- 
mon microorganism,  (b)  The  pneumococcus  is  probably  the  most  fre- 
quent among  the  non-tuberculous  varieties.  It  was  first  found  by 
Frankel  and  simultaneously  by  Bardoni-Uffreduzzi.  This  form  may 
be  primary,  or  secondary  to  pneumonia,  (c)  Pyogenic  organisms, 
especially  the  Streptococcus  pyogenes  and  the  Staphylococcus  pyogenes 
aureus;  (d)  the  Meningococcus  intracellularis  (Diplococcus  intracellu- 
laris  meningitidis)  which  was  found  by  Marchiafava  and  Celli,  then 
by  Weichselbaum  (1887),  and  Jager,  and  was  first  withdrawn  by 
Heubner  by  lumbar  puncture;  and  (e)  the  typhoid  bacillus  (Roux, 
Adenot,  Lenhartz),  the  colon  bacillus  (Braun,  Chantemesse,  Widal, 
Netter),  the  influenza  bacillus  (Pfuhl  and  Hagerstedt),  Friedlander's 
pneumobacillus.  Bacillus  pyogenes  foetidus,  Bacillus  pyocyaneus,  pro- 
teuSjgonococcus,  Bacillus  anthracis,  Bacterium  lactisaerogenes,  Bacillus 
aerogenes  meningitidis  (Cantani),  and  trypanosoma  are  also  found. 


I.  Suppurative  Meningitis. 

This  is  usually  a  secondary  affection. 

Pathology. — 1.  Macroscopically  a  purulent  exudate  is  found  between 
the  dura  and  leptomeninges  and  in  the  meshes  of  the  arachnoid.  The 
dura  is  tense  and  its  inner  surface  dry.  The  leptomeninges  are  reddish, 
cloudy  and  are  often  dotted  with  punctate  hemorrhages.  The  exudate 
is  clearly  purulent,  yellow  or  whitish-green,  and  succulent.  The 
infection  spreads  rapidly,  follows  the  perivascular  lymphatics,  as 
streaks  of  pus,  imbeds  the  vessels  and  nerves  in  its  meshes,  obliterates 
the  sulci,  and  involves  not  only  the  brain  membranes  but  also  those 
of  the  cord.  It  is  a  misapprehension  that  the  epidemic  cerebrospinal 
form  {v.  i.)  involves  the  spinal  meninges,  and  that  other  suppurative 
forms  do  not.  The  brain  is  always  altered;  it  is  succulent,  swollen, 
springs  out  as  the  membranes  are  cut,  is  vascular,  and  sometimes 
locally  anaemic  from  compression  by  the  exudate;  its  surface  is  most 
affected,  by  such  changes  as  small  abscesses,  punctate  hemorrhages  or 
minute  islets  of  softening  or  encephalitis.  The  convexity  is  most 
often  involved  in  the  metastatic  form  (convexity  meningitis)  and  the 
base  most  frequently  in  ear  disease.  There  may  be  primary  or  second- 
ary sinus  thrombosis.  The  ventricular  fluid  is  often  increased,  and 
is  cloudy,  purulent  or  sometimes  serous.  The  apertures  of  the  ven- 
tricles may  be  occluded  (see  Hydrocephalus);  inflammation  may 
be  noted  in  the  velum  interpositum,  choroid  plexus  or  ependyma. 
In  the  spinal  membranes  the  changes  are  similar  and  are  most  marked 
over  the  posterior  part  of  the  dorsal  region.  The  process  is  usually 
diffuse.     On  incising  the  membranes,  the   swollen   cord   bulges  out 


1044  DISEASES  OF  THE  XERVOUS  SYSTEM 

and  the  same  changes  are  seen  as  in  the  brain.  The  process  may 
extend  along  the  nerve  trunks  and  bloodvessels,  even  into  the  orbit. 

2.  Microsco'pically  there  are  the  usual  findings  of  inflammation, 
perivascular  exudation  of  red  and  white  cells,  and  fibrin  formation. 
Vascular  dilatation  and  exudation  are  seen  in  those  cases  in  which 
the  membranes  appear  normal  to  the  naked  eye.  Exudation  is  most 
marked  over  the  cortex  and  near  the  ventricles,  but  may  also  occur 
deeper  in  the  medullary  substance.  The  ganglionic  cells  show  degen- 
eration, although  they  have  not  been  studied  systematically.  Analo- 
gous findings  are  present  in  the  cord,  on  its  surface  or  about  the  central 
canal.  In  the  optic  nerve,  exudation,  hemorrhage  and  oedema  are 
seen,  possibly  also  in  other  cerebral  and  spinal  nerves.  Various  bac- 
teria are  found  {v.  s.),  as  the  pyogenic  organisms,  the  pneumococcus, 
and  the  meningococcus.  Mixed  infections  are  not  uncommon.  It 
must  be  remembered  that  pathologically  (though  not  bacteriologically), 
the  suppurative  and  epidemic  forms  are  identical,  and  some  writers 
still  maintain  that  the  epidemic  is  but  a  subtype  of  the  suppurative 
variety. 

Sjnnptoms. — Prodromal  phenomena  are  ambiguous  and  vary  with 
the  causal  disease;  otitis,  pneumonia  or  pyaemia  may  long  overshadow 
or  totally  obscure  meningeal  manifestations.  Complete  latency  is  pos- 
sible, as  in  a  case  seen  by  the  author  with  Dr.  Besley;  a  convalescent 
pneumonia  patient,  while  dining,  felt  dizzy  and  died  in  a  few  minutes. 
The  autopsy  revealed  a  massive,  purulent  cerebrospinal  meningitis, 
which  had  produced  not  a  single  sign  or  symptom,  (a)  The  onset 
may  be  sudden  with  chill  and  fever.  (6)  Headache  is  usually  the  first 
and  most  prominent  symptom,  and  is  often  associated  with  vomiting. 
(c)  The  sensorium  is  disturbed,  there  is  vertigo,  and  delirium  which 
is  succeeded  by  stupor  and  finally  by  coma,  in  which,  however,  head- 
ache may  still  be  evidenced  by  the  patient  holding  his  head,  {d) 
Convulsions  may  occur;  they  are  particularly  equivocal  in  children. 
(e)  Oftic  neuritis  may  develop  if  the  course  of  the  disease  is  not  too 
precipitate.  (/)  Rigidity  of  the  neck  and  spine  is  soon  noted  as  well 
as  (g)  hypercBsthesia,  hyperalgesia  and  muscular  rigidity,  (h)  Fever  is 
usually  present,  although  in  very  rare  instances  (v.  s.)  it  may  be  absent. 
It  is  usually  higher  than  in  other  types,  perhaps  104°  to  105°,  and 
rather  more  continuous.  Toward  the  end  it  may  be  107°  or  it  may 
even  drop  to  subnormal,  (i)  The  pulse  is  usually  faster  and  often 
irregular,  (j)  Irritation  and  paralysis  of  the  cerebral  nerves  develop, 
(they  are  considered  more  fully  under  the  epidemic  form),  and  are 
manifested  by  ocular  paralysis,  nystagmus,  strabismus,  pupillary 
inequality  and  tardy  reaction  to  light,  facial  paresis,  grinding  of  the 
teeth  or  trismus  especially  if  the  inflammation  is  basal,  (k)  If  the 
process  involves  the  convexity,  cortical  irritation  may  be  manifested 
by  Jacksonian  epilepsy  and  mono-  or  hemiplegia  (which  is  sometimes 
due  to  reflex  inhibition),  (l)  Lumbar  puncture  (see  Diagnosis)  reveals 
purulent  or  clear  fluid  and  frequently  the  organisms  of  suppuration. 
Increased  tension  is  also  observed,      (w)    Kernig's  sign   (see  Diag- 


EPIDEMIC  CEREBROSPIXAL  MEXIXGITIS  1045 

Nosis)  is  present,  (n)  There  may  be  other  symptoms.  Constipation 
is  usually  present.  The  abdomen  is  often  retracted,  there  may  be 
vomiting,  the  urine  is  febrile  and  frequently  contains  albumin  and 
peptone.  The  course  is  generally  rapid;  it  lasts  a  few  hours  to  more 
usually  a  few  days  (two  to  ten)  and  almost  invariably  results  fatally 
in  coma.  The  diagnosis,  differentiation  and  treatment  are  considered 
with  the  other  types. 


II.  Epidemic  Cerebrospinal  Mening-itis. 

This  form  has  been  definitely  recognized  only  during  the  last  century. 
Though  many  authorities,  as  Schultze,  Dieulafoy  and  Netter,  deny 
that  it  is  an  absolutely  independent  affection,  it  is  usually  described 
as  a  specific  infection  involving  the  cerebrospinal  meninges,  caused  by 
the  Diplococcus  intracellularis  meningitidis  and  occurring  epidemically 
or  sporadically. 

Bacteriology. — The  meningococcus  resembles  the  pneumococcus 
and  gonococcus.  It  lies  in  pairs  or  even  tetrads,  its  contiguous  sides 
are  flattened,  and  it  resembles  two  coffee  grains  with  their  flat  sides 
apposed.  It  is  wider  than  the  pneumococcus  and  less  lanceolate.  It 
is  usually  but  not  always  intracellular,  being  enclosed  in  the  poly- 
morphonuclear leukocytes.  Unlike  the  pneumococcus,  it  usually  has 
no  capsule,  although  one  may  develop  in  serum  cultures.  It  decolorizes 
by  Gram's  method,  although  Jager  has  sometimes  observed  the  con- 
trary. Cultures  do  not  show  very  active  growths;  it  develops  best  on 
agar  or  blood  serum  as  white,  viscid,  shining  colonies.  It  grows 
poorly  on  gelatin.  Subcutaneous  inoculations  are  usually  negative, 
therein  differing  from  the  pneumococcus,  but  it  produces  inoculation- 
meningitis,  and  peritonitis.  The  meningococcus  is  found  in  the  nose, 
from  which  it  is  thought  to  invade  the  brain.  Lord  found  it  in  the 
nose,  in  cases  with  and  without  meningitis.  Goodwin  and  Scholly 
(1906)  isolated  the  cocci  from  the  nasal  mucus  in  50  per  cent,  of 
meningitis  patients  and  in  10  per  cent,  of  those  in  close  contact  with 
them.  Its  presence  has  been  demonstrated  in  the  blood  (in  25  per 
cent,  of  cases,  Elser),  kidneys,  joints,  spleen,  ear,  tonsils,  lymphatic 
nodes,  pleura,  lung,  heart  valves,  pericardium  and  more  rarely  in  the 
sputum  and  urine;  it  probably  travels  by  way  of  the  lymph  vessels. 

Predisposing  Etiology.— Children  and  young  adults  are  especially 
predisposed;  it  occurs  more  often  in  males,  is  apparently  more  fre- 
quent in  the  country,  although  it  is  often  endemic  or  epidemic  in 
barracks,  prisons,  hospitals  and  tenements.  The  disease  has  closely 
followed  the  movements  of  armies  or  regiments.  Though  not  very 
directly  contagious,  its  contagiousness  seems  proven  beyond  question. 
As  many  as  seven  members  of  a  family  have  been  successively  stricken. 
Most  cases  are  seen  in  the  late  winter  and  early  spring;  the  author 
has  always  seen  some  cases  in  these  months.  One  thousand  deaths 
occurred  in  New  York  in  tlie  first  four  months  of  1905.     Trauma, 


1046  DISEASES  OF  THE  XERVOUS  SYSTEM 

overwork,  and  depression  are  but  predisposing  causes.  Like  pneu- 
monia, it  often  attacks  the  robust.  It  may  recur;  Councilman  col- 
lected five  instances  of  recurrence.  The  disease  is  also  seen  in  the 
horse  and  goat. 

Pathology. — The  findings  in  the  main  are  those  of  the  suppurative 
form,  viz.,  those  of  an  acute  fibrinopurulent,  or  less  often  a  sero- 
purulent  leptomeningitis.  The  cerebral  dura  is  seldom,  and  the  spinal 
dura  often,  involved.  The  inflammation  follows  the  lymphatics  and 
vessels  penetrating  the  brain  and  cord,  resulting  in  encephalitic  or 
myelitic  foci,  small  abscesses,  parenchymatous  and  interstitial  changes. 
The  axis  cylinders  are  sometimes  lost.  Flexner  and  Barker  observed 
rows  of  cells  "like  miniature  tubercles,"  of  which  some  were  two  to 
eight  times  the  size  of  the  leukocytes.  The  exudate  is  rich  along  the 
fissures,  fossa  of  Sylvius  and  at  the  base  about  the  chiasm  or  the 
surface  of  the  pons  and  cerebellum.  Hydrops  ventriculorum  is  fairly 
frequent,  in  cases  of  long  standing.  Some  consider  that  caseation 
may  occur  as  the  beginning  of  resolution  and  healing.  In  other  organs 
the  changes  are  those  of  acute  infection,  the  muscles  are  brownish- 
red,  dry  and  degenerated,  there  is  parenchymatous  degeneration  in  the 
heart  and  kidneys,  and  sometimes  acute  splenic  tumor,  arthritis, 
pneumonic  foci  or  swollen  glands  in  which  {v.  s.)  the  coccus  may  be 
found. 

Symptoms. — The  period  of  incubation  is  not  definitely  known,  but 
lasts  from  a  few  hours  to  several  days  (three  to  eleven).  Prodromes  are 
vague,  as  malaise,  or  headache.  Striimpell  and  others  observed 
initial  coryza.  The  onset  may  be  gradual  or  sudden,  sometimes  with 
a  chill  and  usually  wdth  fever.  In  general,  the  course  is  febrile, 
attended  by  brain  irritation;  by  an  almost  constant  triad  of  symptoms, 
headache,  rigid  neck  and  hyper CBsthesia;  by  vomiting,  mental,  motor 
and  sensory  symptoms,  and  in  most  cases  death  results  from  paralysis, 
convulsions  or  coma. 

1.  General  Nervous  Symptoms. — (a)  Headache  is  almost  invariable, 
though  it  is  sometimes  absent  in  very  young  children,  in  alcoholics 
and  in  sepsis.  It  develops  early,  is  most  severe  and  is  at  first  localized 
(frontal  or  occipital),  but  soon  becomes  generalized.  Though  it  varies 
somewhat  in  intensity,  it  is  constant,  with  exacerbations,  and  provokes 
the  short,  plaintive,  clear  meningeal  cry,  cri  hydrencephalique  (Coindet, 
1817),  which  is  largely  heard  in  children.  The  headache  is  throbbing 
or  lancinating,  even  under  narcotics,  and  persists  after  delirium  and 
even  coma  have  set  in.  Its  cause  may  be  compression  of  the  dura, 
changes  in  the  brain,  inflammation  of  the  nerve  trunks,  or  ventricular 
exudation.  (6)  Hypercesthesia  or  hyperalgesia  affects  the  special 
senses  (causing  intolerance  of  light  and  noise),  or  general  sensation 
(affecting  the  arms  most,  the  trunk  less  and  the  legs  least).  It  is  rarely 
absent,  is  always  suggestive,  and  is  probably  due  to  root  neuritis,  (c) 
Rigidity  of  the  neck  aiid  spine  is  caused  by  inflammation  of  the  nerve- 
roots,  possibly  from  lesions  in  the  pons  or  medulla.  The  head  is 
retracted,   sometimes  so   severely  that  the  occiput  lies   between  the 


EPIDEMIC  CEREBROSPIXAL  MEXIXGITIS  1047 

shoulders,  producing  decubitus.  The  entire  body  may  be  hfted  by 
the  head.  Swallowing  is  rendered  difficult.  Marked  opisthotonos  may 
be  present.  Flexion  and  extension  of  the  head  are  impossible,  although 
lateral  movement  is  sometimes  possible.  Retraction,  although  absent 
in  exceptional  instances,  is  one  of  the  cardinal  triad.  Closely  associated 
and  caused  in  the  same  way,  is  severe  spinal  pain  with  tenderness, 
chiefly  in  the  neck  and  loins,  which  is  felt  rather  to  the  side  of  the 
spine  than  directly  over  it.  It  may  radiate  to  the  trunk  and  in  33  per 
cent,  of  cases  to  the  extremities,  and  may  affect  every  muscle,  (d) 
Contractures  of  the  limbs  are  caused  by  root  inflammation,  increased 
pressure,  or  lesions  in  the  pyramidal  tracts.  Kernig's  sign  (see  Diag- 
nosis) comes  under  this  head,  (e)  Mental  symptoms  often  occur  early, 
especially  in  children,  neurotics  and  alcoholics;  they  include  unrest, 
insomnia,  delirium  (sometimes  with  periods  of  normal  intelligence), 
and  mania  which  is  followed  by  stupor  and  incomplete  coma.  (/) 
Vomiting,  in  the  initial  stage,  is  due  to  vagus  irritation;  later  it  results 
from  ventricular  hydrops  or  increased  cerebrospinal  pressure.  It  is 
of  the  cerebral  type,  i.  e.,  it  occurs  without  nausea,  without  relation  to 
eating,  is  often  projectile  and  is  not  amenable  to  gastric  therapy. 
Vomiting  is  more  typical  and  common  in  children.  The  tongue  may 
later  become  coated  and  foul,  (g)  The  pulse  at  first  is  increased,  and 
is  sometimes  disproportionately  rapid,  considering  the  fever.  Some- 
times it  slows  later  because  of  brain  pressure  but  ultimately  it  is  fast 
again.  It  may  be  irregular  in  rhythm  and  oscillating  in  rate.  Friis 
noted  variation  from  84  to  144  within  a  minute,  (h)  Respiration  is 
irregular  in  20  per  cent,  of  cases;  Cheyne-Stokes  breathing  is  not 
common,  save  toward  the  end.  Deep  breathing  with  apnoeic  pauses 
(Biot's  breathing)  is  quite  common,  though  less  so  than  in  the  tuber- 
culous type,  {i)  Convulsions  are  most  common  in  the  young;  they 
may  occur  at  the  onset  or  later.  They  are  important,  but  ambiguous 
from  their  frequent  occurrence  in  other  diseases  of  childhood. 

2,  Focal  Nervous  Symptoms. — These  are  partly  irritative  and  partly 
paralytic,  (a)  Symptoms  relating  to  the  cranial  nerves  are  as  follows: 
These  nerves  are  most  involved  in  basal  localization,  while  the  limbs 
are  most  affected  in  that  of  the  convexity.  The  optic  nerve  is  fre- 
quently inflamed,  if  the  disease  lasts  over  four  days.  The  disk  is 
swollen  and  its  margin  is  "washed"  (see  Plate  V,  Fig.  4).  Neuritis 
is  less  frequent  than  in  tumor;  hemorrhage  and  choking  are  uncom- 
mon. The  ocular  muscles  may  be  involved.  The  pupils  at  first  are 
usually  small,  often  unequal,  and  sometimes  variable  like  the  pulse 
Later  they  widen  spontaneously  or  on  movement  of  the  head,  and 
irritation  of  the  skin,  but  do  not  react  to  light.  These  as  well  as 
the  following  changes,  result  from  cortical  or  basal  disease.  Ptosis, 
diplopia,  nystagmus,  and  strabismus  (spasmodic  or  paralytic)  are 
frequent  but  often  vary  from  time  to  time.  Complete  paralysis  of 
the  third  nerve  is  not  common.  Involvement  of  the  fifth  nerve  is 
unusual,  although  trismus,  grinding  of  the  teeth  and  trigeminal  neural- 
gia have  been  noted.     Involvement  of  the  facial  nerve  is  frequent. 


1048  DISEASES  OF  THE  XERVOUS  SYSTEM 

ranking  next  to  that  of  the  third  nerve.  If  diseased  at  the  base,  its 
paralysis  is  usually  total;  if  at  the  cortex  it  is  of  the  cerebral  type,  and 
its  upper  third  escapes.  The  paralysis  varies  from  time  to  time  (v.  s.). 
The  facial  expression  shows  suffering,  the  brows  are  shghtly  elevated 
and  the  forehead  is  corrugated.  The  risus  sardonicus  is  not  frequent. 
The  auditory  nerve  is  often  bathed  in  pus,  and  hemorrhagic  inflam- 
mation in  the  labyrinth  results  from  extension.  The  tongue  on 
protrusion  may  deviate  to  one  side;  dysarthria  or  dysphagia  are  some- 
times seen.  ih)  Symptoms  relating  to  the  limbs  occur  as  follows: 
Paralysis  of  the  limbs  is  not  very  frequent,  although  Belor  noted  it 
particularly  in  one  epidemic.  Hemiplegia  is  rarely  complete,  occurs 
Tvdth  or  without  participation  of  the  tongue  and  face,  and  is  not  always 
caused  by  involvement  of  the  cortex  or  changes  in  the  pyramidal 
tracts,  but  sometimes  is  apparently  due  to  reflex  inhibition.  It  is 
frequently  accompanied  by  rigidity  of  the  limbs  and  aphasia.  It  is 
most  frequent  in  children,  occurs  early  or  late  and  may  be  temporary 
or  permanent.  Monoplegia  is  not  common  and  most  often  concerns 
the  face  or  arm.  Choreiform  or  athetotic  movements,  twitchings  and 
tremor  are  occasional.  Convulsions  are  frequently  Jacksoniaii  in  t^'pe. 
Sometimes  the  paralyses  are  spinal,  as  shoulder  atrophy  or  paraplegia, 
which  also  involves  the  functions  of  the  bladder  and  rectum.  The 
tendon  reflexes,  as  the  patellars,  may  be  increased  at  first  and  are  often 
decreased  or  abolished  late  in  the  disease.  The  reflexes  of  the  skin 
are  variable. 

3.  General  and  Somatic  Symptoms. — ia)  There  is  almost  always 
fever,  though  afebrile  cases  exceptionally  occur.  The  temperature 
rises  suddenly,  is  sometimes  very  high  and  although  it  follows  no 
definite  cycle,  lysis  is  usual  in  cases  which  recover.  An  inverse  form 
is  sometimes  seen.  A  temperature  of  107°  or  higher  may  be  registered 
before  death,  (b)  The  blood  shows  leukocytosis,  which  is  early,  con- 
stant and  of  no  prognostic  import;  the  white  cells  may  number 
25,000  to  40,000;  the  meningococcus  has  been  found  (v.  s.).  (c)  The 
abdomen  is  often  retracted,  and  is  scaphoid,  especially  in  the  iliac 
regions,  although  less  so  than  in  the  tuberculous  type.  It  may  be 
due  to  retraction  of  the  abdominal  walls,  but  Traube  gave  the  best 
explanation,  namely  that  the  intestines  are  tonically  retracted  from 
irritation  of  the  vagus,  which  also  causes  the  constipation,  (d)  The 
spleen  is  often  palpable,  (e)  The  urine  is  febrile,  albuminous  (33  per 
cent.)  and  may  show  peptonuria,  hsematuria  (in  malignant  cases),  and 
rarely  glycosuria  or  polyuria  (Traube).  (/)  The  nutrition  suffers, 
which  Leube  explains  as  due  to  cerebral  influences,  {g)  As  to  the 
skin :  the  tache  cerebrale  described  by  Trousseau  has  no  differen- 
tiating; value,  for  it  occurs  in  manv  febrile  and  other  conditions. 
Eruptions  are  more  common  in  the  epidemic  than  the  sporadic  cases, 
and  vary  with  the  individual  epidemic.  Herpes  (40  to  75  or  even  90 
per  cent.)  varies  with  the  epidemic;  it  is  most  frequent  on  the  face, 
but  may  develop  anywhere;  it  spreads  more  rapidly  than  in  any 
other  disease  (v.  Ziemssen);    in  one  case  the  author  saw   it   extend 


TUBERCULOUS  MEXIXGITIS  1049 

from  the  lip  to  the  ear,  neck,  chest  and  shoulder.  Purpura,  which 
gave  the  name  ''spotted  fever"  to  the  disease,  occurs  in  the  more  severe 
types.  Other  eruptions,  as  erythema,  roseola,  urticaria  or  gangrene 
are  uncommon.     (See  General  Diagnosis  for  lumbar  puncture.) 

Clinical  Forms. — Hirsch  distinguishes  (a)  the  acute  or  subacute  type, 
the  ordinary  form  in  which  the  acute  symptoms  of  onset  are  followed 
by  the  general  nervous  symptoms  enumerated,  then  by  focal  nervous 
symptoms,  somatic  symptoms,  death  in  coma,  or  slow  recovery;  (b) 
the  foudroyant  form,  with  violent  onset,  rapid  course  and  death  in  a 
few  hours  (three  to  thirty-six)  vnth  apoplectic  symptoms,  or  purpura, 
high  fever,  irregular  heart  and  early  coma;  (c)  the  abortive  form,  with 
low  fever  and  symptoms  so  mild  that  the  disease  is  recognized  only 
by  its  association  with  an  epidemic;  the  ambulatory  type  is  included 
here ;  and  (d)  Heubner's  chronic  form,  which  lasts  several  (two  to  six) 
months,  with  marasmus,  and  recurrent  fever. 

Complications. — These  vary  with  the  epidemic.  Pneumonia,  bron- 
chitis, tonsillitis,  pleurisy,  parotitis,  endo-  and  pericarditis,  arthritis 
(J.  Jackson,  Sr.)  and  nephritis  are  the  most  common.  Pneumonia 
may  be  due  to  the  pneumococcus,  but  the  meningococcus  has  been 
found  in  small  isolated  foci  in  the  lung  (Councilman).  The  arthritis 
is  either  poly-  or  mono-articular,  simple  or  suppurative,  and  may  heal 
even  when  suppurative;  it  occurred  in  2-5  per  cent,  of  Flexner's  and 
Barker's  series. 

Sequelae. — ^Mental  alteration,  paralysis,  contractures,  obstinate 
headache,  optic  atrophy,  deafness  or  ^Meniere's  syndrome  may  remain 
after  recovery.  Chronic  hydrocephalus,  paroxysmal  headache,  vomit- 
ing, pains,  and  convulsions  (v.  Ziemssen)  may  result.  In  an  epidemic 
in  Heidelberg,  Moos  found  as  sequels  deaf-mutism  in  60  per  cent., 
absolute  deafness  in  .31  per  cent,  and  an  atactic  gait  in  .50  per  cent, 
of  the  cases. 

Prognosis. — The  average  mortality  is  .30  to  40  percent.  (37  per  cent., 
Hirsch  in  15,632  cases),  but  varies  with  the  epidemic,  and  may  reach 
75  per  cent.  Fifty  per  cent,  of  the  deaths  occur  in  the  first  five  days. 
Recovery  is  exceptional,  although  possible,  after  deep  coma,  repeated 
convulsions,  high  fever  or  paralysis  of  the  vagus.  Obstinate  vomiting, 
disturbed  respiration,  sudden  drop  of  temperature  and  inanition  are 
ominous  signs. 

III.  Tuberculous  Meningitis. 

Etiology. — Most  cases  occur  between  the  second  and  tenth  year, 
some  cases  develop  in  adolescence,  and  few  late  in  life;  at  least  three 
times  as  many  cases  occur  in  children  as  in  adults.  Tuberculosis  in 
children  is  usually  generalized,  and  miliary  tuberculosis  is  in  SO  per 
cent,  associated  with  meningeal  disease.  Tuberculous  meningitis  is 
almost  always  secondary,  and  follows  pulmonary  or  glandular  tuber- 
culosis, less  frequently  joint  disease,  genito-urinary,  brain  tubercle  and 
other  localizations.     Extension  bv  contiguitv  from  the  nose,  eve,  or 


1050  DISEASES  OF  THE  XERVOUS  SYSTEM 

spinal  cord  is  possible.  Striimpell  and  Leube  believe  that  infection 
may  creep  from  the  pleura,  along  the  nerve  sheaths  to  the  spinal 
cord,  whence  it  reaches  the  brain.  Heredity  is  clearly  a  factor  in  some 
cases.  Measles,  whooping-cough,  typhoid  or  pneumonia  may  be  the 
proximal  cause,  for  the  virus  of  the  disease  seemingly  arouses  latent 
glandular  or  other  tuberculous  foci.  Trauma  is  not  a  frequent  cause 
but  is  of  distinct  clinical  and  medico-legal  importance.  In  the  case 
of  a  baggage  man  thrown  upon  his  occiput  by  the  sudden  stopping  of 
the  train,  an  acute  tuberculous  meningitis  developed,  which  resulted 
in  death  in  three  weeks.  The  autopsy  disclosed  an  apical  focus,  from 
which  the  bacilli  infected  the  injured  brain.  In  a  case  seen  with  Dr. 
J.  H.  Hess,  the  affection  immediately  followed  an  anaesthetic  (given 
to  examine  a  tender  spine),  and  was  fatal  within  a  week. 

Pathology. — The  diagnosis  is  made  macroscopically  in  the  majority 
of  cases,  although  in  some  instances  the  changes  are  slight.  The 
exudate  is  gray,  yellow  or  green,  gelatinous,  sticky,  purulent  or  serous, 
and  covers  the  base  (basilar  meningitis)  from  the  chiasm  to  the  medulla. 
Tiny  tubercles  are  found  on  the  basal  nerves  and  deep  in  the  fissure 
along  the  Sylvian  artery  where  "they  look  like  lice  eggs  on  a  hair." 
Careful  search  is  sometimes  necessary  for  their  detection.  They  are 
most  clearly  seen  in  the  translucent  arachnoid,  and  on  superficial 
examination  look  like  minute  air  bubbles.  They  are  seen  quite  fre- 
quently over  the  convexity  and  may  cause  adhesions  between  the  two 
hemispheres.  The  ventricular  fluid  is  increased  in  80  per  cent,  of 
cases,  and  usually  measures  a  few  ounces;  tubercles  and  inflammation 
of  the  ependyma  are  not  uncommon;  the  external  and  internal  com- 
munications of  the  ventricles  may  be  obliterated.  The  substance  of 
the  brain  shows  the  same  changes  as  in  other  forms,  as  ischsemic  or 
encephalitic  softening  or  sometimes  large  tubercles.  The  cerebrospinal 
fluid  is  usually  increased  and  is  clear  or  cloudy.  In  the  cord  the 
exudate  nlay  be  a  quarter  of  an  inch  in  thickness,  and  is  largely  dis- 
posed over  the  posterior  part  of  cord  because  of  the  patient's  dorsal 
decubitus.  The  cord  membranes  are  almost  regularly  affected,  and 
sometimes  appear  granular,  as  "though  sown  with  fine  sand."  Tuber- 
cles in  the  substance  of  the  cord  are  not  considered  common,  but 
Wartmann  found  them  in  87  per  cent,  of  his  cases.  The  cranial  and 
spinal  nerve  sheaths  are  pyriform  and  bulging.  Microscopicalhj, 
exudation  is  found  as  in  the  other  forms  above  described.  The  nodes 
are  proven  to  be  tubercles;  bacilli  are  found  in  them  and  in  the 
cerebrospinal  fluid.  The  microscope  differentiates  between  tuber- 
culous inflammation  and  tuberculosis  of  the  meninges  (without  inflam- 
mation), and  again  in  some  cases  proves  the  existence  of  tuberculous 
meningitis  not  visible  to  the  naked  eye.  Neuritis  of  the  cranial  and 
spinal  nerves  is  constant.  The  optic,  oculomotor  and  facial  nerves  are 
the  most  often  affected.  In  the  cortex,  base  and  ependyma  of  the  brain, 
the  usual  histopathology  of  tubercle  is  seen,  with  tuberculous  endar- 
teritis from  mural  inflammation  (Hektoen),  and  periarteritis,  small 
encephalitic  and  myelitic  foci  in  practically  every  case,  vessel  throm- 


TUBERCULOUS   MEXLXGITIS  1051 

bosis,  swelling  of  the  neuroglia  and  degeneration  of  the  nerve  cells 
and  of  the  lateral  columns,  especially  of  the  axis  cylinders. 

Sjnnptoms. — '^Prodromes  are  more  prominent  in  children  than  in 
adults.  Fever,  emaciation  and  anaemia  are  due  to  preexisting  lung  or 
glandular  tuberculosis.  Irritability,  change  in  disposition,  tendency  to 
cry,  inability  in  children  to  play  or  in  adults  to  work,  unrest,  insomnia, 
headache,  nausea  and  constipation  may  develop  in  a  week  or  two  or 
in  one  to  three  months.  Trauma,  measles,  and  pertussis  may  be  the 
apparent  cause.  The  outbreak  develops  with  much  the  same  symp- 
toms as  those  described  under  the  epidemic  form,  but  they  appear 
more  gradually,  so  that  the  classical  description  comprises  three  stages: 
(a)  The  stage  of  irritation,  with  headache,  vomiting,  remittent  fever 
reaching  102°  in  the  evening,  the  cri  hydrencephalique  of  Coindet, 
night  terrors,  pain  and  rigidity  in  the  neck  and  spine,  small  irregular 
pupils,  delirium,  grinding  of  the  teeth,  hypersesthesia,  rigidity  of  the 
limbs  and  Kernig's  sign;  (b)  the  stage  of  brain  pressure,  with  paralytic 
and  irritative  conditions  in  the  eye  muscles,  as  ptosis  or  strabismus; 
with  paralysis  of  other  cranial  nerves  or  of  the  extremities,  as  mono- 
plegia, especially  of  the  face,  or  hemiplegia  from  involvement  of  the 
cortex,  and  very  frequently  aphasia  and  dulness;  with  general  or 
Jacksonian  convulsions,  slow,  irregular  and  quite  variable  pulse; 
retracted  abdomen,  constipation,  continued  vomiting;  sighing  respi- 
ration; and  very  frequently  with  optic  neuritis;  and  (c)  the  stage 
of  paralysis,  in  which  the  vomiting  and  often  the  headache  cease, 
the  sensorium  is  dulled,  absolute  coma  develops,  the  pulse  becomes 
rapid  and  vacillates  in  rate  and  rhythm.  Biot's  or  Cheyne-Stokes 
breathing  appears,  emaciation  is  extreme,  the  pupils  are  wide  and 
immobile,  the  eyeballs  roll  upward,  and  a  typhoid  state  with  dry 
tongue  or  abdoipinal  distention  exists.  Temporary  remissions  of  days, 
weeks,  or  even  a  year  are  occasional  in  which  the  pulse  remains 
irregular,  but  the  patient  lapses  again  into  coma,  the  fever  rises  very 
high  (107°)  or  falls  low  (even  to  93°),  and  death  occurs  in  several 
weeks  from  cardiac  or  respiratory  failure,  dysphagia,  inanition  or 
hypostasis.  This  division  into  stages  is  not  wholly  satisfactory, 
because  the  symptoms  of  one  stage  may  merge  into  those  of  another 
but  the  progression  of  symptoms  is  somewhat  as  described. 

Tubercles  in  the  choroid  were  first  found  anatomically  by  Autenrieth 
(1808),  and  Gueneau  de  Mussy  (1837),  and  chnically  by  Jager, 
Manz,  and  Busch;  they  are  rare  clinically,  being  found  by  Garlick 
in  4  per  cent,  and  Kramer  in  13.6  per  cent,  of  cases.  Heinzell  did 
not  find  them  in  41  cases.  At  postmortem  examination  Litten  found 
them  in  about  75  per  cent,  (See  Plate  VI,)  Leukocytosis  is  usually 
absent,  unless  it  occurs  during  the  agony  or  from  mixed  infection. 
The  spleen  is  enlarged  in  33  per  cent,  of  cases. 

Many  variations  exist.  The  process  may  be  w^holly  latent,  being 
masked  by  miliary  tuberculosis  (or  meningeal  symptoms  may  dominate 
when  the  greatest  pathological  changes  are  in  the  lungs) .  Coma  may 
be  sudden  and  the  disease  may  run  a  short  course,  resembling  apoplexy. 


1052  DISEASES  OF  THE  NERVOUS  SYSTEM 

especially  in  adults;  in  these  cases  the  hemiplegia  probably  results 
from  changes  in  the  arteries.  It  may  appear  to  be  a  psychosis.  In 
adults  the  course  is  more  rapid,  the  headache  and  delirium  more 
marked  and  the  convexity  more  frequently  involved  than  in  children. 
Death  is  usual,  but  rare  recoveries  are  recorded  by  Waterhouse,  Ord, 
Leube,  Fiirbringer,  Dujardin-Beaumetz,  Freyhan,  Rilliet  and  Barthez, 
Jansen,  Carrington,  Hensch,  Politzer,  and  lately  by  Gross,  even  after 
bacilli  were  found  by  lumbar  puncture  or  after  choroidal  tubercles 
were  demonstrated. 

IV.  Serous  Meningitis. 

This  is  more  frequently  seen  at  the  bedside  than  at  the  autopsy. 
It  is  often  tuberculous.  The  inflammation  is  slight,  the  membranes 
are  glistening,  clear  or  fiocculent  fluid  is  seen  in  the  arachnoid  meshes 
and  ventricles,  which  may  be  the  sole  seat  of  the  disease,  and  the  pia 
especially  shows  exudation.  It  is  often  mistaken  for  oedema  of  the 
brain.  The  microscope  may  be  necessary  to  demonstrate  inflamma- 
tion, which  frequently  is  circumscribed.  The  process  sometimes  occurs 
with  encephalitis,  poliomyelitis,  Landry's  ascending  paralysis,  typhoid 
or  pneumonia. 

Symptoms. — In  the  serous  (non-suppurative  and  non-tuberculous) 
form,  no  definite  symptoms  can  be  outlined.  The  disease  certainly 
exists,  although  it  is  relatively  infrequent,  but  with  equal  certainty 
it  is  too  frequently  diagnosticated.  Headache  is  common;  vomiting, 
rigidity,  fever,  slow  and  labile  pulse,  optic  neuritis,  hyper sesthesia, 
spasms,  and  paralysis  of  the  cerebral  nerves  are  much  less  frequent 
than  in  the  other  forms  of  meningitis  though  they  are  occasionally 
observed.  The  symptoms  resemble  those  of  brain  tumor.  Lumbar 
puncture  in  some  instances  has  given  absolute  relief;  the  prognosis 
is  most  favorable  in  this  type. 

General  Diagnosis  of  Meningitis. — The  first  step  is  the  diagnosis  of 
meningitis,  which  in  general  has  an  acute  or  subacute  onset,  with 
signs  at  first  of  general,  then  local  inflammation  of  the  surface  of  the 
brain.  The  second  step  is  determination  of  the  variety  (suppurative, 
epidemic,  tuberculous,  primary  or  secondary),  or  the  cause,  and  the 
locality  (convexity  or  base). 

Cardinal  Symptoms. — The  early  triad  oi  (a)  headache,  (6)  retraction 
and  rigidity  of  neck  and  (c)  hypersesthesia,  is  important  and  develops 
early,  (d)  Other  general  symptoms,  as  causeless  vomiting,  abdominal 
retraction,  pulse  and  respiratory  changes,  fever  or  convulsions,  are 
important  in  their  grouping,  (e)  Lumbar  puncture  (Quincke,  1890) 
is  of  diagnostic  value.  Its  technique  is  as  follows:  The  patient  lies 
on  the  side  with  the  knees  drawn  up  and  the  body  bent  as  far  forward 
as  spinal  rigidity  allows;  with  or  without  chloroform,  an  aspirating 
needle  or  small  trocar  is  introduced  in  the  median  line  in  children, 
and  a  quarter  to  half  an  inch  to  one  side  in  adults,  between  the  third 
and  fourth  lumbar  vertebrte  (Quincke)  or  between  the  last  lumbar 


DIAGXOSIS   OF  MEXIXGITIS 


1053 


Fig.  62. 


vertebra  and  sacrum  (Chipault),  and  is  pushed  forward  toward  the 
median  line  and  a  little  upward,  one  and  a  half  inches  (2^-  cm.)  deep 
in  children  and  1.5  to  2.5  inches  (4  to  6  cm.)  in  adults,  until  it  passes 
into  the  canal.  Fiirbringer  prefers  to  have  the  patient  in  the  sitting- 
posture.  Not  more  than  4  to  5  drams  (15  to  20  cm.)  should  be  with- 
drawn, lest  fatal  results  ensue.  Negative  taps  result  from  needle 
occlusion  by  clots.  Results:  (i)  normally,  the  pressure  with  the  patient 
in  the  lateral  position,  equals  100  to  150  mm.  of  water  and  the  escap- 
ing fluid  only  trickles  out.  In  meningitis,  the  pressure  is  greatly  in- 
creased (200  to  700  mm.)  and  the  fluid  often  spurts  out.  (ii)  The 
normal  fluid  is  clear,  has  a  specific  gravity  of  1,007-09  and  contains 
little  albumin  (^  to  1  pro  mille).  Though  the  fluid  may  be  clear  in  all 
forms  of  meningitis,  it  is  usually  clear  in  the  serous  form,  but  cloudy, 
■flocculent  or  sometimes  bloody  in  other  forms;  in  the  tuberculous 
variety  it  is  usually  clear  or  slightly  yellow  with  a  whitish  clot  forming 
on  standing;  in  the  epidemic  form,  it  may  be  turbid  or  clear,  with  a 
yellowish  clot  (Netter) ;  in  the  purulent  type  it  is  opaque,  and  in  rare 
cases  it  is  pure  pus.  The  specific  gravity  is  about  1,010  in  the  serous, 
1,011  in  tuberculous,  and  1,015  in  purulent  or  epidemic  variety,  al- 
though these  figures  are  not  absolute.  The  percentage  of  albumin  is  small 
in  the  serous,  2  pro  mille  in  tuberculous,  and  3  or  even  8  or  9  pro  mille  in 
the  suppurative  forms,  (iii)  Bacteriologically  (see  Bacteriology)  in 
the  purulent  type  the  strep- 
tococcus, staphylococcus, 
pneumococcus,  typhoid  and 
colon  bacilli  are  found;  in 
the  epidemic  variety,  the  men- 
ingococcus, which  was  posi- 
tive in  100  per  cent,  in  the 
last  New  York  epidemic,  is 
present;  in  the  tuberculous 
type,  tubercle  bacilli  exist  in 
66  percent,  of  cases  as  an  aver- 
age (73  per  cent.  Bernheim 
and  Mosler,  81  per  cent.  Fiir- 
bringer, and  100  per  cent. 
Holtzmann);  even  in  this 
form,  mixed  infection  with 
the  pus  organisms  and  men- 
ingococcus may  be  seen;  the 
tubercle  bacilli  are  often  found 
on  cover  slip  preparations; 
cultures  grow  too  slowly  for 
clinical  diagnostic  value,  (iv) 
The  cellular  morphology  icyto- 
diagnosis)  is   a  valuable  aid. 

In  the  purulent  and  epidemic  form  the  leukocytes  are  largely  polymor- 
phonuclear;    in  the  tuberculous  form  the  lymphocytes  predominate, 


Kernig's  sign,  showing  retraction  of  head  and  back  and 
prominence  of  knees  in  the  erect  posture,  i.  e.,  the  im- 
possibility of  extension  of  knees.     (Dieulafoy.) 


1054 


DISEASES  OF  THE  NERVOUS  SYSTEM 


according  to  Widal,  Sicard,  and  Rivault  (see  Cytodiagnosis, 
Pleurisy);  some  dissension  exists  on  this  point,  as  well  as  on  the 
statement  that  iodine  given  by  mouth  is  found  in  the  tuberculous 
and  not  in  the  purulent  (epidemic)  exudate. 

(/)  Kernig  (St.  Petersburg,  1882),  described  a  sign  known  as  Ker- 
nig's  sign.  When  the  patient  sits,  it  is  impossible  (in  75  to  95  per  cent, 
of  all  meningitis  cases)  to  extend  the  knees,  as  shown  in  Fig.  62. 
The  legs  and  thighs  are  flexed  (flexor  contracture)  and  the  knees 
cannot  be  pressed  down,  i.  e.,  cannot  be  extended  when  the  patient  is 
sitting  but  this  is  possible  when  he  is  lying.  It  indicates  that  the 
spinal  meninges  are  involved.  It  lasts  well  into  convalescence,  whence 
as  Netter  states,  "  a  retrospective  diagnosis  may  be  made. "  It  occurs  at 
times  in  subdural  hemorrhage,  sinus  thrombosis,  encephalitis,  and 
cerebellar  tumor.  It  is  sometimes  unilateral.  It  may  possibly  indicate 
degeneration  of  the  pyramidal  tracts. 

Xg)  Local  signs  usually  follow  the  general  signs,  ajid  are  more  impor- 
tant. They  include  the  pupillary  changes,  strabismus,  facial  paralysis, 
and  hemiplegia.  Often  their  late  development  lessens  their  value  for 
early  diagnosis. 


Epidemic  Form. 


Tuberculous. 


Suppurative. 


Onset : 


Fever: 

Eruptions : 

Leukocytosis: 
Rigidity  of  neck: 

Other  symptoms: 
Course : 

Lumbar  puncture: 


Sudden,  with  few  pro- 
dromes. 


Fairly  high. 

Herpes  and  purpura 
very  common. 

Regular  and  marked. 

Most  frequent. 


Peptonuria. 

Rapid — more  recov- 
eries. 

Meningococcus; 
leukocytes  poly- 
nuclear. 


Longer    prodromes; 
family  history; 
other  evidences  of 
tuberculosis. 


Less;  inversed  type 
frequently;  some- 
times absent. 

Rare. 


Exceptional. 

Spinal     symptoms 
somewhat  less  fre- 
quent. 

Choroidal    tubercles. 

Subacute,  slower, 
fatal. 

Tubercle  bacilli; 
mononuclear. 


Sometimes     primary 
but  oftenest 
secondary    to     ear 
disease,  acute  in- 
fections, trauma, 
pneumonia. 

Especially  high,  with 
chills,   perhaps 
pysemic  type. 

Rare— polymorphous 
septic  rashes. 

Frequent. 

Sometimes  absent 
(pneumococcic 
form). 

Peptonuria. 

More     acute,     very 
rarely  recover. 

Pyogenic  cocci, 
pneumococcus; 
polynuclear. 


Diagnosis  of  the  Variety. — This  is  more  difficult.  Cases  of  tuber- 
culous meningitis  sometimes  increase  when  the  epidemic  form  prevails, 
and  the  meningococcus  may  be  found  in  these  cases  (Heubner,  Len- 


DIAGXOSIS  OF  MEXIXGITIS  1055 

harz,  Netter).  Sporadic  cases,  due  to  the  meningococcus,  may  be 
indistinguishable  from  primary  pneumococcic  meningitis,  save  by 
lumbar  puncture. 

Diagnosis  of  Location. — (a)  Localization  on  the  convexity  results 
from  trauma,  or  metastatic  infection;  it  is  characterized  by  more  fre- 
c{uent  delirium,  Jacksonian  convulsions,  mono-  or  hemiplegia,  less 
cranial  nerve  paralysis  and  less  optic  neuritis.  (6)  Localization  at  the 
base  results  from  the  tuberculous  form,  chronic  nephritis,  cachectic 
states,  and  the  non-tuberculous  forms  which  occur  in  childhood ;  it  is 
characterized  by  more  frequent  cranial  neuritis,  and  optic  neuritis. 
(c)  The  ventricular  form  rarely  involves  the  cranial  nerves. 

Differentiation. — 1.  From  nervous  toxgemic  symptoms,  as  those  of 
typhoid  {q.  v.).  Jenner  pointed  out  that  in  acute  infections  the  head- 
ache ceases  when  delirium  begins.  This  is  also  true  of  the  pseudo- 
meningeal  symptoms  of  pneumonia,  typhoid,  sepsis,  etc.  Some  cases 
with  focal  symptoms  are  most  confusing  (see  Uremia),  but  the  albu- 
minuric retinitis,  the  cardiovascular  changes,  and  albuminuria,  casts, 
and  deficient  elimination  are  usually  sufficient  for  distinction.  Acute 
inflammation  of  the  labyrinth  may  resemble  meningitis,  for  it  sometimes 
produces  headache,  vomiting,  fever,  convulsions,  stiff  neck,  and  even 
optic  neuritis.  If  labyrinthitis  involves  the  meninges,  the  facial  nerve 
is  likely  to  be  affected.  Such  conditions  resembling  meningitis,  Dupre 
(1894)  called  meningismus,  and  Bouchut  (1895)  pseudomeningitis. 

2.  From  Brain  Disease. — Syphilitic  meningitis  {q.  v.),  brain  abscess 
(9-.  v.),  cerebral  hemorrhage  (q.v.),  and  encephalitis  (q.v.),  have  been 
considered.  Great  difficulty  is  sometimes  experienced  in  differentiat- 
ing between  slow  tuberculous  meningitis  and  tumors  of  the  brain,  as 
tubercle  of  the  pons,  or  rapidly  growing  glioma.  A  moderately  severe 
optic  neuritis  may  suggest  tumor  or  meningitis;  intense  neuritis,  with 
choking,  swelling  and  hemorrhage  is  indicative  of  tumor.  Paralysis 
is  more  sudden  in  meningitis  than  in  tumor. 

3.  From  Hydrencephaloid  (see  Brain  Anemia). — 4.  Hysteria  is 
marked  by  its  usual  stigmata,  viz.,  psychical  alteration,  limitation  of  the 
field  of  vision,  ansesthesia  and  other  stigmata.  Hysterical  strabismus  is 
always  spastic  and  convergent,  and  is  often  associated  with  small 
pupils;  meningitic  strabismus  is  often  divergent  (always  a  sign  of 
organic  disease),  and  the  pupils  are  unequal. 

Treatment. — Prophylaxis  and  treatment  of  the  causal  disease  are 
indicated.  The  patient  should  be  kept  quiet  in  a  dark  room,  the 
head  elevated  without  flexion,  an  ice-bag  applied  to  the  head  and 
spine,  or  an  ice-pillow  should  be  used.  Nutrition  should  be  maintained 
by  feeding  with  the  nasal  tube  or  by  nutrient  enemata,  if  retraction  of 
the  neck  causes  dysphagia.  The  bowels  should  be  mildly  relaxed,  and 
the  bladder  should  be  watched.  Vomiting  is  treated  as  in  acute  gastritis 
(q.v.),  but  therapy  is  usually  unavailing,  for  the  cause  is  cerebral  irrita- 
tion ;  of  drugs  the  bromides  are  customarily  most  servicable.  Feeding 
by  the  rectum,  sucking  of  ice,  and  the  remedies  indicated  for  the  head- 
ache give  the  greatest  relief.     Counterirritation  bv  blisters  and  the 


1056  DISEASES  OF  THE  NERVOUS  SYSTEM 

use  of  the  cautery  are  dangerous  because  the  skin  sloughs  readily. 
Headache,  restlessness  and  convulsions  necessitate  the  use  of  opiates, 
though  theoretically  opium  congests  the  brain  and  its  membranes. 
The  hypodermic  use  of  morphine,  or  the  use  of  the  deodorized  tincture 
of  opium  by  mouth,  is  necessary,  and  free  from  harm ;  no  other  analgesic 
is  equally  potent.  Ergot  should  relieve  the  congestion,  but  it  never 
replaces  the  opiates.  Atropine  reinforces  the  analgesic  action  of  opium. 
Chloral  is  used  chiefly  for  the  convulsions  and  for  unrest.  Warm  baths 
were  first  recommended  by  Aufrecht  and  Waroschilsky,  and  in  the  epi- 
demic type  are  considered  almost  specific  by  Netter.  Stimulation  is 
indicated  when  the  heart  weakens,  and  coma  is  imminent,  until  which 
time  alcohol  should  be  withheld.  Resorhents ,  as  iodides,  are  of  little 
value,  (although  Niemeyer  recommended  them).  Mercurial  inunctions 
are  regarded  as  inefficacious,  although  milder  types  of  meningitis,  as  the 
serous  form,  are  apparently  benefited. 

Lumbar  'puncture  can  permanently  relieve  only  the  simple  or  serous 
forms.  Its  repeated  use  may  induce  punctate  hemorrhages,  although 
sudden  death  is  much  less  likely  to  occur  from  its  use  than  in  urssmia 
or  brain  tumor;  isolated  cases  of  recovery  in  the  pneumococcic  and 
tuberculous  forms  have  followed  repeated  puncture.  Surgery  is  indi- 
cated in  circumscribed  rather  than  in  diffuse  meningitis.  Macewen, 
Jaboulay,  Greave,  Gluck,  Joel,  and  Barker,  have  operated  with,  as  a 
rule,  no  remarkable  results.  Macewen  saved  all  of  six  cases  of  sup- 
purative cerebral  meningitis,  and  one  of  six  cerebrospinal  cases. 
Ventricular  puncture,  first  recommended  by  Wernicke,  in  1883, 
lapsed  into  disuse  and  was  needlessly  revived  by  Horsley,  Paget, 
Rickett,  von  Beck,  and  Benninghous.  Diphtheria  antitoxin  has  been 
used  (Wolff),  but  its  exact  benefit  is  still  uncertain. 


CHRONIC  LEPTOMENINGITIS. 

Etiology. — (a)  It  may  result  from  acute  leptomeningitis.  (6)  The 
leptomeninges  thicken  after  trauma,  in  atrophic  and  sclerosing  brain 
disease,  as  paretic  dementia,  hydrocephalus,  and  softening,  and  in 
alcoholism,  gout,  nephritis,  or  plumbism.  (c)  Chronic  productive 
inflammation  occurs  in  syphilis,  tuberculosis  and  suppuration. 

Pathology  and  Symptoms. — The  leptomeninges  are  diffusely  or 
locally  dense,  thick,  opaque  and  microscopically  show  fibrous  tissue. 
In  the  chronic  tuberculous  form,  the  membranes  are  thick,  fibrous, 
and  caseous;  they  compress  the  cortex,  especially  the  psychomotor 
areas,  and  produce  generalized  and  Jacksonian  convulsions,  headache, 
monoplegia,  aphasia,  and  mental  changes.  It  may  sometimes  heal. 
In  the  chronic  suppurative  form,  the  pus  loculi  are  situated  in  a  firm, 
fibrous  tissue.  The  symptoms,  if  cortical,  are  like  those  of  the  chronic 
tuberculous  form;  if  basal,  nerve  paralysis  and  optic  neuritis  are  com- 
mon. In  the  chronic  simple  form  (Gee  and  Barlow)  the  process  may  begin 
acutely  and  may  persist,  especially  at  the  base  and  in  the  posterior 


DISEASES   OF    THE  SPIXAL   CORD  1057 

fossa.  Possibly  it  is  a  sequel  of  a  localized  epidemic  type  (this  theory 
was  rather  favored  by  Koplik  in  a  recent  paper),  or  of  hereditary 
syphilis,  trauma,  or  otitis.  It  is  seen  especially  in  children  ("simple 
meningitis  of  children");  76  per  cent,  of  cases  occur  in  the  first  year 
of  life.  Rigid  neck  is  the  leading  symptom,  though  convulsions  and 
rigidity  of  the  extremities  do  occur.  Paralyses  are  rare.  Fifty  per  cent, 
of  patients  die.  The  alcoholic  Jorm  is  slight,  diffuse  and  cortical ;  men- 
ingitic  symptoms  are  obscured  by  alcoholic  disease  of  the  liver,  kidneys, 
heart  or  peripheral  nerves.  Headache  is  little  developed;  there  is 
moderate  delirium  and  slight  optic  neuritis.  Diagnosis  is  difficult, 
and  thera'py  is  wholly  etiological. 


DISEASES  OF  THE  SPINAL  CORD. 

(A).   GENERAL  ANATOMICAL,   PHYSIOLOGICAL,  AND  SYMPTOM- 
ATIC CONSIDERATIONS. 

The  nervous  system  is  made  up  of  numerous  similarly  constituted 
units,  called  neurones  (Waldeyer).  Each  neurone  comprises  (a)  a 
central  nerve  cell;  (b)  protoplasmic  processes  or  dendrites  from  the  cell 
which  conduct  (cellulipital)  impulses  to  the  cell;  (c)  an  axis  cylinder 
or  axone  arising  from  the  cell  and  conducting  impulses  (celluHfugal) 
from  the  cell;  and  {d)  the  terminal  ramifications  of  the  axis  cylinder,  also 
known  as  end  brushes  or  arborizations.  The  axis  cylinder  often  gives 
off  lateral  branches,  known  as  collaterals  or  paraxones.  The  nutrition 
of  the  nerve  cell  probably  depends  upon  the  integrity  of  its  nucleus,  and 
the  nutrition  of  the  cell  governs  that  of  its  neurone.  Disease  of  the 
cell  causes  degeneration  of  the  entire  neurone ;  division  of  a  process  or 
axis  cylinder  results  in  its  degeneration  below  the  point  of  separation 
from  the  nutrient  cell.  It  is  still  uncertain  whether  the  neurones  are 
wholly  independent  of  each  other,  although  most  authorities  favor 
this  view.  At  times,  and  especially  in  the  retina,  some  degree  of  anas- 
tomosis between  the  dendrites  of  different  systems  exists  (Dogiel). 
The  nerve  cells  are  closely  grouped  in  the  gray  cortex,  gray  substance 
of  the  cord  and  in  the  ganglia  of  the  peripheral  nerves.  The  axis 
cylinders  largely  course  through  their  white  substance.  To  compre- 
hend the  most  important  point  in  spinal  diseases,  the  localization,  we 
must  recognize  that  pathological  processes  are  in  general  of  two  varie- 
ties: (a)  those  involving  certain  neurones,  or  system  diseases,  as  tabes, 
and  (6)  those  not  involving  given  tracts  or  neurones,  or  the  non- 
system  diseases. 

The  junctions  of  the  cord  are  (1)  conduction  of  motor  impulses  to 
the  muscles;    (2)  conduction  of  sensory  impressions  to  the  brain;    (3) 


1058 


DISEASES  OF  THE  XERVOUS  SYSTEM 


certain  reflexes;    (4)  centres  governing  the  bladder,  rectum,  etc.,  and 
(5)  trophic  influences. 

1.  The  viotor  tract  is  composed  of  two  sets  of  neurones  or  segments. 
The  upper  segment  has  its  origin  in  the  cells  of  the  motor  cortex  (A  Fig. 
63),  and  runs  through  the  white  substance,  i.  e.,  the  corona  radiata, 
internal  capsule,  crus,  pons,  and  in  the  anterior  pyramids  of  the  medulla 


Fig.  63. 


Illustrating  the  course  of  the  two  motor  neurones:  A,  cortical  cell  of  origin  of  motor  tract;  B,  de- 
cussation in  medulla;  C,  course  in  lateral  columns  of  cord:  DD,  branches  to  anterior  horns  in 
cord;  in  second  (lower)  neurone,  E,  cells  of  anterior  horns;  E",  cells  in  pons;  F,ner\-e  trunks; 
G,  motor  end  plates;    H.  muscles. 

(whence  the  name  pyramidal  tracts),  it  crosses  to  the  opposite  side,  (B 
Fig.  63),  running  down  in  the  lateral  columns  of  the  cord  (C)  and 
giving  off  branches  (DD)  to  the  anterior  horns,  where  the  tract  ends  in 
fine  terminal  filaments,  which  surround  the  motor  ganghon  cells  in  the 
anterior  horn.  (For  the  general  course  of  the  upper  motor  neurones, 
see  Fig.  56).  The  loiver  segment  begins  with  the  motor  cell  in  the 
anterior  horn  (E),  the  dendrites  of  which  are  in  contact  with  theater- 


LOCALIZATION  IN  THE  SPINAL  CORD 


1059 


minal  ramifications  of  the  axis  cylinder  of  the  upper  segment  by  con- 
tact (Ramon  y  Cajal)  or  by  concrescence  (Held) ;  it  extends  along  its 
own  axis  cylinder  into  the  anterior  nerve  roots  and  nerve  (F),  and  ends 
in  terminal  ramifications  (G)  (motor  end  plates)  in  a  muscle  of  the 


Fia.  64. 


GANGLION  CELL  OF 

CORTEX.    BEGINNING 

OF  1ST  NEURONE 


TERMINAL  FILAMENTS 
END  OF  FIRST  NEURONE- 


'^^GANGLION  CELL  OF  ANT.   HORN 
BEGINNING  OF  2ND  NEURONE 


-END  OF2N0  NEURONE 
IN  MUSCLE  PLATES 


Jllustrating  the  general  outlines  of  the  upper  and  lower  neurones  and  of  the  direct  (DPT),  and 
crossed  (CPT) ,  pyramidal  tracts. 


arm  or  leg,  which  is  on  the  side  opposite  to  the  origin  of  the  cortical 
motor  centre.  From  the  cells  of  both  segments  the  motor  impulse 
travels  downward  from  the  cell  (cellulifugal  conduction).  About  75 
per  cent,  of  the  upper  motor  neurones  cross  as  above  described,  are 
called  the  crossed  'pyramidal  tracts  (C.  P.  T.  in  Figs.  63  and  64),  and  lie 
in  the  lateral  columns  of  the  cord.  Twenty-five  per  cent,  of  the  motor 
fibers  (rarely  40,  even  90  or  100  per  cent.,  Zenner),  do  not  cross  (decus- 
sate) in  the  medulla,  but  pass  down  in  the  anterior  columns  of  the  same  side 
and  are  called  the  anterior  or  direct  pyramidal  tracts  (D.  P.  T.  in  Figs. 
63  and  64) .  The  anterior  direct  pyramidal  tract  usually  ends  in  the  mid- 
dorsal  region,  but  if  small  may  reach  only  to  the  cervical  enlargement 
of  the  cord,  or  if  large  may  even  reach  the  fourth  or  fifth  sacral  nerves. 
This  tract  probably  crosses  to  the  anterior  horn  of  the  opposite  side 
by  way  of  the  white  portion  of  the  commissure  of  the  cord.  There  are 
probably  some  other  motor  tracts  in  the  cord.    The  upper  segment  is 


1060 


DISEASES  OF  THE  NERVOUS  SYSTEM 


largely  (75  per  cent.)  crossed,  but  the  lower  segment  (or  neurone)  is  a 
direct  tract,  the  cells  in  the  anterior  horns  supplying  muscles  of  the 
same  side  of  the  body. 

The  cord,  therefore,  contains  parts  of  both  neurones,  the  course  of 
which  has  been  ascertained  by  the  secondary  descending  degeneration 
which  follows  neurone  lesions,  Morgagni,  Cruveilhier,  and  Rokitansky 
noted  some  atrophy  in  the  cord  after  brain  lesions  which  destroyed  the 
motor  paths,  but  Ttirck  first  fully  described  its  occurrence  and  Bou- 
chard, and  Barth  confirmed  his  findings.  Flechsig,  and  later  Bech- 
terew  added  information  from  embryological  studies.  After  a  lesion, 
as  hemorrhage  in  the  internal  capsule,  the  fibers  of  the  upper  neurone 
below  the  lesion  show  signs  of  degeneration.  In  a  few  days  granule- 
bearing  cells  appear  and  somewhat  later  the  axis  cylinders  swell, 
degenerate  and  stain  poorly,  especially  when  studied  by  the  Marchi 


Fig.  65. 


Showing  the  different  tracts  of  the  cord.     (Gowers.) 

method.  These  changes  occur  because  the  axones  are  separated  from 
the  nutrient  cortical  cells.  The  neuroglia  tissue  increases  and  corpora 
amylacea  develop.  Degeneration  is  seen  in  the  opposite  lateral  pyra- 
midal tracts,  and  in  the  anterior  column  on  the  same  side  as  the  brain 
lesion.  Sometimes  slight  degeneration  occurs  in  the  lateral  pyramidal 
tracts  of  the  same  side  (Pitres,  Hadden,  Sherrington),  which  probably 
have  some  connection  with  the  anterior  uncrossed  pyramidal  tract 
of  the  same  side  (see  Broadbent  's  theory  under  Chronic  Symptoms  of 
Brain  Hemorrhage).  Since  the  vitahty  of  the  neurone  fibers  decreases 
as  their  distance  from  their  trophic  cell  increases,  the  degeneration 
is  greatest  in  the  most  peripheral  part  of  the  axone.  The  degenera- 
tion usually  stops  at  the  end  ramifications  of  the  axone  (see  Excep- 
tions, under  Brain  Hemorrhage,  Pathology).  (Some  fibers  lying 
between  the  direct  pyramidal  tract  and  the  direct  cerebellar  tract  degen- 


A 


PLATE  XVI. 


B 


C 


vm 


^m 


V'Hit 


A.  Ascending  degeneration  in   the  posteromedian  column    and  anterolateral  ascending  tracts  from 
lumbar  lesion.     (After  Gowers.) 

B.  Ascending  degeneration  after  injury  to  Cauda.     (After  Schultze.) 

C.  Descending  degeneration  of  pyramidal  tracts  from  right-sided  cerebral  hemorrhage.     (After  Mott.) 


LOCALIZATIOX  IX   THE  SPIXAL   CORD 


1061 


Fig.  66. 


C  1. 


^ 
a 


erate  downward;    possibly  thev  are  part  of  the  lateral    pyramidal 

tract  [from  Deiter's  nucleus  in  the  medulla,  Russel].     Fibers  lying  just 

anterior  to  the  lateral  pyramidal  tract  also 

degenerate  downward  [from  the  posterior 

corpora  quadrigemina,  Boyce,  and  Sakow- 

itsch].  Schultze  describes  a  comma-shaped 

descending-    degeneration    in    the    anterior 

third  of  Burdach's  column).      See  Plate 

XVI. 

Degeneration  in  the  Lower  Segment. — 
Disease  of  the  anterior  horns,  division  or 
disease  of  the  nerve  trunk,  causes  degener- 
ation of  the  nerve  toward  the  periphery 
and  trophic  muscle  changes.  The  degen- 
erated nerve  responds  neither  to  the  faradic, 
nor  to  the  galvanic  current.  The  muscle 
does  not  answer  to  the  faradic  current,  but 
to  the  galvanic;  it  answers  slowly  instead 
of  sharply  (as  is  the  case  with  the  nor- 
mal muscle).  These  differences  constitute 
the  reaction  of  degeneration  (see  Neuritis). 
After  amputation,  the  motor  nerves  and 
anterior  roots  concerned,  waste  (Berard, 
1829)  very  slowly  because  of  lack  of  func- 
tion, or  because  of  peripheral  irritation. 

The  two  neurones  do  not  correspond  in 
number,  because  one  neurone  of  the  upper 
segment  is  connected  with  several  lower 
neurones,  i.e.,  various  cells  in  the  anterior 
horns  at  different  levels  are  probably  ex- 
cited by  a  single  pyramidal  fiber.  For 
complex  movements,  as  of  the  hands, 
there  are  more  pyramidal  fibers  than  for 
simple  movements,  as  of  the  intercostal 
muscles.  The  anterior  spinal  root  nerves 
join  with  fibers  from  the  posterior  roots, 
and  passing  downward,  leave  the  spinal 
cord  between  the  vertebrae,  thus  form- 
ing the  spinal  nerves,  whose  area  of  origin 
in  the  cord  is  called  a  segment.  The  peri- 
pheral nerves  often  arise  from  several  seg- 
ments, which  are  sometimes  considerably 
separated ;  muscles  with  similar  function 
have  similar  spinal  localization,  because 
movements  rather  than  muscles  are  localized 
in  the  cord,  as  well  as  in  the  brain.  The 
appended  table  gives  the  localization  of  the      "JT"™  J-^^^  lowers,  showing  re- 

rr  fc>  _  ^  lation  of  vertebral  spines  to  their 

muscles,    with   special   regard   to    their   cells  bodies  and  to  the  nerve-roots. 


A 


IL 


-IS 


-Co 


1062 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Segment, 


Muscles. 


Skin:  Sensation. 


Reflexes. 


2-3  Cervical 


4  Cervical 


5  Cervical. 


6  Cervical. 


7  Cervical. 


8  Cervical. 


1  Dorsal. 


2-12  Dorsal. 


1   Lumbar. 


2  Lumbar. 


3  Lumbar. 


4  Lmnbar. 


5  Lumbar. 


1-2  Sacral. 


3-5  Sacral. 


Sterno-cl-mastoid,  trape- 
zius, scaleni,  neck  mus- 
cles. Diaphragm  (3,  4,  5, 
6  cerv.). 

Lev.  ang.  scapulae,  rhom- 
boideus,  supra-  and  in- 
fra-spinatus,deltoid,sup- 
inator  longus,  biceps. 

Supinator  brevis,  serrat. 
mag,  clavicular  portion 
of  pectoralis  maj.,  teres 


Pronators,  coraco-brachi- 
alis,  brachialis  ant.,  tri- 
ceps, long  extensors  of 
hand  and  fingers.  Lower 
neck  muscles  and  middle 
part  trapezius,  6,  7,  8,  C 
and  1  D. 

Costal  portion  of  pectoralis 
maj.,  latissimus  dorsi, 
teres  maj . 

Long  flexors  of  the  hand 
and  fingers. 


Extens.  poll.  long,  et  brev. 
Small  muscles  of  hand. 


Neck  and  occiput. 


Shoulder     (anterior    part, 
Dana). 


Radial  side  of  arm  (volar 
and  dorsal  surface)  to 
the  insertion  of  deltoid. 
Post,  surface  of  shoulder? 


Sudden  inspiration  by 
sharp  pressure  below  the 

ribs. 


Widening  of  pupil  from 
irritation  of  neck ,  4-7  cer- 
vical. 


Scapular  reflex  (fifth  cerv. 
to  first  dorsal).  Tendon 
reflexes  of  this  group  of 
muscles. 


Muscles  of  back  (also  low- 
est part  of  trapezius)  and 
abdomen.  Intercostals 
D,  1-10. 


Abdominal  muscles,  quad- 
ratus  lumborum.  Ileo- 
psoas. 

Sartorius  (or  third  lumbar), 
flexors  of  hip.  Quadri- 
ceps femoris  (extensors 
of  knee),  cremaster. 

Internal  rotators  of  thigh 


Adductors    of    hip, 
Sartorius  (?), 
Abductors  of  hip, 
Tibialis  anticus. 
Calf  muscles. 
Flexors  of  knee  ( ?) ,  gluteals 
(extensors  of  hip). 

External  rotators  of  hip. 
Flexors  of  foot  (?), 
Extensors  of  toes. 
Peronei. 

Flexors  of  foot  and  toes. 
Small  muscles  of  foot. 


Muscles  of  perineum. 


Dorsal  and  volar  surface  of 
radial  side  of  hand  to 
midline  of  middle  finger, 
and  up  to  base  of  hand, 
narrow  strip  on  volar  and 
dorsal  surface  up  to  axil- 
la,connecting  with  above 
area. 

Ulnar  part  of  hand  (dorsal 
and  volar)  from  middle 
of  the  fourth  to  middle  of 
third  finger  and  connect 
ing  with  it,  a  moderate 
strip  on  volar  and  dorsal 
surface  of  arm. 

Dorsal  and  volar  surface  of 
hand  to  middle  of  fourth 
finger,  narrow  strip  on 
dorsal  and  volar  surface 
of  arm  up  to  axilla. 

Narrow  strip  on  ulnar  sur- 
face arm  and  forearm 
down  to  base  of  hand, 
(The  upper  part,  per- 
haps, belongs  to  the  sec- 
ond dorsal  segment.) 

Chest,  back,  abdomen  and 
upper  gluteal  region. 
(Umbilicus,  tenth  dor- 
sal :  ensiform,  sixth  to 
seventh  dorsal). 


Pubic  area,  anterior  aspect 
of  scrotum. 


Anterior  and  inner  side 
of  hip,  inner  side  leg  to 
malleolus,  inner  side 
of  foot,  external  sur- 
face of  hip,  lumbar  re- 
gions. 

Posterior  surface  of  hip 
thigh,  external  surface 
of  leg  and  foot. 

Back  of  foot. 


Skin   of   sacrum,    anus 
perineum,    genitalia. 


Tendon  reflexes  of  muscles 
named. 


Volar  reflex  of  hand,  peri- 
osteal reflexes  of  radius 
and  ulna.  Tendon  re- 
flexes of  muscles  named. 


Corresponding  tendon  re- 
flexes. 


Tendon  reflexes. 


Abdominal  reflex.  Epi- 
gastric reflex  (according 
to  Dinkier,  theepigastric 
is  at  the  ninth  dorsal,  the 
middle  and  lower  ab- 
dominal at  the  tenth  and 
twelfth,  respectively.) 

Cremasteric  reflex  (1-3 
lumbar). 


Patellar  reflex  (2-4  lum- 
bar). Erection  (lumbar 
cord).  Uterus  (lumbar 
cord). 


Gluteal   reflex    (4-5    lum- 
bar). 


Plantar    reflex;    ejacula- 
tion (3-4  sacral). 

Achilles  tendon  reflex. 

Bladder  and  rectum  reflex. 


The  brackets  to  the  left  concern  only  the  muscles,  and  indicate  the  origin  of  the  muscles  from 
several  nuclei. 


PLATE  XVII 


Scheme  of  Sensory  Conduction.     (Strumpell.) 

A.  Entrance  of  posterior  sensory  roots  into  lumbar  cord:  r/.i.,  intervertebral  ganglion;  c. p., 
posterior  root;  part  of  the  fibers  end  in  the  posterior  horns,  from  whose  cells  other  fibers  arise  and  enter 
the  lateral  columns,  partly  on  the  same  and  partly  on  the  opposite  side;  other  fibers  from  the  posterior 
roots,  course  upward  in  the  posterior  columns  and  form  in — 

B.  (the  cervical  cord),  GoU's  columns  (G);  B.('.,  Burdach's  columns. 

C.  Medulla  oblongata,  G  and  B  are  the  nuclei  wherein  GoU's  and  Burdach's  columns  end.  From 
these,  new  fibers  arise  which  decussate  and  form  the  fillet  (lemniscus,  L)  in — 

D.  L,  lemniscus;  Py,  pyramidal  tract;  O,  the  olive;  c.r.,  corpus  restiforme. 
I'J.     Pons;  IV,  fourth  ventricle. 

/•'.  Ij.  lemniscus  of  fillet  ;  n.r.,  nucleus  ruber;  Py,  i)yramidal  tract  in  cms  cerebri;  N.Ij., 
nucleus  lenticularis;  T.H.,  ii|)tic  thahunus  (bcginniiiK  of  new  neurono  to  cortex?), 


LOCALIZATION   IX  THE  SPINAL  CORD  1063 

(the  beginning  of  the  second  neurone)  as  well  as  of  the  skin  and 
reflexes.  The  cord  is  shorter  than  the  spinal  canal,  reaching  only  to 
the  second  1-umbar  vertebra.  The  nerve  roots  descend,  and  therefore 
their  level  at  the  point  of  exit  does  not  correspond  with  their  level 
of  origin.     Fig.  66  shows  this  relation. 

Table  giving  localization  of  function  in  the  various  spinal  segments 
(from  Edinger,  Starr,  von  Leyden,  Remak,  Thoburn,  Ferrier,  Yeo, 
Gowers,  and  Kocher)  will  be  found  on  page  1062. 

2.  The  sensory  tract  conducts  upward  and  is  more  complicated  and 
less  clearly  understood  than  the  motor  tract,  because  the  interpreta- 
tion of  experiments  made  on  animals  is  frequently  confusing.  It  is 
composed  of  three  or  more  neurones.  The  cells  of  the  first  neurone 
are  in  the  intervertebral  ganglia,  whose  cells  end  in  an  axis  cylinder 
dividing  into  a  branch  to  the  skin,  and  another  to  the  cord  by  the  pos- 
terior root.  These  ganglia  are  the  homologues  of  those  of  the  vagus, 
or  trigeminus  {q.  v.).  Embryologically  studied,  it  would  seem  less 
likely  that  the  axis  cylinder  of  the  ganglion  cell  divided  than  that  the 
branches  from  the  skin  (the  peripheral  sensory  nerves)  represented 
the  protoplasmic  process  or  dendrites  of  the  ganglion  cells,  and  the 
branch  to  the  cord  represented  the  axis  cylinder.  However,  all  periph- 
eral sensory  fibers  originate  in  the  ganglia,  and  almost  all  fibers  of 
the  posterior  nerve  roots  come  from  these  ganglia.  From  the  posterior 
roots  the  fibers  reach  the  cord,  where  (a)  some  pass  into  the  posterior 
column,  (b)  some  into  the  gray  matter,  and  (c)  others  run  to  the  cells 
of  the  anterior  horns,  and  are  clearly  part  of  reflex  arcs. 

(a)  The  fibers  entering  the  white  substance  (the  posterior  columns) 
divide  into  a  short  descending  branch  (which  probably  is  concerned 
in  reflex  processes,  giving  off  some  collaterals  and  ending  in  the  gray 
matter),  and  into  a  long  ascending  branch,  which  is  the  more  important 
one;  they  enter  the  posterior  column  obliquely  and  by  the  entrance  of 
new  fibers  at  higher  levels  become  more  centrally  located  in  the  column 
of  Goll  (posterior  median  column)  in  which  the  lowest  fibers  (e.  g.,  the 
sciatic),  are  most  posterior  and  the  highest  (e.  g.,  the  cervical)  are 
most  anterior.  The  posterior  columns  convey  fibers  for  muscle  sense 
(sense  of  posture  and  movement  association)  and  possibly  also  for 
simple  tactile  sensation.  "Sensations  we  do  not  feel"  travel  in  these 
columns  (Gowers).  The  posterior  median  (GoU's)  column  ends  in 
the  nucleus  gracilis  of  Goll  (or  postero-median  nucleus)  in  the  medulla. 
It  is  uncrossed,  i.  e.,  direct.  The  posterior  external  (Burdach's) 
column  ends  in  the  nucleus  cuneatus  of  Burdach  (or  posterior  external 
nucleus)  in  the  medulla.  It  is  likewise  uncrossed  or  direct.  The  first 
neurone  ends  in  these  nuclei.  The  second  neurone  crosses  above  the 
motor  decussation  in  the  medulla  (interior  arcuate  fibers)  to  the  opposite 
side  and  unites  with  fibers  that  have  already  crossed  in  the  cord,  thus 
forming  the  fillet  (see  below,  6).  This  neurone  is  crossed.  The  pos- 
terior nuclei  communicate  with  the  opposite  cerebral  cortex,  with  the 
cerebellum  of  the  same  and  opposite  side  and  with  the  external  arcuate 
fibers. 


1064  DISEASES  OF  THE  NERVOUS  SYSTEM 

(b)  The  fibers  entering  the  gray  matter  of  the  posterior  horns  also  divide 
into  ascending  and  descending  branches.  Some  He  at  the  zona  ter- 
minaHs,  the  most  posterior  part  (Lissauer's  zone)  of  the  posterior  horn. 
All  these  fibers  end  with  terminal  ramifications  about  ganglion  cells 
in  the  gray  matter;  they  form  the  beginning  of  a  second  neurone  which 
crosses  in  the  commissure  of  the  cord  and  courses  upward  in  the 
antero-lateral  column  and  anterior  ground  fibers  of  the  opposite  side 
(just  anterior  to  the  lateral  pyramidal  tracts),  and  they  unite  in  the 
medulla  with  the  fibers  of  the  second  neurone  of  (a)  {v.  s.).  (See  Plate 
XVII.  The  fibers  entering  the  posterior  horn  convey  temperature 
and  pain  conduction,  and  travel  between  the  posterior  median  column 
and  the  central  canal.  Tactile  sensation  is  probably  conveyed  in 
the  antero-lateral  column.  Gowers  holds  that  the  antero-lateral 
columns  convey  most  of  the  upward  sensory  impulses,  since  their 
division  causes  anaesthesia.  Both  (a)  and  (6)  then  run  in  the  median 
lemniscus  of  the  fillet,  and  in  part  of  the  longitudinal  bundles  of  the 
formatio  reticularis  of  the  pons,  tegmentum  of  the  crus  and  posterior 
limb  of  the  internal  capsule,  beyond  which  their  course  is  somewhat 
uncertain.  Some  fibers  run  directly  to  the  motor  cortex  or  back  of  it  to 
the  parietal  lobes,  while  others  end  in  the  optic  thalamus,  whence  per- 
haps they  are  connected  by  a  third  neurone  coursing  to  the  cortex. 

The  sensory  tracts  degenerate  upward  (ascending  degeneration). 
Plate  XVI  Fig.  A  shows  degeneration  in  the  posterior  and  antero- 
lateral columns.  Most  ascending  degenerations  stop  in  the  medulla. 
The  direct  cerebellar  tract,  which  begins  at  the  first  lumbar  nerve, 
also  degenerates  upward.  It  increases  somewhat  in  size  as  it  rises 
because  of  reception  of  additional  fibers,  but  most  of  its  fibers  come 
from  the  lower  dorsal  and  first  lumbar  nerves;  some  of  them  come 
from  the  gray  substance  of  Clark's  columns  to  which  collaterals  are 
sent  from  the  posterior  fibers;  its  function  is  uncertain,  though  Flechsig 
believes  that  it  conveys  muscular  impressions  from  the  lower  part  of 
the  trunk  and  the  legs;  its  destination  is  the  middle  lobe  of  the  cere- 
bellum by  way  of  the  restiform  body;  some  fibers  then  cross  to  the 
opposite  lobe. 

The  spinal  sensory  nerves  descend  lower  than  do  the  corresponding 
motor  nerves,  and  skin  sensation  for  a  given  area  is  often  supplied 
by  two,  three,  or  more  nerves,  whence  anaesthesia  results  only  when 
all  of  them  are  diseased  (Sherrington).  See  Wichmann's  plate,  Plate 
XVIII. 

Lesions  of  the  conus  medullaris  down  to  the  fourth  sacral  nerve 
produce  paralysis  of  the  bladder  and  rectum,  and  saddle-shaped  anaes- 
thesia on  the  anus,  gluteal  region,  perineum,  genitalia,  under  surface 
of  the  thigh  (pudendal  and  coccygeal  plexus)  but  the  scrotum  escapes 
because  the  spermatic  plexus  and  external  spermatic  nerve  connect 
with  the  lumbar  plexus.  The  cremaster  reflex  is  normal.  In  Bern- 
hardt's  case,  sexual  desire  and  erection  were  preserved,  while  ejacula- 
tion was  incomplete. 


PLATE  XVIII. 


5d 


J2£ 


Ss' 


31 
21 


II 


5  s 


Ui: 


These  figures  have  been  devised  by  Wichmann  in  order  to  show  the  distribution  of  the  sensory  areas 
corresponding  to  the  segments  of  the  spinal  cord.  The  colors  used  correspond  to  those  of  the  normal  spec- 
trum, red,  orange,  yellow,  green,  blue,  indigo,  and  violet,  with  brown;  respectively — the  first,  .second,  third, 
fourth,  etc.,  segments  in  each  portion  of  the  spinal  cord- -cervical,  dorsal,  lumbar,  and  sacral.  The  last  four 
segments  in  the  dorsal  region  are  left  white.  The  advantage  of  the  plate  is  that  it  shows  very  clearly  the 
overlapping  of  the  segments  that  has  been  demonstrated  by  Sherrington.  The  dark  heavy  black  lines 
on  the  arms  indicate  the  division  between  the  two  sides  of  innervation — that  from  the  upper  portion  of 
the  cervical  enlargement  and  that  frf>m  the  lower  portion.  The  heavy  black  lines  of  the  legs  indicate  the 
divisions  between  the  sacral  and  lumbar  areas  of  innervation.  The  figures  and  letters  indicate  the  seg- 
ments in  which  the  supply  has  been  drawn  and  have  been  introduced  for  the  sake  of  making  the  diagram 
more  available  for  ready  reference.  C — cervical,  D — dorsal,  L — lumbar,  and  S — sacral.  The  horizontal 
bands  of  color  without  dividing  linos  between  them  indicate  that  both  segments  innervate  the  areas 
involved.      (Musser ) 


LOCALIZATIOX  IN    THE   SPINAL   CORD 


1065 


Lesions  of  the  cauda  equina  (where  the  roots  He  closely  together) 
are  usually  symmetrical.  In  its  upper  part,  the  above  symptoms  with 
paralysis  of  both  legs  are  noted;    paraplegia    dolorosa   is  frequent 


Fig.  67. 


FiQ.  6S. 


Lesion  at  the  level  of  the  second  lumbar  segment 
(Strijinpell  and  MuUer,  from  whom  also  follow- 
ing figures  are  borrowed) . 


Lesion  at  third  lumbar  segment. 


Fig.  69. 


Fig.  70 


Lesion  at  fifth  lumbar  segment. 


Lesion  at  first  sacral  segment. 


(See  Plate  XVI,  Fig.  B),  A  lesion  below  the  third  lumbar  vertebra 
is  usually  limited  to  the  pudendal  and  sciatic  distribution.  Von  Leyden 
holds  that  there  is    no  certain  distinction  between  cauda  and  conus 


1066 


DISEASES  OF  THE  NERVOUS  SYSTEM 


lesions,  unless  external  signs  exist,  as  trauma,  tumor  or  caries,  or  per- 
haps absence  of  the  reaction  of  degeneration  or  the  occurrence  of 
fibrillary  contractions  (Strumpell  and  Schultze).  Paraplegia  dolorosa 
is  rare  in  pure  lesions  of  the  conus,  while  it  is  common  in  those  of  the 


Fig.  71. 


Fig.  72. 


Lesion  at  second  sacral  segment. 


Lesion  at  third  sacral  segment. 


Fig.  73. 


Lesion  at  fourth  sacral  segment. 

Cauda.  In  conus  lesions  there  may  be  partial  or  dissociated^  anaes- 
thesia (Schlesinger  and  Higier)  which  never  develops  in  affections  of 
the  Cauda. 


LOCALIZATIOX  IN    THE   SPIXAL   CORD  1067 

3.  In  the  gray  matter  there  are  reflex  centres  which  are  enumerated 
and  locahzed  in  the  table  given  above.  The  reflex  arcs  comprise  the 
afferent  sensory  fiber  with  its  termination  in  the  gray  matter  and  the 
motor  nucleus  with  its  efferent  motor  fiber.  Collaterals  probably 
connect  the  centres  at  different  levels.  Hutchinson  first  suggested 
that  the  fibers  of  the  oculopupillary  reflex  ran  by  way  of  the  sym- 
pathetic nerve  (rami  communicantes)  to  the  cord.  Irritation  of  its 
centre  produces  dilatation  of  the  pupil  (mydriasis),  especially  in  spina 
caries.  Paralysis  from  disease  of  the  centre  produces  myosis,  narrow- 
ing of  the  eye  fissure,  sometimes  retraction  of  the  eyeball,  and  less 
often  flattening  of  the  cheek;  Madame  Klumpke-Dej^rine  found  that 
this  paralysis  was  produced  by  section  of  the  eighth  cervical  and  first 
dorsal  segments;  i.  e.,  the  localization  is  the  same  as  for  paralysis 
of  the  forearm  and  anaesthesia  of  the  ulnar  surface  of  the  hand  and 
arm.  It  occurs  more  often  in  disease  of  the  nerve  roots  than  in  dis- 
ease of  the  cord  itself.  The  tendon  reflexes  will  be  considered  under 
the  individual  cord  diseases.  They  are  inhibited  from  the  brain  and 
probably  also  from  the  cord.  Evacuation  of  the  bladder  and  rectum 
is  partly  a  reflex  and  partly  a  voluntary  process.  There  are  muscular 
fibers  to  evacuate  the  organs  and  sphincters  to  retain  their  contents. 
The  former  are  stimulated  by  distention  and  the  latter  relax;  they 
are  controlled  normally  by  the  will.  If  inhibition  fails,  the  bladder 
or  rectum  is  evacuated,  sometimes  with  the  knowledge  of  the  patient, 
as  in  disease  of  the  pyramidal  tracts,  or  at  other  times  unconsciously, 
as  in  coma  or  when  the  sensory  nerves  of  the  parts  are  diseased.  When 
the  lumbar  centre  itself  is  affected,  there  is  continuous  evacuation. 
As  to  the  rectum,  Gowers  discovered  that  disease  of  the  centre  dis- 
closes itself  by  relaxation  of  the  sphincter  on  digital  examination; 
disease  above  the  centre,  by  normal  tonicity  of  the  sphincter. 

From  the  above  considerations,  the  leading  points  are  given  regard- 
ing the  level  of  the  lesion  and  the  course  of  the  chief  systems.  Total 
transverse  disease  of  the  cord  produces  paralysis  of  the  muscles  at  and 
below  that  level,  and  sensory  interruption.  From  these  symptoms 
the  upper  level  of  the  lesion  is  determined,  but  it  might  be  difficult 
to  decide  whether  the  cord  were  affected  through  a  narrow  horizontal 
level,  or  whether  all  the  cord,  below  it,  were  diseased,  unless  the  reflexes 
below  were  noted.  Hypersesthesia  usually  discloses  the  level  of  the 
lesion.  Lesions  of  the  pyramidal  tract  (first  neurone)  produce  motor 
paralysis  at  the  level  of  the  lesion,  increased  reflexes  and  spasticity 
(hypertonic  muscular  rigidity)  but  with  no  muscular  atrophy,  reaction 
of  degeneration  or  sensory  disturbance.  In  lesions  of  the  posterior 
columns,  the  chief  alteration  is  sensory  disturbance,  especially  in  the 
muscle  sense,  and  therefore  incoordination  or  ataxia.  The  reflex  arc 
may  be  interrupted.  I^esions  of  the  anterior  horns  or  anterior  roots 
produce  a  flaccid  paralysis  followed  by  atrophy  and  the  reaction  of 
degeneration  if  the  process  is  acute.  (If  it  is  chronic,  the  atrophy  is 
more  marked  than  the  paralysis,  and  the  reaction  of  degeneration  is 
absent  or  atypical.    The  trophic  cells  are  not  specialized  in  the  horn. 


1068  DISEASES  OF  THE  NERVOUS  SYSTEM 

but  all  cells  are  probably  trophic.)  The  motor  nerve  (Nasse,  1839) 
and  the  muscle  degenerate;  the  reflexes  are  abolished;  the  muscle 
tension  (myotatic  irritability)  is  lost,  there  is  vasomotor  paralysis  (since 
the  fine  fibers  of  the  anterior  roots  are  vasomotor),  and  contractures 
result  (from  sensory  irritation,  Goldscheider),  If  the  lesion  is  in  the 
anterior  horn,  there  may  be  fibrillary  muscular  contractions.  Irrita- 
tion of  the  anterior  horns  may  increase  the  reflexes  and  induce  con- 
tractures. In  lesions  of  the  posterior  horns,  there  is  disturbance  of  the 
temperature  and  pain  sense  and  some  alteration  of  the  tactile  sense; 
the  reflexes  may  be  disturbed.  (Some  maintain  that  vasomotor  symp- 
toms occur).  In  lesions  of  the  posterior  roots,  the  reflexes  are  disturbed, 
there  is  anaesthesia  and  therefore  ataxia.  Irritation  of  these  roots 
causes  pain,  hypersesthesia  in  the  form  of  a  girdle  sensation  in  the 
trunk  or  lancinating  pains  in  the  extremities  and  reflex  contractures. 
The  importance  of  the  spinal  ganglion  as  the  trophic  centre  must  be 
remembered  (Waller,  1852),  although  Vejas  and  Joseph  declare  that 
some  fibers  pass  directly  through  the  ganglion  without  connecting 
with  it.  Vasomotor  fibers  leave  the  cord  through  the  anterior  roots,  by 
the  rami  communicantes,  and  course  down  either  in  the  lateral  columns, 
or  in  the  intermediolateral  tract  (Gaskell)  from  the  vasomotor  centre 
in  the  medulla.  Most  of  the  vasoconstrictor  fibers  leave  the  cord 
between  the  third  dorsal  and  second  lumbar  segments,  while  the  vaso- 
dilator fibers  are  much  more  diffusely  scattered  through  the  cord. 


(B).^ DISEASES   OF   THE  VERTEBRA;    FRACTURE,  DISLOCATION, 
TUMOR,  AND  COMPRESSION  OF  THE  CORD. 

I.  Fracture  of  the  Vertebrae. 

Its  incidence  is  rare,  for  it  constitutes  but  -3-  of  1  per  cent,  of  all 
fractures  (Gurlt). 

Etiology. — Fracture  in  the  dorsal  and  lumbar  regions  occurs  mostly 
(66  per  cent.)  in  the  vertebral  bodies,  while  in  the  cervical  region  the 
processes  are  often  (50  per  cent.)  fractured.  Falls,  sudden  flexion,  or 
blows  are  the  most  common  causes,  though  in  rare  cases  it  is  caused 
by  simple  muscular  exertion.  Previous  disease,  caries  and  tabes  may 
favor  fracture.  Corresponding  to  the  obvious  angle  in  the  spine,  the 
upper  portion  usually  slips  downward  and  forward,  crushing,  com- 
pressing or  even  severing  the  cord,  while  the  dura  is  rarely  ruptured, 
although  the  abundant  epidural  plexus  of  veins  ruptures  and  forms 
a  hsematoma  back  of  the  cord.  Gurlt  found  fracture  most  often  in 
the  fifth  and  sixth  cervical,  the  last  dorsal  and  first  lumbar  vertebrae. 
The  cord  is  the  seat  of  hemorrhagic  softening  or  later  of  inflammation 
(myelitis),  which  sometimes  develops  without  cord  compression. 
Marked  or  permanent  injury  results  in  ascending  and  descending 
degeneration. 


'  FRACTURE  OF  THE  VERTEBR.E  1069 

Symptoms. — They  may  be  (a)  local  i.  e.,  direct.  Dislocation  with 
deformity  (in  68  per  cent.)  is  the  most  frequent  sign;  'pain  is  frequent; 
crepitation'  (in  38  per  cent.)  is  uncommon  save  when  the  processes 
are  fractured;  its  elicitation  should  not  be  attempted.  (6)  General 
symptoms  include  those  of  shock  and  concussion,  (c)  Spinal  symp- 
toms are  more  or  less  complete  paraplegia  (in  71  per  cent.),  i.  e.,  paral- 
ysis of  both  arms,  legs,  or  of  parts  below  the  lesion.  The  reflexes  are 
decreased  as  a  result  of  the  shock;  in  complete  division  of  the  cord, 
the  patellars  are  totally  abolished,  even  when  their  lumbar  centre  is 
not  implicated,  as  in  cervical  fracture  (Bastian,  Bruns,  Bowlby);  the 
reason  is  not  clear;  Jackson  held  that  the  cause  was  withdrawal  of 
the  cerebellar  influence;  others  have  suggested  that  shock  or  irritation 
was  causative;  the  abruptness  of  the  lesion  is  certainly  a  factor, 
since  the  patellars  are  present  in  slow  compression  (Gerhardt).  The 
paralysis  may  be  unilateral  (see  Brown-Sequard's  Paralysis  under 
Trauma  of  the  Cord).  Sensation  is  less  involved,  but  radiating  pains 
into  the  extremities  may  occur  when  the  lesion  is  at  the  cervical  or 
lumbar  enlargement;  they  are  sometimes  associated  with  muscular 
spasm.  Continuous  erection  (priapism)  is  almost  constant,  especially 
in  cervical  fracture,  and  ejaculation  occurs  at  the  time  of  the  lesion. 
Paralysis  of  the  bladder  and  rectum  is  usual.  The  bladder  can  often 
be  emptied  by  suprapubic  pressure.  Meteorism  may  result.  Decubitus 
(bed-sores)  is  common. 

Fracture  of  the  first  and  second  cervical  vertebrae  usually  results  in 
sudden  death;  most  cases  result  from  caries  (Bergmann).  Some 
subjects  die  in  a  few  days,  while  in  a  few  instances  recovery  is  possible. 
The  author  has  seen  two  cases  with  deformity  in  the  spine  and  pharynx 
without  any  sign  of  cord  compression.  There  is  pain  in  the  neck, 
pain  on  movement,  fixation  of  the  head,  often  palpable  deformity 
in  the  pharynx,  dysphagia,  dyspnoea,  vomiting,  and  paralysis  of  the 
tongue,  palate  and  of  all  the  limbs,  usually  with  preservation  of  the 
reflexes.  The  temperature  may  reach  111°.  The  pulse  is  often  slowed 
(to  40  or  20)  by  paralysis  of  the  accelerator  fibers  of  the  heart  which 
run  from  the  medulla  by  way  of  the  lateral  columns  to  the  fourth  to 
ninth  dorsal  anterior  roots  and  cardiac  plexus.  Their  irritation  may 
produce  paroxysmal  tachycardia.  Fracture  of  the  third  and  fourth 
cervical  vertebrae.  Involvement  of  the  phrenic  nferve  results  in  respira- 
tory paralysis  and  early  death.  In  fracture  of  the  fourth  cervical  to 
second  dorsal  vertebrte,  paraplegia,  which  increases  after  the  injury 
from  hemorrhage,  is  the  chief  symptom.  In  the  arms  it  is  often  some- 
what asymmetrical.  Atrophy  may  follow  injury  to  the  cervical  en- 
largement. Pains,  hyperalgesia  and  tonic  or  clonic  spasms  in  the 
arms  are  frequent.  Anaesthesia  is  usually  less  marked  than  the  paral- 
ysis. The  intercostal  muscles  being  paralyzed,  the  patient  breathes 
with  the  diaphragm  and  the  accessory  respiratory  muscles  of  the  neck. 
Vasomotor  manifestations  may  occur  in  the  pupils,  face,  trunk  or 
extremities.  In  fracture  of  the  third  to  twelfth  dorsal  vertebrae,  para- 
plegia,  anaesthesia   and   often   paralysis   of  the   bowel   and   bladder 


1070  DISEASES  OF  THE  NERVOUS  SYSTEM 

result.  The  temperature  is  often  low  in  lesions  of  the  lower  cord. 
Lumbar  fracture,  except  in  the  first  lumbar  vertebra,  is  infrequent. 
Paralysis  is  not  a  frequent  result,  unless  there  is  marked  dislocation 
when  paraplegia,  especially  in  the  peronei,  and  atrophy,  pains  in  the 
legs  along  the  sciatic  and  femoral  nerves,  and  anaesthesia  occur  {v.  s., 
Lesions  of  the  Conus  and  Cauda). 

Diagnosis. — The  diagnosis  is  based  on  the  trauma,  symptoms 
shown  by  the  cord,  and  deformity  which,  though  sometimes  absent, 
serves  for  differentiation  from  spinal  concussion.  In  doubtful  cases, 
the  examination  for  tender  points,  fixation  of  the  spine  and  radiating 
pains  must  be  made  most  carefully,  lest  the  cord  injury  be  thereby 
increased. 

Course. — Healing  is  difficult,  uncertain  and  incomplete,  because 
callus  formation  is  rarer  than  cartilaginous  and  fibrous  union,  and 
dislocation  may  occur  after  the  trauma.  Early  death  frequently 
results  from  fractures  in  the  higher  vertebrae  while  in  those  lower 
down  a  later  death  is  likely  to  occur  from  cystitis,  decubitus  or  sepsis. 
The  prognosis  is  most  favorable  in  fractures  between  the  third  dorsal 
and  second  lumbar  vertebrae  (Gurlt).  x4.ccording  to  Burrell — from 
whose  collation  of  244  cases  (1905)  most  of  the  above  statistics  are 
taken, — ^the  average  mortality  is  65  per  cent. ;  the  mortality  is  86  per 
cent,  in  cervical,  76  per  cent,  in  upper  dorsal,  56  per  cent,  in  lower 
dorsal  and  50  per  cent,  in  lumbar  fractures. 

Treatment. — Surgical  interference  is  not  indicated  in  fresh  cases, 
unless  a  comminuted  process  may  press  on  the  cord.  If  paralysis 
persists  from  pressure  of  a  process  on  the  cord,  especially  in  the  lumbar 
region,  operation  is  indicated. 


II.  Dislocation  of  the  Vertebrae. 

Dislocation  is  traumatic,  or  spontaneous  from  previous  vertebral 
disease.  Traumatic  luxation  is  sudden,  injures  the  cord  to  a  greater 
extent  and  results  from  falls  or  blows  on  the  head  or  neck.  Fracture 
very  frequently  accompanies  dislocation.  Luxation  from  previous 
vertebral  disease  is  gradual,  though  sometimes  sudden,  and  injures 
the  cord  less,  since  it  is  often  incomplete  (subluxation).  It  occurs 
most  often  in  the  cervical  region,  especially  in  the  first  and  second,  or 
fifth  and  sixth  vertebrae.  It  is  infrequent  elsewhere  in  the  spine.  The 
vertebrae  sometimes  are  torn  apart  without  actual  displacement. 

Symptoms. — The  head  is  often  bent  forward  toward  the  sternum  or 
shoulder,  very  rarely  backward.  Movement  is  suspended  or  limited. 
Tenderness  and  pain  are  elicited  and  the  local  deformity  may  be  felt 
or  even  seen.  The  cord  is  injured  by  direct  compression,  contusion, 
hemorrhage  and  later  by  myelitis,  with  much  the  same  symptoms  as 
in  fracture.  Sometimes  no  spinal  symptoms  are  observed.  Sudden 
death  is  very  common  in  the  higher  dislocations  from  pressure  on  the 
medulla. 


CARIES  OF  THE  VERTEBRJE  1071 

Treatment. — Reduction  is  indicated  even  when  the  cord  is  not 
injured,  and  may  reheve  all  symptoms. 

III.  Caries  of  the  Vertebrae. 

Etiology  and  Pathology. — Pott's  disease  (Pott,  1779),  spondylar- 
throcace,  is  the  most  common  vertebral  disease  involving  the  cord. 
Caries  is  almost  always  tuberculous.  It  is  most  common  after  the 
fourth  year  and  in  adolescence,  but  may  be  seen  at  any  age.  Tuber- 
culosis in  other  organs  is  frequent  in  Pott's  disease;  it  usually  begins 
"spontaneously,"  in  one  or  several  vertebral  bodies  or  more  rarely  in 
the  articulations.  It  may  follow  trauma.  The  spongy  portion  of  the 
vertebral  body  is  first  involved.  Granulation  tissue  is  the  earliest 
finding;  later  caseation  occurs  with  extension  to  contiguous  parts, 
the  connective  tissue,  hgaments,  processes  and  cartilage.  The  collapse 
of  the  altered  body  usually  produces  .an  angle  and  prominence  in  the 
spine  called  Pott's  boss,  and  the  diseased  body  slips  backward,  some- 
times compressing  the  cord.  By  extension  the  nerve  roots  may  be 
involved;  they  are  bathed  in  pus,  sometimes  show  connective  tissue 
induration  and,  in  cases  of  long  standing,  atrophy.  The  outer  surface 
of  the  dura  is  very  frequently  inflamed  (peripachymeningitis  or  pachy- 
meningitis externa);  collections  of  thick,  caseous  pus  gather  in  the 
cellular  tissue  between  the  dura  and  the  posterior  surface  of  the  body 
of  the  vertebra;  the  cord  is  more  injured  by  caseous  or  purulent 
pachymeningitis  than  by  deformity  of  the  spine.  It  was  once  thought 
that  the  cord  was  not  only  compressed  but  also  inflamed,  whence  the 
name,  compression  myelitis. 

Compression  paralysis  (so-called  compression  myelitis)  may  result 
from  (a)  vertebral  disease,  tuberculosis,  cancer,  or  exostoses;  (6) 
disease  of  the  spinal  cord  and  its  membranes,  as  tumors,  pachy- 
meningitis hypertrophica,  syringomyelia,  or  hydromyelia;  (c)  com- 
pression by  aneurysm,  or  echinococcus.  Pathologists  differ  as  to  the 
a,ctual  changes  in  the  compressed  cord.  Myelitis  may  develop  in 
some  cases,  according  to  the  older  pathology  (a)  from  compression  by 
bone  fragments  or  exudate,  or  acute  extension  by  contiguity  of  the 
inflammation  to  the  cord;  (6)  from  slower  inflammatory  reaction, 
following  degeneration  of  the  nervous  structures,  or  (c)  rarely,  from 
tuberculous  myelitis.  "Compression  myelitis"  is  probably  nearly 
always  softening  (myelomalacia).  OEdema  of  the  cord  results  from 
mechanical  lymph  stasis  in  the  dura  (Kahler  and  Schmaus)  and 
suspends  but  does  not  necessarily  destroy  its  functions.  Anaemia  of 
the  cord  (Ziegler)  is  of  less  importance.  Vessel  thrombosis  may  cause 
softening.  In  some  cases  with  marked  paralysis,  the  postmortem 
examination  shows  no  changes  in  the  cord,  whence  it  is  certain  that 
pressure  may  interrupt  nerve  impulses  without  structural  cord  disease. 
In  other  cases  all  gradations  of  alteration  are  found,  from  a  few  granule 
bearing  cells  or  swollen  axis  cylinders  to  marked  disintegration,  corpora 
amylacea,  neuroglia  overgrowth  and  induration. 


1072  DISEASES  OF  THE  XERVOi'S  SYSTEM 

Symptoms. — The  symptoms  usually  develop  in  the  order  of  group- 
ing given  below. 

1.  Spinal  Column. — Angular  deformity  {kyphosis,  gibbus,  Pott's 
boss)  is  common  but  not  invariable;  it  is  most  marked  in  upper 
dorsal  disease,  and  is  at  times  accentuated  by  periosteal  induration. 
Quite  frequently  there  is  only  lateral  deviation  (scoliosis)  in  which 
connection  it  must  be  remembered  that  ordinary  lateral  curvature 
of  the  spine  practically  never  affects  the  cord  or  its  nerve  roots. 
Local  tenderness  over  or  beside  the  affected  vertebrae  and  pain  are 
usually  localized  and  develop  early.  The  application  of  heat,  which 
is  not  felt  over  the  normal  vertebrae,  may  cause  pain  over  the 
diseased  focus  (Copeland).  Pain  and  tenderness  are  very  common 
in  the  neuroses,  but  the  hyperalgesia  is  largely  cutaneous,  is  usually 
diffuse,  and  varies  more  than  in  caries.  Rigidity  of  the  spine  is  most 
conspicuous  in  disease  of  the  cervical  or  lumbar  regions,  where  move- 
ment is  normally  most  free;  it  is  usually  an  effort  to  spare  pain. 
Gravitation  abscesses  are  fairly  frequent  and  follow  along  the  planes 
of  least  resistance  in  the  tissues.  Dysphagia  from  retropharyngeal 
abscess  or  low  compression  of  the  cesophagus  may  cause  errors  in 
diagnosis. 

2.  Nerve  Roots. — Eccentric  pain  is  usually  the  earliest  symptom; 
it  radiates  into  the  trunk  or  extremities  and  indicates  involvement 
by  pachymeningitis  of  the  posterior  nerve  roots.  It  is  much  less  acute 
than  in  cancer  and  is  especially  elicited  by  movement.  Sensory  are 
more  common  than  motor  root  symptoms,  and  irritative  symptoms,  as 
hyperaesthesia,  are  more  common  than  anaesthesia.  Root  symptoms 
are  most  pronounced  in  lumbar  and  sacral  disease;  and  least  pro- 
nounced in  dorsal  disease. 

3.  Spinal  Cord. — Compression  (a)  interrupts  function  at  its  level, 
disturbs  reflexes,  impairs  rectal  and  vesical  evacuation  and  (6)^  inter- 
rupts upward  and  downward  cordal  conduction,  producing  spastic 
paresis  or  paralysis,  anaesthesia  affecting  all  varieties  of  sensation, 
and  increase  of  skin  and  tendon  reflexes,  whereas  root  disease 
does  not  interrupt  conduction.  Cord  symptoms  develop  slowly; 
Oppenheim  placed  the  average  time  at  one  year;  weakness  of  the 
legs  is  followed  by  paresis,  this  in  time  by  paraplegia,  which,  however, 
may  develop  suddenly.  Anaesthesia  and  other  sensory  manifestations 
are  less  common  than  are  motor  symptoms,  because  the  sensory 
tracts  are  more  resistant  or  more  protected,  since  the  greatest  com- 
pression is  exerted  on  the  outer  lateral  surface  of  the  cord.  Ataxia  is 
usually  obscured  by  the  paralysis.  Marked  anaesthesia,  paralysis  and 
atrophy  are  usually  correctly  referred  to  the  cord  rather  than  to  the 
more  resistant  nerve  roots.  The  reflexes  are  increased  (unless  their 
arc  is  destroyed  at  the  level  of  the  lesion)  since  cerebral  inhibition  is 
interrupted;  Sternberg  and  Sherrington  believe  there  is  also  a  spinal 
inhibition. 

Special  Localization. — 1.  Dorsal  Caries. — This  is  the  most  frequent 
type.    Gradual  deformity  is  usual,  with  formation  of  a  sharp  or  obtuse 


CARIES  OF  THE  VERTEBRAE  1073 

angle.  Acute  deformity,  such  as  might  result  from  a  fall  or  lifting  a 
heavy  burden,  is  much  less  common.  Paraplegia  develops  in  varying 
degrees  of  intensity  with  increased  muscle  tonus  (spasticity),  increased 
leg  reflexes,  or  even  clonus,  or  paralysis  of  the  bladder  and  rectum; 
it  sometimes  develops  with  contractures  but  rarely  with  marked  sensory 
changes,  other  than  intercostal  root  pains  in  the  chest  wall,  which 
sometimes  produce  precordial  oppression  or  a  girdle  sensation. 
Herpes  zoster  may  develop.  The  level  of  the  lesion  may  be  marked 
by  a  zone  of  hypersesthesia  or  hyperalgesia.  Trophic  changes  in  the 
skin  are  common,  as  glossiness,  smoothness  or  dryness.  There  is  no 
essential  atrophy  save  from  disuse,  nor  is  there  any  reaction  of  degen- 
eration, unless  the  anterior  horns  are  diseased.  In  cases  of  partial 
paralysis,  the  tendon  of  the  tibialis  anticus  becomes  prominent  (tibialis 
phenomenon).  The  tendon  reflexes  may  be  increased,  even  when  the 
paralysis  is  apparently  flaccid.  They  are  almost  always  increased 
below  the  lesion.  Exaggeration  of  the  patellars  is  an  early  symptom, 
often  antedating  the  paralysis.  The  skin  reflexes  below  the  lesion  are 
often  increased,  but  may  be  decreased  in  cases  of  severe  compression, 
though  they  are  seldom  absent.  The  Babinsky  reflex  (see  Brain 
Hemorrhage)  is  often  found. 

2.  Cervical  and  Upper  Dorsal  Caries. — This  form  ranks  next  in 
frequency;  radiating  pains  reach  the  shoulder,  arm  and  hand,  and 
may  be  felt  in  or  about  the  joints  on  one  or  both  sides.  Anaesthesia 
is  more  common,  along  the  ulnar  nerve,  over  the  sternum  and  scapula, 
because  the  posterior  roots  are  more  often  affected.  Paralysis  may 
result  from  compression  of  the  cord,  or  from  disease  of  the  anterior 
roots,  and  involves  the  small  muscles  of  the  hand,  forearm  and  triceps. 
The  fore-finger  and  thumb  often  cannot  be  apposed  (the  ape  hand), 
and  from  atrophy  of  the  interossei,  the  main  en  griff e  (v.  i.)  results. 
The  forearms  are  flexed  and  pronated,  while  the  arms  are  adducted 
(Thoburn).  The  tendon  reflexes  usually  persist.  In  other  cases, 
marked  atrophy  occurs  instead  of  paralysis  and  the  reaction  of  degen- 
eration sometimes  develops.  Spastic  para-paresis  or  -plegia  in  the 
legs  from  compression  of  the  pyramidal  tracts  usually  accompanies 
the  diplegia  (paraplegia)  brachialis,  which,  however,  sometimes  occurs 
alone,  when  the  anterior  horns  or  roots  are  diseased.  Myosis  is  com- 
mon from  injury  to  the  oculospinal  centre  (Rollet,  1864),  and  there 
may  be  narrowing  of  the  eye  fissure  and  less  often  retraction  of  the 
eyeball,  which  is  more  frequently  unilateral  than  bilateral,  or  differs 
in  degree  on  the  two  sides.  Flattening  and  reddening  of  the  cheek 
are  less  common.  These  are  less  symptoms  of  disease  of  the  cord 
than  of  the  anterior  roots.  The  reflexes  of  the  legs  are  increased ; 
total  compression  of  the  cord  may  destroy  the  tendon  reflexes;  this 
is  caused  by  secondary  changes  in  the  lumbar  cord;  when  the  paralysis 
is  flaccid,  the  urine  is  retained  at  first,  and  later  there  is  incontinence. 
There  is  usually  constipation. 

3.  Disease  of  the  First  Two  Cervical  Vertebrae. — (Rust's  Disease). — 
In  disease  of  the  atlanto-occipital  articulation,  nodding  is  impossible, 


1074  DISEASES  OF  THE  XERVOUS  SYSTEM 

while  the  involvement  of  the  odontoid-atlas  articulation  prevents  turn 
ing  of  the  head.  In  body-movements  the  patient  supports  the  head 
with  the  hands  (Rust).  The  head  may  be  held  as  it  is  in  torticollis, 
and  induration  under  the  occiput  is  common.  Pains  radiate  to  the 
eye,  ear,  and  occiput.  The  typical  paralysis  in  disease  of  the  two 
upper  cervical  vertebrae  is  brachial  paraplegia,  which  usually  occurs 
without  atrophy.  Spasms  in  the  face,  anaesthesia  in  the  neck  and 
upper  chest,  aphonia  and  other  symptoms  indicating  involvement  of 
the  medulla  oblongata  may  be  present.  Charcot  observed  a  slow  pulse 
with  attacks  of  syncope.  The  spinal  accessory  supply  to  the  head  and 
palate  and  the  hypoglossus  supply  may  be  affected.  The  course  is 
usually  more  rapid  (one  to  two  years)  than  in  carcinoma;  recovery  is 
possible  (v.  Bergmann).  It  has  long  been  held  that  degenerated  axis 
cylinders  do  not  regenerate,  but  Fickler  made  the  interesting  obser- 
vation that  the  fibers  of  the  severed  lateral  pyramidal  tract  grew  around 
the  old  scar  to  reach  the  anterior  horns  below  it.  Gravitation  abscess 
may  reach  the  neck  or  pharynx.  Sudden  death  is  not  unusual,  because 
dislocation  readily  occurs,  since  the  disease  is  in  the  articulations  rather 
than  in  the  vertebral  bodies. 

4.  Lower  Dorsal  and  Upper  Lumbar  Caries. — This  type  produces 
atrophic  flaccid  paraplegia,  destruction  of  the  lumbar  reflexes,  urinary 
incontinence,  anaesthesia  of  the  legs,  pain  in  the  abdomen  or  possibly 
in  the  groins  or  anterior  thighs.  When  it  occurs  in  the  lower  lumbar 
region  there  is  flaccid  atrophic  paralysis,  absence  of  the  patellars,  and 
spastic  paralysis  of  the  legs,  with  clonus  of  the  Achilles  tendon  (see 
CoNus  AND  Cauda  Localization). 

Diagnosis. — Cases  may  be  classed  under  three  groups  (a)  those  with 
spine  symptoms,  (b)  those  with  spine  and  spinal  cord  symptoms,  and 
(c)  those  with  cord  symptoms  only.  Cases  are  almost  unmistakable 
in  which  the  paralysis  follows  signs  of  bone  disease  in  early  life.  Re- 
peated examinations  usually  determine  the  nature  of  doubtful  cases 
in  which  bone-symptoms  develop  after  compression  of  the  cord  or 
nerve  roots,  and  in  which  there  are  early  increase  of  the  skin  or  tendon 
reflexes,  root-symptoms,  which  are  usually  bilateral,  as  cervical  neural- 
gia, lumbago  (Janeway),  anaesthesia,  and  muscular  atrophy  or  paral- 
ysis. The  Roentgen  rays  may  aid  in  diagnosis.  Gravitation  abscesses, 
fever,  and  tuberculosis  elsewhere  are  significant.  In  persons  of 
advanced  years,  cancer,  tumor  within  the  spinal  canal  and  aneurysm 
must  be  considered  (see  Diagnosis  of  Cancer  of  the  Spine). 

Prognosis. — The  prognosis  is  unfavorable,  since  about  50  per  cent, 
of  cases  die.  Relative  recovery  with  deformity  is  possible,  especially 
in  children,  but  even  then  the  process  may  break  out  anew.  A  rapidly 
fatal  course  is  rare.  iVbsolute  paralysis  may  disappear  after  months 
or  even  years.  The  prognosis  is  best  in  diseases  of  the  lower  dorsal 
region  and  is  least  favorable  in  disease  of  the  atlas  and  axis.  Gowers 
remarks  that  recovery  or  improvement  is  more  frequent  than  in  any 
other  disease  with  symptoms  of  equal  severity.  There  is  hope  of 
recovery  in  most  cases,  and  yet  there  are  few  in  which  it  is  sure.    Cystitis 


CARCINOMA  OF  THE  SPIXE  1075 

is  common,  and  leads  to  pyelonephritis;  bed-sores  are  frequent,  and 
death  results  from  sepsis,  mixed  infection,  amyloid  disease  or  lung 
tuberculosis.- 

Treatment. — (a)  Medical  treatment  includes  administration  of  iron, 
arsenic,  and  cod-liver  oil;  fresh  air  and  a  full  diet  are  equally  impor- 
tant. The  skin  and  bladder  should  receive  special  attention.  Elec- 
tricity is  contra-indicated,  (b)  Orthopedic  treatment  produces  the  most 
successful  results.  Rest  in  bed  on  the  back  should  be  enforced  for 
months.  Extension,  fixation  by  braces  of  the  neck  and  back,  suspen- 
sion, and  for  lighter  cases  or  those  involving  the  lower  spine,  the 
plaster  cast,  are  described  in  works  on  orthopedic  surgery,  (c)  Sur- 
gical intervention  is  indicated  only  when  other  treatment  has  been 
given  thorough  trial.  The  results  are  not  encouraging  and  disease  of 
the  affected  bodies  is  difficult  of  access.  The  dura  should  never  be 
incised.  According  to  Chipault,  the  indications  are  (i)  disease  restricted 
to  the  arches,  (ii)  cold  abscess,  (iii)  flaccid  paralysis,  since  Babinsky 
noted  that  this  occurs  in  moderately  severe  dorsal  disease,  and  (iv) 
healing  of  the  bone  focus  and  replacing  of  granulation  tissue  by  con- 
nective tissue,  as  in  the  cases  first  operated  on  (Macewen,  1888).  The 
contra-indications  are  (i)  multiple  vertebral  disease,  (ii)  lung  tubercu- 
losis, and  (iii)  disease  of  the  cord  itself.  Victor  Horsley  advises  ortho- 
pedic treatment  for  two  months  in  children,  and  then,  in  case  of 
failure,  laminectomy.  In  adolescents  and  in  those  of  advanced  years, 
he  considers  that  laminectomy  is  indicated  practically  at  once. 


IV.  Carcinoma  of  the  Spine. 

Carcinoma  is  almost  always  secondary  to  carcinoma  of  the  mamma 
and  less  often  of  the  digestive  tract,  uterus,  prostate  or  thyroid;  it 
generally  involves  the  bodies,  usually  of  several  vertebrae. 

Symptoms. — Angular  deformity  is  less  common  than  in  caries,  A 
tumor  may  be  felt.  Bruns  considers  a  sinking  in  of  the  vertebrae  or 
softening  of  the  spinal  column  as  rather  characteristic.  Rigidity  is 
common  but  is  less  conspicuous  than  in  caries.  Tenderness  is  common. 
The  spinal  symptoms  closely  resemble  those  of  compression  by  caries, 
and  are  present  in  60  per  cent,  of  cases  (Schlesinger).  Compression 
of  the  posterior  roots  is  most  common  and  produces  neuralgic 
pain,  which  is  at  first  paroxysmal  and  later  constant,  lancinating, 
and  incoercible;  it  is  located  along  the  spinal  column,  while  in  caries 
pain  is  felt  over  the  spine  or  in  the  side  of  the  chest  (Gull).  Closely, 
associated  are  hyperalgesia  and  anaesthesia,  tenderness  on  pressure, 
painful  reflex  muscular  spasm  and  herpes  zoster.  Compression  of  the 
cord  is  less  common  and  occurs  late;  if  paralysis  develops  it  is  usually 
rapid  and  painful.  The  veins  of  the  lower  extremities  thrombose 
frequently  and  fatal  pulmonary  embolism  may  result  (Schlesinger). 

Diagnosis. — Diagnosis  depends  upon  (a)  recognition  of  a  primary 
cancer  (which  is  sometimes  latent  or  overshadowed  by  the  secondary 


1076  DISEASES  OF  THE  XERVOUS  SYSTEM 

deposit) ;  (6)  local  signs  (tumor,  spinal  irregularity,  arcuate  k}-pliosis) ; 
(c)  cachexia;  (d)  advanced  age,  for  caries  commonly  occurs  in  young 
individuals;  (e)  pain,  which  is  usually  bilateral  and  is  increased  by 
movement;  paraplegia  dolorosa  (Cruveilheir)  is  much  more  common 
and  incomparably  more  intense  in  cancer  than  in  caries,  from  infil- 
tration of  the  sensory  roots;  anaesthesia  with  pain  (antesthesia  dolorosa) 
is  also  common;  and  (/)  rapid  onset  and  course.  Sarcoma  may  be 
primary  or  secondary.  Cachexia  is  less  common;  it  is  more  often 
seen  in  youth  than  in  elderly  persons,  and  is  more  frequently  multiple. 
Vertebral  syphilis  is  very  uncommon,  as  gummata  in  the  bone  or 
periosteum,  but  responds  to  antisyphilitic  treatment.  S}"philis  simulates 
caries  rather  than  carcinoma.  Actinomycosis  rarely  causes  compres- 
sion of  the  cord;  it  is  recognized  by  its  presence  in  other  organs 
and  by  the  sulphur  bodies  in  the  sinuses  and  aspirated  fluid.  Arthritis 
deformans  (q.  v.)  is  recognized  by  exostoses,  tenderness,  ankylosis, 
in  rare  cases  by  crepitus,  by  alterations  in  other  joints  and  by  root- 
symptoms  caused  by  narrowing  of  the  foramina  (radiating  pains, 
vasomotor  symptoms  and  atrophic  paralysis).  Aneurysmal  erosion 
of  the  spine,  cer^-ical  pachymeningitis,  hydatids,  exostoses,  tumors 
within  the  spinal  canal,  glands  compressing  the  intercostal  nerves 
and  tabetic  pains  in  the  trunk  must  be  considered.  The  prognosis 
is  absolutely  unfavorable,  and  the  treatment  is  directed  chiefly  against 
the  pain. 

(C).  DISEASES  OF  THE  SPINAL  MENINGES. 

Few  diseases  of  the  vertebrae  and  cord  do  not  to  some  degree  affect 
the  meninges  but,  v^-ith  few  exceptions,  the  meningeal  symptoms  have 
little  independent  clinical  interest. 


I.  Hyperaemia. 

At  autopsy  the  blood  gravitates  to  the  dependent  parts,  and  there- 
fore congests  or  discolors  the  meninges.  At  the  present  day  but 
little  importance  is  attached  to  the  symptoms  referred  by  Frank, 
Oliver  and  Brown-Sequard  to  meningeal  congestion.  Stasis,  conges- 
tive diseases  as  tetanus,  eclampsia,  and  chorea,  or  asph}-xiating  poisons, 
as  carbon  monoxide,  or  strychnine,  doubtless  congest  the  membranes. 


II.  Hemorrhage. 

(a)  Between  the  vertebrae  and  dura,  hemorrhage  is  frequent  from 
rupture  of  the  subdural  plexus  of  veins.  It  surrounds  the  nerve  roots 
and  is  most  severe  over  the  posterior  cord;  it  results  mostly  from 
trauma  and  to  a  lesser  extent  from  convulsive  affections,  as  tetanus, 
or  strychnine  poisoning,  vertebral  disease,  stasis  or  aneurysmal  rupture. 


PACHYMENINGITIS  1077 

(6)  In  the  arachnoid  sac  hemorrhage  (hsematorrhachis)  is  equally  fre- 
quent and  results  from  the  above  named  causes,  and  from  asphyxia, 
extraction  by  the  foot  during  labor,  hemorrhagic  diseases,  or  virulent 
leptomeningitis.  Severe  hemorrhage  may  follow  brain  hemorrhage, 
especially  at  the  base  (from  rupture  of  aneurysm,  or  apoplexy)  and  the 
entire  spinal  canal  may  be  filled  with  blood,  (c)  In  the  pia,  hemor- 
rhage rarely  attains  either  pathological  or  clinical  interest. 

Symptoms. — Small  hemorrhages  cause  no  symptoms,  and  meningeal 
apoplexy  may  easily  be  overshadowed  by  brain  or  traumatic  cord 
symptoms.  Pain,  localized  in  the  small  of  the  back  or  sometimes 
generalized,  rigidity,  radiating  pains  from  compression  of  the  posterior 
roots,  hyperffisthesia  or  hyperalgesia,  painful  reflex  muscular  spasms, 
motor  weakness  (and  paraplegia),  anaesthesia,  sphincter  disturbance, 
and  abolition  of  the  tendon  reflexes  are  the  common  symptoms. 
They  develop  suddenly,  affect  the  lower  more  than  the  upper  cord, 
increase  for  a  day  or  so,  produce  inflammatory  reaction  for  two  or 
three  days  and  usually  subside  in  from  four  to  eight  weeks.  Physical 
signs  vary  with  the  location ;  for  instance,  brachial  paraplegia  is  present 
in  cervical  hemorrhage,  and  involvement  of  the  legs  in  lumbar  or 
dorsal  hemorrhage.  There  are  no  cerebral  symptoms,  except  those 
resulting  from  the  initial  shock  in  traumatic  cases. 

In  making  a  diagnosis  the  most  important  symptoms  are  those  of 
irritation,  which  is  sometimes  followed  by  paralysis,  while  in  hemor- 
rhage of  the  cord  (haematomyelia)  paralysis  prevails  and  pain  is  less 
frequent.  In  non-traumatic  cases,  exact  diagnosis  is  impossible.  The 
treatment  is  symptomatic.  Absolute  rest  in  the  lateral  decubitus  or 
on  the  face  should  be  enjoined. 


III.  Pachymeningitis. 

(a)  This  may  be  external  (peripachymeningitis),  as  described  under 
caries.  It  may  follow  penetrating  bed-sores,  deep  cellulitis,  psoas  or 
retropharyngeal  abscess.  Its  symptoms  are  those  of  compression  by 
vertebral  caries  (q.v.).  Root  symptoms  and  fever  are  frequent.  The 
prognosis  is  unfavorable,  and  the  treatment  is  that  of  the  cause,  or 
is  expectant  or  surgical,  (b)  Internal  pachymeningitis  hemorrhagica 
is  a  second  form.  Its  causes  are  those  of  the  cerebral  form,  as  paretic 
dementia,  alcoholism,  trauma  and  sometimes  tuberculosis,  (c)  Char- 
cot (1871)  and  later  Joffroy  described  a  form  involving  chiefly  the 
cervical  region  (pachymeningitis  cervicalis  hypertrophica) ,  in  which 
the  inner  surface  of  the  dura  is  thickened  by  annular  concentric  fibrous 
deposits.  The  dura  adheres  to  the  vertebrae  and  leptomeninges  and 
compresses  the  nerve  roots,  which  indurate.  Several  cervical  segments 
are  involved.  The  process  is  most  marked  on  the  dorsal  aspect  of 
the  cord,  which  is  flattened  anteroposteriorly  and  shows  peripheral 
induration  by  extension  of  the  process  to  it  through  the  pial  vessels 
(meningomyelitis) ;  this  causes  the  frequent  ascending  and  descending 


1078  DISEASES  OF  THE  NERVOUS  SYSTEM 

degeneration.  Cold,  syphilis,  alcoholism  and  trauma  are  probable 
causes. 

Symptoms. — Charcot  described  three  stages;  (a)  the  neuralgic  stage, 
which  lasts  two  to  three  months,  and  corresponds  to  involvement  of 
the  posterior  nerve  roots,  in  which  pains  radiate  from  the  nape  of  the 
neck  or  occiput  into  the  ulnar  and  median  nerve  supply.  They  are 
continuous,  with  paroxysmal  exacerbations,  with  localization  at  times 
in  the  arm  joints,  with  rigidity  as  in  caries,  parsesthesia  in  the  arms, 
some  motor  weakness  and  sometimes  vesicular  eruptions.  Hyperaes- 
thesia  is  common,  (b)  The  second  stage  is  that  of  atrophic  paralysis 
of  the  arms  in  which  the  process  involves  the  anterior  nerve  roots. 
The  pains  are  replaced  by  atrophy  and  paralysis  in  the  ulnar  and 
median  nerve  areas,  while  the  radial  area  is  usually  unaffected;  this 
produces  flexor  paralysis  in  the  forearms  and  hands,  and  the  claw 
hand  {main  en  griff e)  results  from  contracture;  the  wrist  is  over- 
extended, the  first  phalanges  are  extended,  the  second  and  third  are 
flexed;  ulnar  and  median  anaesthesia  and  the  reaction  of  degeneration 
are  found.  The  shoulder  and  elbow  muscles  may  be  involved.  Mus- 
cular atrophy  is  not  constant  and  other  deviations  from  Charcot's 
complex  are  at  times  noted,  as  absence  of  contracture  or  extension  to 
the  lower  cord,  (d)  In  the  third  stage,  the  legs  show  a  spastic  paralysis 
without  atrophy,  and  the  bladder  and  rectal  functions  and  sometimes 
the  sensory  conduction  are  disturbed  from  secondary  changes  in  the 
cord. 

Diagnosis. — The  process  is  usually  localized  with  ease  as  a  disease 
in  the  cervical  region.  The  marked  pain  is  characteristic  but  may 
also  occur  in  tumors,  cervical  spondylitis,  syphilitic  meningomyelitis 
and  at  times  in  syringomyelia.  Some  cases  result  from  syphilis.  Von 
Leyden  and  others  maintain  that  diagnosis  is  usually  impossible  and 
that  the  process  is  not  a  unit  but  only  a  cervical  localization  of  a  men- 
ingomyelitis. Amyotrophic  lateral  sclerosis  (q.  v.)  and  progressive 
spinal  muscular  atrophy  have  no  such  severe  pains,  and  syringomyelia 
(q.  V.)  is  characterized  by  dissociated  anaesthesia  as  well  as  by  muscular 
atrophy,  painless  felons  and  trophic  changes  in  the  joints.  Tumors 
(q.  V.)  are  difficult  to  differentiate.  Neuritis  causes  symptoms  which 
are  usually  limited  entirely  to  the  limbs,  and  over  whose  nerve  trunks 
there  is  often  tenderness. 

The  prognosis  is  usually  unfavorable,  and  chronic  progression  for 
two  or  more  years,  cystitis,  etc.,  usually  develop.  Instances  of  recovery 
are  recorded. 

Treatment. — Warm  baths,  cautery  for  counterirritation,  sedatives, 
narcotics,  mercury,  iodides,  and  care  of  the  skin  and  bladder  are  indi- 
cated. 

IV.  Spinal  Leptomeningitis. 

This  closely  corresponds  to  the  description  given  under  cerebral 
meningitis,  as  to  the  spinal,  pathological  and  clinical  findings.     It 


TUMORS   OF    THE  MEM  BR  AXES  1079 

may  occur  (a)  in  the  acute  form,  from  trauma,  regional  extension  from 
pleuritis,  lung  cavities,  bed-sores  or  other  adjacent  infections,  from 
general  infjections,  and  from  epidemic,  suppurative  or  tuberculous 
meningitis;  or  it  may  occur  (b)  in  the  chronic  form,  which  has  little 
independent  clinical  interest,  which  results  from  tabes,  trauma,  myelitis, 
syphilis  (q.  v.)  or  alcoholism.  The  symptoms  are  pain  in  the  back, 
rigidity,  hypersesthesia,  and  radiating  pains;    the  course  is  afebrile. 


V.  Syphilitic  Affections.     (See  Syphilis.) 
(D).  TUMORS  OF  THE   SPINAL  CORD  AND  ITS  MEMBRANES. 

These  are  rare;  about  200  cases  are  reported.  Brain  tumors  are 
six  times  as  frequent  (Schlesinger). 

I.  Tumors  of  the  Membranes. 

These  may  arise  from  the  dura  or  leptomeninges.  In  a  collection  of 
20  extradural  tumors,  Horsley  found  five  sarcomata,  four  lipomata, 
four  tubercles,  three  echinococcus  cysts,  and  one  each  of  myxoma, 
hbrochondroma,  carcinoma,  and  fibrosarcoma.  Cysticercus  often 
causes  no  symptoms.  These  growths  are  more  likely  to  cause  erosion 
of  the  vertebrae  than  compression  of  the  cord.  Intradural  tumors  are 
nearly  twice  as  frequent.  Horsley  collected  38,  of  which  there  were 
twelve  myxomata,  seven  sarcomata  (endotheliomata),  seven  fibromata, 
four  psammomata,  four  tubercles,  two  parasitic,  and  two  syphilitic 
tumors.  Lipomata,  echinococci,  cysticerci,  neuromata  and  angiomata 
are  rarer.  Though  they  are  usually  single,  multiple  occurrence  may 
be  noted  in  sarcomata,  parasitic  tumors  and  neuromata.  This  group 
compresses  the  cord  or  its  nerve  roots.  The  cord  is  altered  as  in  caries; 
there  is  oedema,  flattening,  discoloration,  peripheral  hardening  and 
central  softening,  and  secondary  ascending  and  descending  degenera- 
tions.   The  membranes  thicken  and  the  nerve  roots  flatten  and  atrophy. 

Symptoms. — Extradural  growths  produce  more  vertebral  than  cord 
symptoms.  The  first  symptoms  are  usually  those  of  compression  of 
the  nerve  roots,  e.g.,  rigidity;  hypersesthesia ;  radiating  pains,  first  on 
one  side,  then  on  both,  which  run  into  the  arms,  trunk  or  legs,  according 
to  their  localization,  and  advance  from  one  root  to  another;  partes- 
thesia;  anoesthesia  which  is  less  common  since  it  implies  involvement 
of  at  least  three  roots  (Sherrington's  law) ;  atrophic  paralysis  with 
vasomotor  symptoms;  and  spontaneous  muscular  contractions.  Local 
tenderness  is  rare.  Early  symptoms  sometimes  date  from  trauma. 
The  symptoms  recall  those  of  carcinoma  of  the  spine  aside  from  its 
vertebral  signs.  Later,  evidences  of  comj^ression  of  the  cord  appear, 
as  paresis  perhaps  of  one  side  first  (Brown-Sdquard's  type,  v.  i.)  or 
paraparesis  with  atrophy  if  the  anterior  horn  is  involved  at  that  level. 


1080  DISEASES  OF  THE  XERVOUS  SYSTEM 

with  increased  reflexes  (unless  the  arc  is  broken  or  total  compression 
results),  with  spasticity  and  contractures;  and  with  sensory  changes. 
In  this  type,  as  in  carcinoma  of  the  vertebrae,  the  paraplegia  dolorosa 
of  Cruveilhier  is  common,  as  is  anaesthesia  dolorosa  (the  "eccentric 
projection"  or  reference  of  pain  to  the  anaesthetic  areas).  Finally, 
there  is  total  paraplegia,  anaesthesia,  bladder  and  rectal  paralysis  and 
decubitus. 

II.  Tumors  in  the  Cord  Substance. 

These  are  six  times  less  common  than  tumors  in  the  membranes; 
they  include  glioma  (which  is  most  frequent  in  the  cervical  and  upper 
dorsal  regions),  sometimes  gumma,  sarcoma  (in  thepia),  tubercle  (in 
the  gray  substance  or  posterior  horn)  and  cysticercus.  Most  of  them 
are  circumscribed,  though  glioma  tends  to  vertical  diffusion.  Unlike 
meningeal  tumors,  they  are  rarely  metastatic. 

Symptoms. — In  intramedullary  growths,  root  symptoms  are  absent, 
especially  in  gliomata  and,  since  there  is  gradual  compression  of  the 
cord,  the  clinical  picture  may  resemble  chronic  myelitis  and  syringo- 
myelia. The  cord  symptoms  are  disturbed  conduction;  spastic  para- 
plegia; marked  increase  of  reflexes  (unless  the  arc  is  broken  or  absolute 
cord  compression  develops) ;  bilateral  symptoms,  or  if  unilateral,  they 
soon  reach  the  other  side;  extensive  muscular  atrophy,  if  the  cervical 
or  lumbar  enlargement  is  diseased,  often  then  with  the  reaction  of 
degeneration;  and  sensory  changes  involving  all  varieties  of  sensation 
or  certain  varieties  only,  as  pain  or  temperature  (dissociated  or  par- 
tial anaesthesia).  Some  writers,  as  Bruns,  maintain  that  the  lesion 
and  symptoms  are  at  first  unilateral.  Then  the  Brown-Sequard 
complex  is  found;  on  the  side  of  the  tumor  there  is  paralysis  with 
increase  of  the  reflexes,  loss  of  muscle  sense,  a  zone  of  anaesthesia 
just  below  and  one  of  hyperaesthesia  just  at  the  level  of  the  lesion, 
and  on  the  other  side  there  is  total  anaesthesia  save  that  the  muscle 
sense  is  preserved.  As  the  tumor  grows,  total  paraplegia  and  anaes- 
thesia may,  in  rare  cases,  develop  below  the  level  of  the  lesion  aided 
perhaps,  by  softening,  oedema,  or  actual  myelitis. 

Localization. — Accurate  determination  of  the  localization  is  most 
important  but  this  can  rarely  be  done  until  the  cord  itself  is  compressed. 
The  most  common  error  is  in  locating  the  tumor  too  low.  Atrophic 
paralysis,  in  the  cervical  or  lumbar  regions,  is  the  most  certain  aid, 
and  sensory  changes  are  less  reliable.  The  actual  lesion  is  one  or 
two  (three  or  four)  segments  higher  than  the  anaesthesia  (Sherrington's 
law)  because  anaesthesia  results  only  from  involvement  of  at  least  three 
roots.  The  hyperaesthesia  usually  represents  the  level  of  the  lesion, 
and  local  spinal  tenderness,  though  rare,  is  very  important.  Finally, 
the  spinal  segment  involved  must  be  considered  in  terms  of  the  corre- 
sponding vertebrae  (r. 5., page  1061  Gower's  cut),  (a)  When  the  tumor  is 
in  the  upper  cervical  cord,  there  are  pains  in  the  cervical  plexus  and  per- 
haps anaesthesia;    at  first  after  the  Brown-Sequard  syndrome,  there 


TUMORS  IX  THE  CORD  SUBSTANCE  1081 

may  be  a  spinal  hemiplegia  differing  from  cerebral  hemiplegia  in  that 
the  face  and  hypoglossiis  escape  and  the  anaesthesia  is  contralateral 
to  the  paralysis;  then  there  is  spastic  paralysis  of  all  four  extremities, 
which  rarely  lasts  long,  since  affection  of  the  phrenic  nerve  causes 
early  death.  (6)  In  tumor  of  the  cervical  enlargement  there  is  atrophy, 
flaccid  paralysis  and  pain  in  one  arm,  spastic  paresis  in  the  leg  of  the 
same  side,  anaesthesia  of  the  entire  opposite  half  of  the  body  and 
opposite  limbs;  and  then  paralysis  of  both  arms  and  legs  with  anaes- 
thesia, (c)  Localization  in  the  dorsal  cord  often  produces  unilateral 
signs,  as  paresis  of  one  limb  with  its  half  of  the  trunk,  and  anaesthesia 
of  the  corresponding  parts  of  the  other  side;  spastic  paraplegia  of 
legs  and  abdomen,  retention  of  urine  and  later  incontinence;  and 
then  girdle  pains,  {d)  In  tumors  of  the  lumbar  enlargement  there  are 
unilateral  pains  in  the  lumbar  plexus  and  atrophic  paralysis  in  the 
ileopsoas,  quadriceps,  and  adductors;  there  is  total  anaesthesia  when 
the  cord  is  involved  in  the  region  of  the  lumbar  plexus;  later  partial 
anaesthesia  (affecting  the  sense  of  temperature  and  pain)  develops  in 
the  region  of  the  sacral  plexus;  still  later  there  is  complete  paralysis 
and  anaesthesia  in  the  region  of  the  lumbar  plexus,  with  atrophy, 
absence  of  the  patellar  reflexes,  with  the  reaction  of  degeneration,  while 
the  legs  and  feet  are  spastic,  and  with  clonus  of  the  Achilles  tendon,  (e) 
If  the  localization  is  in  the  sacral  cord,  there  is  atrophic  paralysis  of 
the  leg  and  foot,  of  the  posterior  muscles  of  the  thigh,  of  the  gluteal 
and  perineal  muscles,  anaesthesia,  total  paralysis  of  the  bladder  and 
rectum,  impotence,  loss  of  the  Achilles  tendon  reflex  (while  the  patellars 
may  remain),  early  decubitus  and  cystitis. .  (/)  If  the  tumor  is  in  the 
Cauda,  the  symptoms  are  usually  bilateral  from  the  beginning;  the 
Brown-Sequard  complex  cannot  occur;  paraplegia  is  rarely  as  sym- 
metrical as  it  is  in  cord  lesions;  typical  reaction  of  degeneration  is 
indicative  of  caudal  disease;  pain  is  violent,  since  many  sensory  fibers 
are  in  close  contact;  Minor  described  bilateral  and  even  unilateral 
sciatica  as  an  early  symptom.  The  sacral  plexus  is  chiefly  or  first 
involved,  while  growths  of  the  lumbar  enlargement  affect  both  the 
sacral  and  lumbar  plexus. 

Diagnosis. — The  diagnosis  of  meningeal  tumor,  which  is  always 
most  difficult,  is  based  on  (a)  local  pain  and  rigidity,  which  is  especially 
marked  in  the  extradural  type;  (6)  hyperalgesia;  (c)  radiating  pains, 
i.e.,  root  symptoms  which  later,  by  gradual  transition,  give  way  to 
{d)  cord  symptoms,  which  are  usually  or  often  unilateral  at  first  and 
then  bilateral,  as  interrupted  sensory  and  motor  conduction,  and 
increase  of  the  reflexes.  Carcinoma  of  the  vertebrae  produces  more 
pain  on  movement  than  other  tumors.  In  caries  there  is  less  pain, 
local  vertebral  changes  eventually  appear,  and  the  course  is  usually 
more  rapid.  In  myelitis  the  focus  is  less  commonly  near  the  cervical 
enlargement,  and  therefore  the  arms  are  less  often  paralyzed.  In 
myelitis,  radiating  pains  may  occur,  but  are  much  rarer  than  in  tumor, 
and  a  girdle  sensation  is  more  common.  The  local  pain  sometimes 
suggests  aneurysm,  lung  disease  or  periplieral  neuralgias,  the  tender 


1082  DISEASES  OF  THE  NERVOUS  SYSTEM 

points  of  which  are  always  abseiit.  Other  symptoms  in  the  sequence 
above  given  must  be  present  for  diagnosis.  A  quiet  course,  root 
symptoms,  early  interruption  of  cordal  conduction  and  absence  of 
trophic  disturbance  in  the  bones  and  of  dissociated  anaesthesia  argue 
for  tumor  and  against  syringomyelia.  A  diagnosis  of  tuberculosis  or 
syphilis  is  fortified  by  their  presence  in  other  organs.  Age  is  of  diag- 
nostic importance:  in  youth,  tubercle;  at  puberty,  sarcoma  and  glioma; 
in  the  third  and  fourth  decades,  glioma,  tubercle  or  sarcoma;  and  in 
advanced  years  gummata  are  most  frequent.  Disuse  sarcomatosis  is 
usually  cerebrospinal,  rarely  invades  the  cord  substance  as  do  gum- 
mata and  tubercles,  affects  the  posterior  cordal  surface  most  frequently 
(the  lateral  surface  little,  and  the  anterior  very  rarely)  and  generally 
in  the  lumbar  and  lower  dorsal  regions;  it  occurs  largely  in  the  young 
and  its  course  is  rapid.  Abscess  of  the  cord  is  most  rare.  Tabes  in 
one  remarkable  case  was  simulated  by  multiple  tumors  of  the  posterior 
roots.  Tumors  of  the  cord  are  more  difficult  of  differentiation,  for  root 
symptoms  are  often  lacking. 

Course  and  Prognosis. — Slow  development,  progression  which  is 
either  steady  or  "by  starts,"  sometimes  remissions,  and  eventual 
compression  of  the  roots  or  cord  are  usual,  with  death  from  cystitis, 
or  decubitus.  Sudden  paralysis  is  less  common.  The  average  dura- 
tion is  one  to  three  years,  but  a  longer  course  is  possible  (even  ten  to 
fifteen  years). 

Treatment. — 1.  Therapeutics. — Narcotics  must  be  employed  to 
relieve  pain,  but  should  be  used  sparingly  in  the  early  stages,  because 
if  given  freely,  their  effect  may  fail  later  if  the  course  is  protracted. 
Syphilis  is  always  a  possible  factor;  absence  of  evidence  or  history 
of  the  disease  counts  for  little,  and  the  patient  should  receive  the 
benefit  of  antisyphilitic  treatment. 

2.  Surgical  Treatment. — Gowers  in  1887  localized  a  case  of  fibro- 
myxoma  which  Horsley  removed  successfully;  this  was  the  first  case 
on  record.  Bruns  collated  twenty  cases  of  operation;  33  per  cent, 
of  them  recovered  or  improved.  Putnam  and  Warren  collected  33 
operated  cases,  with  over  50  per  cent,  recovery.  Tumors  of  the  cord 
are  less  favorable  than  those  of  the  meninges.  Intramedullary  tumors 
may  only  crowd  the  nerve  paths,  but  their  removal  is  often  attended  by 
danger  of  laceration  or  acute  myelitis,  which  may  possibly  result  in  dam- 
age equal  to  that  of  the  tumor.  Accurate  localization  is  most  important, 
because,  in  one  case,  after  removing  parts  of  several  vertebrae  in 
vain,  further  search  for  the  suspected  growth  had  to  be  abandoned. 
Therefore,  Urban's  osteoplastic  resection  is  valuable;  it  consists  of 
folding  back  the  cut  muscles  and  bone  that  they  may  be  replaced 
and  the  strength  of  the  spinal  column  may  not  be  impaired.  Death 
may  result  from  shock,  escape  of  cerebrospinal  fluid  (Chipault)  and 
less  frequently,  with  modern  methods,  from  infection.  Starr  records 
16  complete  recoveries.  Harte  in  1905,  collected  92  operations;  the 
operative  mortality  was  47  per  cent.;  of  the  balance,  59  percent, 
were  cured,  34  per  cent,  improved  and  7  per  cent,  not  improved. 


HEMORRHAGE  IX  THE  CORD  1083 

(E).   CIRCULATORY  DISTURBANCES;  HEMORRHAGE;  TRAUMA  OF 

THE   CORD. 

I.  Hyperaemia  of  the  Spinal  Cord. 

As  in  the  spinal  meninges,  postmortem  hypostatic  congestion  is  com- 
mon, especially  in  the  dorsal  aspect  of  the  cord.  Sometimes  the  mem- 
branes are  hyperaemic  and  the  cord  anaemic.  The  white  matter  is 
usually  pale.  The  cord  may  be  passively  congested,  as  in  cardiac 
insufficiency.  Vascular  variability  was  formerly  considered  causal  of 
spinal  irritation  which,  however,  is  functional  (hysterical  and  neuras- 
thenic).    No  definite  clinical  picture  can  be  constructed. 


II.  Anaemia  of  the  Spinal  Cord. 

Paralyses  referred  to  anaemia  of  the  cord  are  without  doubt  mostly 
due  to  neurosis,  neuritis,  hemorrhages  in  the  cord  or  nerve  sheaths,  and, 
in  pernicious  anaemia,  to  degeneration  of  the  dorsal  columns.  Paralysis 
following  profuse  hemorrhage  from  the  stomach  or  uterus  may  be  pro- 
perly referred  to  cord  anaemia.  Stenson  (1667)  demonstrated  experi- 
mentally that  compression  of  the  aorta  produced  paraplegia  due  to 
anaemia  of  the  cord,  the  motor  cells  of  which  appear  to  be  especially 
susceptible  to  ischaemia.  The  symptoms  are  referred  by  others  to 
anaemia  of  the  peripheral  nerves.  Ligature  or  compression  of  the 
aorta  after  ligature  of  both  subclavian  arteries  has  identical  effects 
(Kussmaul  and  Tenner) . 

III.  Embolism  and  Thrombosis  (Myelomalacia)  of  the  Spinal  Cord. 

Embolism  of  the  spinal  arteries  is  extremely  rare,  but  has  been 
observed  in  endocarditis  (v.  Leyden,  Weiss.)  No  separate  clinical 
symptoms  can  be  recognized,  although  experimentally  Money  observed 
choreiform  movements.  Thrombosis  is  very  rare.  Venous  throm- 
bosis is  rare,  and  is  secondary  to  other  lesions  of  the  cord.  Arterial 
thrombosis  is  rather  more  common.  It  has  been  found  in  syphilis, 
multiple  sclerosis,  senility  and  perhaps  bears  some  relation  to  acute 
processes  in  the  cord,  as  disseminated  or  focal  myelitis.  It  is  often 
impossible  to  decide  whether  an  area  of  softening  is  ischaemic  (myel- 
omalacia) or  inflammatory  (myelitis). 

IV.   Hemorrhage  in  the  Cord  (Hsematomyelia). 

Etiology  and  Pathology. — Most  cases  of  this  rare  lesion  occur  in 
men  between  20  and  40  years  of  age.  (a)  Capillary  hemorrhages 
rarely  cause  symptoms;  they  occur  about  larger  extravasations  of  blood 


1084  DISEASES  OF  THE  XERVOUS  SYSTEM 

in  foci  of  softening,  in  inflammation,  stasis,  intoxications,  infections  or 
blood  diseases.  (6)  Hemorrhagic  infiltration  occurs  diffusely,  and 
chiefly  in  areas  of  softening  or  near  larger  foci  of  hemorrhage,  (c) 
The  larger  hemorrhagic  focus  may  result  from  trauma,  muscular 
effort,  caisson-disease,  etc;  it  compresses  and  destroys  the  cord  sub- 
stance; it  rarely  exceeds  the  size  of  a  hazelnut  (round  or  oval  form) 
but  may  extend  through  the  entire  length  of  the  cord  (tubal  form  of 
Levier),  following  exactly  the  less  resistant  gray  matter,  while  the  firmer 
white  columns  (pyramidal  tracts)  usually  resist  its  lateral  diffusion ;  if  it 
invades  the  white  matter,  hemorrhage  usually  occurs  in  the  posterior 
columns;  it  occurs  mostly  in  the  cervical  cord;  all  large  non-traumatic 
hemorrhages  occur  in  the  gray  matter.  Effused  blood  undergoes  the 
same  fate  as  in  other  parts;  it  turns  brown,  then  yellow-red,  and  ulti- 
mately deposits  dark  pigment  and  hsematoidin  crystals.  The  nervous 
tissue  is  disorganized  by  larger  hemorrhages,  which  form  in  it  a 
cavity.     Eventually  a  pigmented  apoplectic  scar  or  cyst  results. 

Symptoms. — The  symptoms  vary  with  the  different  forms,  (a)  In 
the  accessory  form  there  is  bleeding  into  a  tumor,  cavity,  softening 
or  inflammation  (Charcot,  Hayem,  Koster) ;  punctate  hemorrhage 
may  accompany  other  affections,  as  hemorrhagic  purpura,  stasis  or 
convulsive  disorders,  and  few  or  no  symptoms  develop,  (b)  The  trau- 
matic (see  Trauma)  form  is  less  important  in  spinal  fracture  than 
concussion;  it  may  develop  during  dystocia  or  foetal  extraction. 
Trauma  causes  90  per  cent,  of  cases  of  hsematomyelia  (Oppenheim). 

3.  The  spontaneous  form  is  rarer  than  it  is  in  the  brain,  because 
the  cord  is  firmer,  subject  to  lower  blood  pressure,  and  most  rarely 
the  seat  of  miliary  aneurysm ;  it  results  from  sudden  exertion  in  man 
(and  more  often  in  the  horse),  from  repeated  coitus,  suppressed  men- 
struation or  rarely  from  arteriosclerosis. 

The  onset  is  sudden,  without  prodromes  or  loss  of  consciousness. 
Previous  symptoms  may  suggest  a  hemorrhage  into  an  inflammatory 
focus.  Local  symptoms  must  vary  with  the  structures  involved,  and 
their  level;  they  embrace  paraplegia,  monoplegia,  often  the  Brown- 
Sequard  syndrome,  paralysis  with  or  without  atrophy  or  spasticity, 
anaesthesia  either  total  or  partial  (i.  e.,  dissociate,  as  in  syringo- 
myelia, Minor),  as  might  be  anticipated  from  its  location  in  the  gray 
substance  and  posterior  horns;  pain  at  the  level  of  the  lesion,  perhaps 
from  involvement  of  the  posterior  horn;  less  often  eccentric  pain, 
girdle  sensation  and  muscular  rigidity.  The  reflexes  and  sphincters 
vary  with  the  level.  In  general  the  reflexes  are  increased  in  small  and 
abolished  in  large  hemorrhages.  The  symptoms  advance  rapidly  and 
may  suffer  an  accession  from  secondary  reaction  or  myelitis.  Early 
death  is  rare.  Late  death  from  cystitis  or  decubitus  is  more  common. 
Recovery  is  rare,  compared  with  recovery  in  cerebral  apoplexy ;  it  occurs 
most  often  in  the  punctate  type;  it  is  rarely  absolute  and  some  disturb- 
ance in  motility  or  sensation  usually  remains. 

Diagnosis. — The  diagnosis  is  usually  only  probable;  it  is  based  on 
the  sudden  onset  of  paresis  and  anfesthesia  and  their  rapid  advance. 


CAISSOX  OR   DIVERS'    PARALYSIS  1085 

For  differentiation  from  meningeal  hemorrhage  (hoematorrhachis) ,  see 
page  1077;  in  the  latter,  meningeal  irritation  is  more  common,  as 
marked  and  radiating  pains,  rigid  spine  and  muscles,  hyperaesthesia  of 
the  skin  and  muscles;  paralysis  is  absent  or  incomplete;  and  recovery 
is  more  complete.  From  acute  myelitis,  differentiation  is  often  uncer- 
tain and  frequently  of  only  academic  interest,  since  each  affection  may 
complicate  the  other  and  the  prognosis  and  treatment  of  each  are 
similar.  In  myelitis  and  anterior  poliomyelitis  elevation  of  temperature 
is  distinctive. 


V.  Caisson  or  Divers'  Paralysis. 

According  to  Pol  and  Watelle  (1854),  this  occurs  in  workers  who  are 
subject  to  pressure  of  at  least  2,  and  usually  3  or  4  atmospheres. 
Symptoms  appear  when  the  individual  comes  suddenly  into  the  open 
air.  They  vary,  and  include  transient  pain  in  the  ears,  sometimes 
deafness  and  vertigo,  headache  and  pains  in  the  limbs,  joints  and  epi- 
gastrium; in  15  to  50  per  cent,  there  is  paraparesis  or  paraplegia, 
sometimes  with  anaesthesia,  and  usually  with  urinary  retention;  much 
less  often  there  is  hemiplegia  or  involvement  of  both  arms;  epistaxis, 
mental  symptoms;  loss  of  consciousness,  and  symptoms  of  brain- 
pressure,  as  vomiting  or  slowed  pulse.  Men  of  heavy  build,  alcoholics, 
and  "new  hands"  seem  to  be  predisposed;  hard  exercise  after  coming 
into  the  air  produces  unhappy  symptoms,  which  are  not  severe  or  are 
absent  if  the  interval  of  work  does  not  exceed  one  hour. 

Pathology  and  Pathogenesis. — The  pathology  and  pathogenesis 
are  undetermined.  Hoppe-Seyler  (1885)  and  Bert  found  that  lessened 
atmospheric  pressure  liberated  oxygen,  nitrogen  or  carbon  dioxide  in 
the  blood  and  tissues,  which  ruptured  the  vessels  and  tissues  and 
promoted  punctate  hemorrhage.  In  the  first  autopsy  made,  v.  Leyden 
found  clots  in  the  cord  substance,  particularly  in  the  posterior  and 
lateral  columns,  surrounded  by  round  cells  (reactive  disseminated 
myelitis) ;  most  changes  were  in  the  dorsal  cord,  the  tissues  of  which 
are  less  compact;  secondary  degeneration  is  found  (von  Rensselaer) 
and  changes  in  the  gray  substance  (Schultze)  which  are  thought  to 
result  from  hemorrhage;  Catsaris  actually  saw  gas  bubbles  in  the 
blood.  Under  moderate  pressure  the  gas  is  given  off  to  the  lungs, 
while  in  extreme  instances  it  is  given  off  to  the  tissues.  The  symptoms 
apparently  result  less  from  the  gas  bubbles  (air  embolism)  accumulat- 
ing in  the  blood  under  high  pressure,  than  from  its  sudden  reduction 
and  the  reactive  apoplective  myelitis.  Andrew  H.  Smith  holds  that 
the  lesion  is  cordal  congestion  and  stasis. 

Prognosis. — A  few  subjects  die  at  once;  others  die  from  cystitis,  as 
in  myelitis;  about  50  per  cent,  recovers  completely  and  50  per  cent, 
partially,  with  spastic  paresis.  The  mortality  ranges  from  2.7  to  15.8 
per  cent. 


1086  DISEASES  OF  THE  NERVOUS  SYSTEM 

Treatment. — The  return  to  normal  atmospheric  pressure  should  be 
made  gradually;  recompression  is  successfully  employed.  Smith 
recommends  erg-ot. 


VI.  Trauma  of  the  Cord. 

Compression  by  caries,  tumor  and  carcinoma  have  been  considered ; 
other  surgical  lesions  can  only  be  touched  on  here.  Crushing  of  the 
cord  may  be  associated  with  hemorrhage,  myelitis  and  secondary 
degenerations.  Total  division  of  the  cord  may  result  from  fracture, 
gun  shot  or  stab  wounds;  it  is  extremely  rare;  early  death  is  usual; 
its  symptoms  are  absolute  paraplegia,  aneesthesia,  bladder  paralysis, 
and  abolition  of  the  patellar  reflexes.  A  recently  reported  case  of 
total  section  with  operation  and  recovery  was  received  with  some 
skepticism.  Gun  shot  wounds  usually  result  in  fracture,  crushing  and 
sometimes  actual  division;  as  a  rule  the  prognosis  is  unfavorable. 
Stab  wounds  may  produce  bilateral  symptoms,  or  unilateral  signs,  as  the 
Brown-Sequard  paralysis;  20  per  cent,  recover;  60  per  cent,  improve 
and  20  per  cent,  of  cases  die  (Wagner  and  Stolper).  Restitution  of 
function  in  lesser  injuries  results  not  from  regeneration  but  from  com- 
pensation by  other  paths  of  conduction.  Laminectomy  is  indicated 
only  in  crushing  injury  of  the  lower  half  of  the  spine,  because  cervical 
cases  almost  never  recover  (Hahn). 


VII.  Brown- Sequard's  Paralysis. 

This  was  described  by  Sequard  and  Tiirck  simultaneously  in  1850. 
According  to  Brown-Sequard's  original  proposition,  on  the  side  of 
section  (cervical  cord)  there  occurs  (a)  paralysis  of  voluntary  motion, 
muscle  sensibility  and  vasomotor  tonus;  (b)  hyperaesthesia  of  trunk 
and  limbs,  to  touch,  pain,  heat  and  cold;  (c)  vasomotor  paralysis  of 
face  and  eyes  (higher  temperature,  narrow  pupils,  and  moderate 
contracture  of  certain  facial  muscles).  On  the  contralateral  side  there 
is  anaesthesia  of  all  varieties  of  sensation,  except  muscle  sensibility. 

Symptoms. — Exact  hemisection  of  the  cervical  cord  produces  a 
spinal  hemiplegia  on  the  side  of  the  section,  but  in  clinical  injuries  and 
experimental  section,  the  trauma  is  rarely  wholly  complete  or  strictly 
unilateral.  (In  some  cases  decussation  of  the  uncrossed  pyramidal 
tracts  may  occur  in  the  cord  lower  down  than  the  usual  crossing  point 
in  the  medulla  [Flechsig]  and  spinal  hemiplegia  with  contralateral 
monoplegia  may  result  from  unilateral  lesion.  Dejerine  and  Thomas 
speak  of  a  third  "homolateral  pyramidal"  tract,  which  may  cause 
restitution  of  motor  function.  Edinger  mentions  a  "reserve"  inner- 
vation by  which  decussation  of  motor  fibers  occurs  lower  than  the 
pyramidal  decussation  in  the  medulla).  The  most  characteristic 
clinical  type  is  the  mid-dorsal  lesion,  but  in  cervical  section  or  in 


BROWX-SEQUARD'S   PARALYSIS 


108- 


pathological  foci,  paresis  of  the  arm  with  paralysis  of  the  leg  is  more 
usual,  because  the  cervical  motor  tracts  are  less  compact  than  they 
are  in  the  lower  cord;  i.  e.,  paralysis  is  more  frequently  hmited  to  a 
group  of  muscles  than  to  an  entire  upper  extremity.  "Conversely, 
paralysis  of  the  leg  may  be  incomplete,  while  that  of  the  arm  is  com- 
plete, owing  to  the  escape  of  fibers  for  the  leg  which  cross  lower  down 
in  the  cord"  (Gowers).  The  paralysis  often  decreases  with  surprising 
rapidity,  and  if  the  anterior  cells  are  intact  it  gradually  becomes  simple 

Fig.  74. 


Brown-S6quard's  paralysis  from  a  left- 
sided  focus  A,  vaso-motor  and  motor 
paralysis;  B  andD,  cutaneous  anses- 
thesia;  C.hypersesthetic  zone.    (Erb.) 


Fig.  7.5. 


VVS.M 


(Combined  fiom  Brown-Sdquard.) — F,  Focus  in  left 
side  of  cord.  V,  Pyramidal  fibers  having  crossed 
in  medulla.  V ,  Vasomotor  fibers,  not  crossing 
in  cord.  Sm,  Fibers  for  muscle  sense,  not  cross- 
ing in  cord:  SS  S'  S' ,  other  sensory  fibers  crossing 
in  the  cord.  The  focus  explains  the  classical  signs 
and  also  how  few  of  the  crossed  sensory  fibers  to  the 
left  side  are  involved  (merely  a  zone  of  anaesthesia), 
while  all  sensory  fibers  to  the  riglit  side  are  severed 
(hemiansesthesia). 


weakness.  The  motor  are  restored  more  readily  than  the  sensory 
functions.  There  is  an  inactivity  atrophy  of  the  muscles  without 
abolition  of  faradic  irritability  and  without  reaction  of  degeneration ; 
the  paralysis  may  be  spastic  or  flaccid.  Respiration  is  rarely  affected, 
and  imperfect  movement  of  the  chest  has  never  occurred.  Involvement 
of  the  thoracic  and  abdominal  muscles  usually  indicates  a  bilateral 
lesion.  Swelling  and  oedema  in  the  paralyzed  members  have  been 
observed,  and  also  swelling  with  pain  in  all  the  joints  on  the  paralyzed 


1088  DISEASES  OF  THE  XERVOUS  SYSTEM 

side.  The  deep  reflexes  are  usually  exaggerated  on  the  side  of  the  lesion  ; 
they  are  abolished  in  a  sudden  total  transverse  lesion  of  the  lower 
cervical  or  upper  dorsal  cord.  The  skin  reflexes  are  abolished  or 
decreased  on  the  side  of  paralysis,  and  on  the  opposite  anaesthetic  side 
they  may  be  normal,  absent  or  increased. 

Hypercestliesia  (Fodera,  1823)  occurs  on  the  paralyzed  side  and  also 
as  a  zone  above  the  anaesthetic  area  and  near  the  level  of  the  lesion. 
If  the  lesion  be  cer\acal  or  lumbar,  the  anaesthetic  or  hypersesthetic 
areas  above  are  not  zonular  but  irregular.  Hypersesthesia  has  been 
referred  to  the  wound  itself  or  to  paralysis  of  inhibition.  Hyperses- 
thesia  or  hyperalgesia  concern  tactile,  pain,  and  heat  and  cold  sensa- 
tions, and  their  absence  infers  incomplete  section  (Kocher).  It  usually 
disappears  rapidly.  The  fibers,  the  section  of  which  results  in  hemi- 
angesthesia,  lie  in  the  lateral  tract  near  the  cerebellar  and  pyramidal 
tracts. 

The  zonular  anaesthesia  on  the  side  of  the  injury  and  of  motor  par- 
alysis is  readily  explained  since  the  lesion  involves  not  only  the  sensory 
fibers  (which  are  ready  to  decussate  to  the  other  side  and  produce  the 
crossed  hemianaesthesia),  but  also  implicates  sensory  fibers  from  the 
contralateral  side,  which  have  just  decussated  to  the  side  of  section. 
Abolition  of  muscle  sensation  on  the  side  of  the  lesion  is  fully  in  accord 
■^dth  the  uncrossed  course  of  the  muscle  sense  fibers  in  Burdach's  col- 
umn, entering  Goll's  column  higher  up.  Muscle  sense  is  preserved  on 
the  side  opposite  to  the  lesion.  Vasomotor  paralysis  occurs  on  the 
side  of  section,  as  the  vasomotor  fibers  course  in  the  anterolateral  col- 
umns. "Sensation  is  affected  on  the  opposite  side,  but  not  quite  up  to 
the  level  of  the  lesion,  because  the  decussation  of  the  sensory  tract  is 
not  immediate  but  occurs  somewhat  above  the  entrance  of  the  nerve" 
(Gowers).  Complete  crossed  hemianaesthesia  occurs  clinically  in 
about  60  per  cent.,  and  partial  anaesthesia  (analgesia  and  thermo- 
anaesthesia)  in  about  40  per  cent,  of  cases. 

Prognosis.— In  clinical  and  experimental  cases  almost  complete 
restitution  to  normal  is  possible;  it  is  not  due  to  reestablishment  of 
conduction  in  the  severed  tracts,  in  which  ascending  and  descending 
degeneration  occurs,  but  rather  to  assumption  of  function  by  the  unin- 
jured side  of  the  cord  (Kocher).  The  prognosis  and  treatment  of  Brown- 
Sequard's  paralysis  vary  with  the  etiology  of  this  symptomatic  syn- 
drome, which  may  be  syphilis,  tumor,  sclerosis,  myelitis,  tuberculosis, 
trauma,  haematomyelia,  fracture  or  luxation. 

VIII.  Concussion  of  the  Cord. 

Gussenbauer  referred  the  severe  symptoms,  as  paralysis,  to  hemor- 
rhage, which  is  produced  in  turn  by  movement  of  the  cerebrospinal 
fluid.  Long  ago  Ollivier  explained  the  symptoms  as  being  due  to 
molecular  alteration  in  the  nervous  tissue;  this  was  confirmed  by  cases 
of  experimental  concussion   (Schmaus  and  Bikeles)   which  resulted 


ACUTE  MYELITIS  1089 

ill  degeneration  of  the  cells  and  cylinders.  Myelitis  and  chronic 
degeneration  may  follow  concussion.  The  "  railway  spine  "  (Erichsen) 
is  one  of  tlie  traumatic  neuroses.  Obersteiner  considers  that  long 
continued  moderate  jarring,  as  in  the  case  of  tramway  drivers,  may 
injure  the  cord.  Symptoms  develop  at  once  or  sometime  later,  as 
paraparesis,  paraplegia,  retention  of  urine  and  anaesthesia,  less  often 
than  parsesthesia.  Some  cases  recover  after  months  to  a  year  or  two. 
In  others  the  symptoms  are  permanent;  in  still  others  death,  usually 
early,  occurs.  In  diagnosis,  fracture,  hsematorrhachis,  hsematomyelia 
and  traumatic  neurosis  should  be  considered.  Simulation,  in  order  to 
obtain  damages  for  accidents,  may  be  difficult  to  exclude,  but  some 
railway  surgeons  and  medical  experts  in  corporation  employ,  err  in 
discounting  the  importance  of  concussion  and  traumatic  neurosis 
iq.  v.).  Paraplegia  and  retention  of  urine  are  indicative  of  structural 
alteration  of  the  cord.  Treatment  consists  of  rest,  local  application  of 
cold  and  avoidance  of  neurotic  tendencies. 


(F).    INFLAMMATION  OF  THE  CORD. 

Myelitis  is  inflammation  of  the  cord.  It  was  described  by  Oliver 
and  Abercrombie  a  century  ago;  the  term  has  long  been  made  to 
cover  many  affections  which  are  not  properly  inflammatory,  as  com- 
pression paralysis.  Oppenheim  and  Marie  have  vigorously  disputed 
the  opinion  of  Gowers,  v.  Leyden,  and  Erb,  that  myelitis  is  a  frequent 
affection. 


I.  Acute  Myelitis. 

Etiology. — There  are  two  prominent  causes,  infections  and  intoxi- 
cations. The  affection  occurs  largely  in  males  between  ten  and  forty 
years  of  age. 

1.  Acute  Infections. — Experimental  myelitis  has  been  produced  by 
the  B.  pyocyaneus,  B.  diphtherise,  B.  coli,  B.  typhosus,  strepto-  and 
staphylococci,  avian  and  human  tuberculosis.  French  writers  have 
contributed  most  to  this  subject.  It  has  followed  epidemic  menin- 
gitis, variola,  typhus,  measles,  rheumatism,  and  other  infections,  caused 
(a)  by  the  germs  themselves  or  secondary  infection  (focal  myelitis  re- 
sulting) or  (b)  by  their  toxins  (disseminated  myelitis  resulting). 

2.  Intoxications.— These  include  poisoning  by  alcohol,  ergot,  and 
lead,  and  perhaps  auto-intoxications,  as  in  cancer,  or  severe  anaemia. 

All  other  causes  are  doubtful;  trauma  (fracture,  concussion,  com- 
pression by  caries  or  cancer)  is  often  considered  of  etiological  impor- 
tance but  probably  causes  softening  or  hemorrhage,  to  which  infection 
may  of  course  be  added;  exposure  to  cold  and  dampness  most  likely 
reduce  the  physiological  resistance,  thus  indirectly  favoring  localization 
of  bacteria;  syphilis  (q.  v.)  may  affect  the  meninges  and  cord  (meningo- 


1090  DISEASES  OF  THE  XERVOUS  SYSTEM 

myelitis),  but  the  so-called  syphilitic  myelitis  is  usually  ischsemdc 
softening  from  vessel  changes.  The  etiological  importance  of  sexual 
excesses  and  emotional  shocks  is  at  present  sharply  questioned,  as  is 
Ton  Leyden's  theory  that  infection  from  the  bladder  may  reach  the  cord 
by  ascending  neuritis. 

Pathology. — On  macroscopic  examination  we  find  redness  and 
swelling;  on  cross  section,  blurring  of  the  cord  tissues,  and  decreased 
consistency,  even  to  fluidity;  as  in  the  brain,  "red  softening"  (hemor- 
rhagic myelitis),  and  in  older  cases  "yellow  softening"  from  fatty 
change,  or  "white  softening"  and  cavity  formation  occur.  ^Myelitis 
can  usually  be  seen  to  best  advantage  after  hardening  in  Miiller's 
solution,  the  normal  tissue  then  appears  green  and  the  diseased,  yellow. 
In  the  ultimate  stages,  atrophy,  cyst  formation,  induration  and  very 
rarely  abscesses  are  found.  Microscopically  there  are,  in  fresh  cases, 
degenerated  swollen  axis  cylinders,  the  disintegrating  medullary 
sheaths  of  which  may  form  myelin  drops;  granules  and  granule  cor- 
puscles (leukocytes  or  vessel  endothelial  cells);  extra vasated  red  and 
white  cells;  turgid  vessels  the  nuclei  of  which  proUferate;  choking  of 
the  perivascular  lymph  spaces  mth  cells;  degeneration,  blurring  and 
vacuole  formation  of  the  nerve  cells  the  processes  of  which  shrink  and 
the  nuclei  vanish;  granular  amorphous  deposits  of  coagulated  albumin 
in  and  about  the  cells;  in  some  cases  the  parenchymatous  far  exceeds 
the  interstitial  alteration,  and  often  parenchymatous  myelitis  were 
better  called  parenchymatous  degeneration.  The  gray  matter  (polio- 
myelitis) is  involved  much  more  often  than  the  white  (leukomyelitis). 
In  older  cases,  there  are  corpora  amylacea,  empty  spaces  corresponding 
to  destroyed  nerve  fibers;  large  "spider"  cells  with  many  processes 
(Deiter's  cells);  and  there  is  disappearance  of  the  vascular  changes 
and  substitution  of  destroyed  tissue  by  focal  interstitial  proliferation. 
In  rare  instances  bacteria  are  found,  as  streptococci,  or  the  colon  or 
typhoid  bacilli,  but  probably  the  toxins  are  more  important  than  the 
organisms.  The  microscope  differentiates  between  the  ischsemic 
inflammation  and  postmortem  softening.  The  degree  and  the  extent 
of  inflammation  vary  greatly;  transverse  myelitis  may  destroy  an 
entire  cross  section;  or  disseminated  foci  may  involve  at  random 
various  structures  at  different  levels.  Meningomyelitis  (perimyelitis, 
annular  or  cortical  myelitis)  chiefly  affects  the  periphery  of  the  cord, 
whence  concentric  invasion  along  the  septa  may  split  the  cord  struct- 
ures; this  is  frequent  in  the  syphilitic  form.  PoUornyelitis  (inflam- 
mation of  the  gray  substance)  is  really  a  type  of  myelitis,  but  involving 
as  it  does  only  the  anterior  horns,  is  usually  classified  by  itself.  De- 
generation and  inflammation  of  the  motor  and  sensory  roots  may  follow 
myelitis  in  the  cervical  or  lumbar  enlargement;  secondary  degenera- 
tions are  common;  the  inflammation  may  ascend  or  descend  the  cord, 
but  usually  affects  only  one  or  two  segments. 

Symptoms. — The  symptoms  vary  with  the  extent,  form  and  locali- 
zation. The  localized  form,  limited  to  a  small  segment,  is  called 
transverse,  while  the  dift\ised  form  is  known  as  disseminated  myelitis. 


ACUTE  MYELITIS  1091 

Acute  transverse  myelitis  is  the  prototype.  The  cord  symptoms 
are  usually  first  in  time  and  always  first  in  importance,  and  consti- 
tutional sympioms  as  fever,  chills,  malaise,  and  in  children  convulsions, 
sometimes  may  precede  but  usually  attend  the  cord  symptoms.  The 
symptoms  resulting  from  involvement  of  the  cord  are  (a)  'paralysis, 
which  is  usually  early,  rapid  but  not  apoplectic  in  onset,  and  is  prom- 
inent, paraplegic,  progressive,  flaccid  and  rather  complete.  In 
complete  paralysis,  the  flexors  are  usually  weaker  than  the  extensors. 
The  toes  alone  may  be  moved;  twitching  of  the  paretic  muscles  is 
usually  associated  with  pain.  Clonic  muscular  spasms  are  sometimes 
present,  inappropriately  designated  by  Brown-Sequard  as  spinal 
epilepsy.  The  paralysis  is  often  preceded  for  a  short  time  by  sensory 
phenomena,  as  numbness,  or  by  darting  pains  in  the  limbs,  joints  or 
back,  which  are  usually  neither  conspicuous  nor  severe;  it  is  less  often 
preceded  by  hypersesthesia,  local  muscular  contractions,  or  general 
convulsions,  especially  in  children.  The  paralyzed  limbs  show  a 
transient  rise  of  temperature,  followed  by  somewhat  subnormal 
temperature.  The  limbs  are  often  dry  and  may  not  sweat  even  after 
injection  of  pilocarpin  (Brieger).  (6)  Sensation  is  frequently  involved. 
The  initial  tingling  pain  has  been  considered.  Anaesthesia  may  be 
complete  to  the  level  of  the  lesion,  but  more  often  incomplete  (hypsesthe- 
sia),  and  rarely  partial,  according  to  the  cordal  tissues  involved.  It 
is  higher  anteriorly  than  posteriorly;  a  zone  of  hypersesthesia  or  "  girdle 
pain"  marks  the  upper  level;  it  is  caused  by  early  irritation  or  late 
cicatrization.  Severe  pain  suggests  vertebral  or  root  disease  rather 
than  myelitis;  gastric  crises  like  those  of  tabes,  dyssesthesia  (Charcot), 
i.  e.,  diffuse  vibrating  sensations  over  the  entire  limb  from  local 
stimulation,  as  by  a  needle,  and  ataxia  (which  is  usually  obscured 
by  the  paraplegia)  are  much  less  common,  (c)  At  the  onset  all  reflexes 
may  be  lost,  but  they  are  usually  increased  below  the  focus,  because 
of  lessening  of  the  cerebral  inhibition  traveling  in  the  lateral 
pyramidal  tracts,  the  skin  reflexes  being  increased  early  and  the 
muscle  reflexes  later;  involvement  of  their  centres  causes  permanent 
loss  of  the  reflexes;  for  instance,  they  are  lost  in  the  arms  and  increased 
in  the  legs  in  cervical  myelitis;  lost  in  the  trunk  and  increased  in  the 
legs  in  dorsal  myelitis;  lost  in  the  legs  in  lumbar  myelitis,  {d)  The 
sphincters  are  afi^ected  almost  constantly  and  early,  perhaps  even  before 
the  onset  of  paraplegia;  initial  difficult  urination  (ischuria)  or  urinary 
retention,  possibly  with  sphincter  spasm  and  later  with  incontinence, 
is  usual;  when  the  bladder  is  full  it  may  dribble  from  relaxation  of 
the  sphincter:  this  is  known  as  ischuria  paradoxa  or  retention  with 
incontinence;  the  patient  may  or  may  not  be  conscious  of  the  retention, 
depending  on  whether  the  afferent  sensory  fibers  are  involved  or  not; 
in  lumbar  myelitis  incontinence  prevails  from  the  beginning.  The 
urine  is  at  first  alkaline  and  later  ammoniacal  on  the  advent  of  cystitis. 
The  sphincter  ani  acts  involuntarily,  i.  e.,  is  spasmodically  contracted; 
the  paresis  of  the  bowel  and  abdomen  are  factors  in  constipation;  in 
lumbar  myelitis  the  sphincter  is  paralyzed,     (c)    Trophic  changes  may 


1092 


DISEASES  OF  THE  NERVOUS  SYSTEM 


occur.  Muscular  atrophy  and  the  reaction  of  degeneration  are  caused 
by  disease  in  the  anterior  horns  and  the  muscles  also  waste  from  in- 
activity. The  skin  is  usually  dry,  sometimes  glossy  or  the  seat  of 
papular  or  vesicular  eruptions,  shedding  or  over-growth  of  the  hair. 


Cord  Symptoms  Grouped  According  to  Localization. 
(Amplified  from  Morton  Prince.) 


In  order  of  fre- 
quency. 


Dorsal  myelitis  most  fre- 
quent. 


Then  Lumbar  myelitis. 


Lastly,  Cervical  myelitis. 


Paralysis. 


Trunk,  back,  intercostal 
and  abdominal  muscles 
(favoring  mucus  stag- 
nation in  lungs).  Arms 
normal.  Paraplegia, 
first  flaccid  then  spastic 
(lateral  columns  in- 
volved) . 


Trunk   and  arms  normal. 
Paraplegia  flaccid 
throughout   (ant.  horns 
involved). 


Atrophy. 


Reaction   of   de- 
generation. 


Sensation. 


Reflexes. 


Sphincters. 


Trophic  changes, 
etc. 


In  trunk;  diflBcult  to  elicit. 
In  legs;  ;only  from  in- 
action. 


Present  in  trunk  muscles; 
absent  in  legs  (or  only 
quantitative  reduction). 

Girdle    pain    and    hyper- 
aesthesia,  between  ensi- 
form  and  navel.    Anaes- 
thesia corresponding 
■with  motor  paralysis. 


Superficial  reflexes,  initial 
loss,  rapid  return  and 
increase. 

Deep  reflexes,  initial  loss, 
slow  return  and  increase. 

Bladder,  initial  retention, 
later  intermittent  over- 
flow or  incontinence. 
Cystitis  common. 

Bowels,  usually  spasm  of 
sphincter  ani;  consti- 
pation. 


Decubitus 
-  etc. 


frora    neglect, 


None  in  arms  or  trunk, 
Atrophy  in  legs:  (ant. 
horn  involved). 


Present  in  legs  or  in  mild 
cases  quantitative  re- 
duction. 

Pain  in  loins  or  legs;    hy- 
persesthesia  in  loins. 
Anaesthesia  of  legs. 


Lost- 
Lost. 


Incontinence  from  begin- 
ning (sphincter  paraly- 
sis). 


Incontinence   (sphincter 
paralysis)  disguised,  per- 
haps, by  constipation. 

Decubitus,  cystitis,  etc. 
from  neglect  and  trophic 
alteration. 


Neck  muscles,  diaphragm, 
arms ,  trunk  and  legs  par- 
alyzed.   Typically,  atro- 
phic flaccid  paralysis  of 
arms  (ant.    horns  invol- 
ved), with  flaccid,  later 
spastic  paralysis  of  legs 
(lat.  columns  involved) : 
however,  paraplegia 
brachialis  with  paralysis 
of  legs  is  very  rare.     In 
rare  lesions  high  in  the 
cervical  cord,   the  neck 
muscles  atrophy  and 
both  arms  and  legs  show 
simple,  then  spastic 
paralysis,  without 
wasting. 

Atrophy  of  neck  muscles 
if  high  lesion  (rare). 
Usually  of  arms  only 
(ant.  horns  involved  at 
level  of  lesion).  In  legs 
only  from  inaction. 


Present  in  arms; 
in  neck). 


(rarely 


Pupils. 


Priapism. 


Mode  of  death. 


Klumpke's     paralysis     of  Absent. 
pupiUif  in  upper  dorsal). 


Often  present  and  painful; 
sometimes  ejaculation 
at  onset. 

Cystitis,  decubitus. 


None.    Impotence. 


Decubitus,  cystitis. 


Pain  and  hyperaesthesia  in 
arm  nerves  (with  highest 
localization);     anaesthe- 
sia in  arms  (lower 
localization);    and  the 
trunk  and  legs. 

Superficial  reflexes;  initial 
loss,  rapid  return  and 
increase. 

Deep  reflexes;  initial  loss, 
slow  return  and  increase. 

Same  as  in  dorsal  myelitis. 


Same  as  in  dorsal  myelitis. 


As  in  dorsal  lesions.  (Oc- 
casionally very  high 
temperature.) 

Paralysis  of  pupil  (lowest 
cervical  region).  Optic 
neuritis  in  isolated  cases. 

Priapism  often  present. 


Medulla  sj-mptom.    vomit- 
ing,  slow  pulse;   UM'ally 
by     involvement     of 
phrenic  nerve  with  ear  y 
death. 


ACUTE  MYELITIS  1093 

The  joints  are  sometimes  swollen  and  the  limbs  oedematous.  Bed- 
sores are  frequent  over  the  sacrum,  trochanters,  heels,  between  or  even 
over  the  knees,  from  the  bed  covers;  they  result  from  neglect  or  in 
lumbar  myelitis  from  trophic  disturbance  (disease  in  the  gray  matter 
or  posterior  horns).  The  same  factors  are  said  by  some  writers  to 
cause  cystitis,  ulcerations  in  the  bladder  or  urethra,  and  the  tendency 
to  cellulitis  or  phlegmon. 

Course  and  Prognosis. — The  onset  may  take  place  in  a  few  hours 
(the  apoplectic  form),  or  in  several  days  to  a  week  (the  subacute  form). 
Four  stages  are  described,  which  however,  blend :  (a)  the  more  or  less 
acute  initial  stage;  (b)  the  advancing  degeneration;  (c)  the  restitution; 
and  (d)  the  stationary  (residual  or  chronic)  stage.  Complete  para- 
plegia and  anaesthesia  may  persist,  but  more  often  sensation  returns 
after  some  weeks,  v/hile  movement  returns  far  more  slowly  and  incom- 
pletely, usually  with  some  residual  spastic  paraplegia.  Contractures 
may  develop,  especially  in  the  adductors  and  the  knee  flexors,  in  which 
case  the  prognosis  is  particularly  unfavorable,  for  profound  disease  is 
indicated.  Contractures,  muscular  contractions,  and  increased  re- 
flexes are  caused  by  secondary  degeneration.  The  immediate  outlook 
in  myelitis  is  always  uncertain,  and  ultimate  recovery  is  usually  incom- 
plete; it  depends  (a)  on  the  etiology,  the  prognosis  being  best  (Oppen- 
heim)  in  acute  infections;  (6)on  the  intensity  of  inflammation;  (c)  on  its 
transverse  or  vertical  dimensions,  and  (d)  on  the  rapidity  or  tardiness 
of  signs  of  improvement.  Complete  recovery  in  mild  circumscribed 
forms  is  barely  possible,  since  indirect  symptoms,  due  to  collateral 
oedema  may  disappear.  Death  results  from  extension  to  the  medulla 
(causing  slow  pulse,  and  vomiting),  phrenic  nerve  phenomena,  and 
sepsis  following  cystitis,  pyelitis^  or  pyelonephritis.  A  form  of  recur- 
rent myelitis  is  said  to  exist  (myelite  a  rechutes). 

Diagnosis. — The  early  onset  of  structural  cord  symptoms,  as  reten- 
tion of  urine,  followed  by  paraplegia  and  by  anesthesia,  is  especially 
significant  after  acute  infections.  Very  rarely  is  there  local  tenderness. 
The  upper  level  of  the  myelitis  corresponds  to  that  of  the  paralysis  or 
anaesthesia.  The  lower  level  may  be  determined  by  the  condition  of 
the  reflex  centres.  Application  of  a  weak  faradic  current  shows  to 
what  extent  the  gray  matter  is  involved.  Anterior  'poliomyelitis  (q.v.) 
does  not  involve  sensation,  and  but  rarely  extends  back  of  the  anterior 
horns.  Compression  by  caries,  or  cancer  usually  causes  local  vertebral 
changes  and  root  symptoms  precede  cord  symptoms.  The  so-called 
syphilitic  myelitis  is  usually  ischeemic  myelomalacia;  it  begins  acutely 
or  subacutely  without  pain,  and  is  rarely  relieved  by  antisyphilitic. 
remedies.  Hemorrhage  in  the  cord  produces  most  sudden  symptoms, 
and  acute  spinal  pain  without  prodromes;  a  precipitate  onset  may 
.cause  confusion  instead  of  being  of  diagnostic  value,  in  case  of  apoplec- 
tic myelitis.  For  differentiation  from  Landry's  paralysis,  see  page 
1102,  and  from  midtiple  neuritis,  see  page  1145.  Meningeal  hemorrhage 
and  meningitis  produce  unmistakable  root  symptoms.  Abscess  of  the 
■cord  is  rare,  for  few  more  than  a  dozen  cases  are  reported;   its  symp- 


1094  DISEASES  OF  THE  NERVOUS  SYSTEM 

toms  are  essentially  those  of  myelitis,  plus  meningeal  symptoms. 
Hysterical  paraplegia  has  a  psychical  etiology;  it  is  characterized  by 
other  stigmata  of  hysteria,  motiveless  variability  of  the  symptoms, 
little  myotatic  irritability,  little  extensor  spasm  (and  then  both  legs 
move  together  when  one  spasmodically  extended  leg  is  lifted);  rarely 
by  incontinence  of  urine  or  fteces,  no  trophic  changes,  no  cystitis,  no 
reaction  of  degeneration,  and  no  decubitus. 

Gower  's  scheme  for  diagnosis  from  the  method  of  onset  is  here  given : 


Disease.                                        Onset. 

Disease. 

Pressure 

and 
Growths. 

Sudden  (few  minutes).           1 
Acute  (few  hours  or  days),   j 
1  Subacute  (1  to  6  weeks). 

[  Subchronic  (6  weeks  to  6  months).                          1 
J  Chronic  (more  than  6  months).                                 j 

^  Vascular  Lesions. 
[  Inflammation. 
^  Degeneration. 

In  the  chronic  stage  the  diagnosis  of  what  has  gone  before  must  be 
uncertain,  unless  the  history  is  most  definite;  the  diagnosis  is  usually 
provisional,  and  atypical  cervical  pachymeningitis,  tumors,  and  most 
often  multiple  sclerosis  of  the  spinal  type,  should  be  considered. 

Treatment. — This  is  symptomatic.  In  the  acute  stage,  the  indica- 
tions are  (a)  absolute  rest  in  bed  for  at  least  two  weeks,  keeping  the 
patient  on  one  side  or  on  the  face,  with  possibly  local  abstraction  of 
blood  and  local  warmth.  Blisters  should  be  avoided  lest  they  develop 
into  decubitus.  (6)  Gowers  recommends  spt.  etheris  nitrosi  with  digitalis 
to  equalize  the  circulation  and  promote  diuresis,  (c)  When  hemor- 
rhagic myelitis  is  suspected  ergotin  (grs.  iij  to  v)  may  be  given  three 
times  daily,  (d)  Mercury  and  iodides  are  usually  without  effect  in 
syphilitic  myelitis  (softening)  or  are  possibly  directly  injurious, 
although  some  rationally  recommend  their  use  unless  unfavorable 
effects  appear,  (e)  Care  of  the  skin  is  necessary.  Though  bed-sores 
may  be  trophic,  practical  experience  shows  that  care  greatly  reduces 
their  frequency  and  extension.  Pressure  and  heat  should  be  avoided 
by  change  of  posture,  by  use  of  rubber  cushions,  soft  thick  pads  of 
cotton  or  the  water  bed.  As  in  typhoid,  the  use  of  two  beds  is  very 
beneficial,  and  the  sheets  should  be  stretched  smooth.  Alcohol  rubs 
are  antiseptic  and  harden  the  skin.  Moisture  and  filth  are  most  dan- 
gerous; the  bowels  should  be  irrigated  if  they  move  involuntarily; 
incontinence  of  urine  is  more  dangerous,  especially  in  women;  hard 
urinals,  if  left  between  the  legs,  may  cause  equal  damage;  the  urine 
should  be  gathered  in  bags  of  oiled  silk  filled  with  cotton;  in  women 
mild  antiseptic  gauze  should  be  disposed  about  the  genitalia.  The 
author  has  used  successfully  the  rubber  dam  used  by  Dr.  ]\Iurphy  in 
laparotomies,  by  spreading  it  over  the  sacrum  and  buttocks  after  care- 
fully cleansing  and  drying  the  skin  and  washing  it  with  ether,  before 
applying  the  dam.  (/)  Care  of  bladder  is  imperative.  Cystitis  develops 
in  most  cases  in  which  the  catheter  is  used,  or  in  which  there  is  incon- 
tinence with  retention;  residual  urine  is  easily  infected,  probably  by 
infection  ascending  the  dribbling,  patent  urethra;   the  urethra  should 


ACUTE  POLIOMYELITIS  OF  CHILDREN  1095 

be  irrigated  before  the  absolutely  clean  catheter  is  introduced;  lavage 
with  Thiersch's  solution  in  cystitis  with  retention  or  incontinence, 
and  grs.  v  to  x,  each  of  urotropin  and  salol  t.i.d.  are  indicated,  (g) 
The  paralyzed  muscles  should  be  gently  massaged  from  the  very  onset. 
In  the  subacute  or  chronic  stage,  tonics,  massage  after  four  weeks, 
mild  faradism  of  the  muscles  of  the  bladder  and  rectum  (not  those  of 
the  cord,  and  only  when  there  is  muscular  wasting  or  incontinence) 
are  indicated.  Bruns  considers  spinal  galvanization  most  efficacious. 
Contractures  are  modified  or  prevented  by  warm  baths  and  massage. 
Hot  baths  are  directly  dangerous. 

II.  Acute  Multiple  Disseminated  Myelitis. 

This  affection  is  relatively  infrequent,  although  of  late  more  cases 
are  reported.  It  is  usually  subacute  in  onset;  foci  develop  irregularly, 
together  or  successively  in  different  parts  of  the  cord  or  perhaps  of  the 
brain  {disseminated  encephalomyelitis),  with  acute  ataxia,  scanning 
speech,  dysarthria,  tremor,  nystagmus,  optic  neuritis,  spasticity,  or 
weakness  of  the  limbs.  Sensation  and  the  sphincters  are  usually  not 
affected.  The  clinical  picture  is  necessarily  irregular,  because  the  inflam- 
mation may  occur  anywhere;  von  Leyden  distinguishes  (a)  the  atactic, 
and  (6)  the  paraplegic  form.  A  myelitis  which  spreads  after  the  first 
two  or  three  days  is  of  the  disseminated  type,  and  may  be  fatal  in  a 
few  days  to  a  few  weeks;  though  it  was  once  thought  very  fatal,  num- 
bers of  recoveries  have  been  reported  lately.  Treatment  is  as  in  the 
acute  transverse  variety. 

III.  Chronic  Myelitis. 

This  m^ay  be  the  stationary  stage  of  a  passed  acute  myelitis,  or  in 
very  rare  cases,  myelitis  may  be  chronic  from  the  beginning,  i.e.,  it 
may  have  a  gradual  onset  and  slow  progression.  Many  deny  the 
existence  of  this  form  and  classify  it  under  the  paraplegic  state,  mul- 
tiple sclerosis,  or  chronic  system-disease.  If  myelitis,  chronic  from  the 
onset,  is  to  be  recognized,  its  symptoms  differ  from  the  acute  form  only 
or  chiefly  in  the  mode  of  onset. 


IV.  Acute  Poliomyelitis  of  Children. 

Acute  poliomyelitis,  also  known  as  atrophic  paralysis,  was  first 
described  clinically  by  v.  Heine  (1840),  and  pathologically  by  Cornil 
(1863),  although  Prevost  and  Vulpian  (1865)  first  accurately  defined 
the  changes  in  the  ganglionic  cells  of  the  anterior  horn.  The  famous 
contribution  of  Charcot  and  Joffroy  (1870)  fixed  the  trophic  relation 
of  the  special  cells  involved  to  the  atrophy  of  the  nerves  and  muscles 


IGid6  DISEASES  OF  THE  NERVOUS  SYSTEM 

supplied,  and  stated  that  the  disease  was  due  to  primary  inflammation 
of  the  cells  themselves.  Archambault  and  Damaschino  found  the  pri- 
mary inflammation  in  the  vessels  (interstitial  myelitis). 

Definition. — An  acute,  probably  independent,  infection,  character- 
ized pathologically  by  acute  myelitis  of  the  anterior  horns,  and  clinically 
by  the  incidence  in  children  of  an  acute  flaccid  paralysis  with  wasting 
in  the  muscles,  loss  of  reflexes,  the  reaction  of  degeneration  and  later, 
contractures. 

Etiology. — In  some  statistics  it  constitutes  as  high  as  8  per  cent,  of 
the  diseases  of  childhood. 

1.  Age. — The  disease  largely  occurs  between  the  first  and  fourth 
years  of  life  (mostly  in  the  second  and  third);  60  per  cent,  of  cases 
occur  in  the  first  three  years,  and  it  is  ten  times  as  frequent  in  the  first 
decade  as  in  all  the  others.  Its  occurrence  in  youth  is  difiicult  to  explain 
although  Lange  refers  it  to  functional  activity  of  the  cord,  as  learning 
to  walk,  etc.  It  has  no  causal  connection  with  dentition,  as  Under- 
wood thought,  although  often  synchronous  with  it. 

2.  It  may  follow  such  infections  as  measles  or  scarlatina,  and  Marie 
thinks  that  it  may  result  from  many  others,  (infectiones  innomminees). 
In  some  localities  it  has  occurred  as  an  independent  epidemic,  as 
Caverly's  series  of  140  in  Vermont,  or  Medin's  series  of  44  in  Sweden. 
Alice  Woods  describes  an  epidemic  of  60  to  70  cases  in  San  Francisco, 
in  May  and  June,  1901. 

3.  Eighty  per  cent,  of  cases  occurs  in  the  summer  months  (Sinkler). 
Cold  and  trauma  are  improbable  factors.  Sex  is  of  no  importance, 
save  after  the  tenth  year,  when  the  disease  is  almost  entirely  confined 
to  males  (Gowers). 

Pathology. — The  affection  is  called  poliomyelitis  (Kussmaul),  because 
it  is  an  inflammation  of  the  anterior  gray  matter,  which  is  supplied  by 
the  central  arteries  of  the  anterior  median  artery  of  the  anterior  longi- 
tudinal fissure.  A  single  vessel  does  not  supply  all  the  anterior  gray 
matter,  but  branches  up  and  down,  supplying  a  cylindrical  vertical 
area  which  measures  two  inches  or  more;  this  is  the  usual  dimension 
of  a  poliomyelitic  focus.  The  inflammation  may  extend  somewhat 
back  of  the  anterior  horns  into  the  white  matter  of  the  antero-lateral 
columns.  Fresh  cases  are  rarely  seen,  since  death  is  unusual;,  to  the 
naked  eye,  the  focus  is  red,  soft,  juts  above  the  cut  section  and  is  mostly 
confined  to  the  anterior  horn,  i.e.,  it  involves  the  beginning  of  the 
second  (or  lower)  motor  neurone.  Microscopically,  the  lesion  is  inflam- 
mation in  and  about  the  vessels  above  named,  in  the  anterior  roots, 
and  in  the  vessels  even  before  they  enter  the  cord.  The  vessels  are 
engorged ;  their  perivascular  spaces  are  full  of  cells  and  granule-cells ; 
there  is  exudation  of  red  and  white  cells  with  actual  hemorrhage  in  the 
severe  cases,  as  shown  by  blood  pigment;  the  ganglion  cells  in  the 
anterior  horn  are  swollen,  glistening,  granular,  pale,  distended, 
decreased  in  number,  and  surrounded  by  leukocytes;  their  dendrites 
may  shrink,  their  nuclei  disappear,  or  the  whole  cell  may  disintegrate, 
while  here  and  there  some  cells  escape;   no  definite  cells  are  involved, 


.  ACUTE  POLIOMYELITIS  OF  CHILDREX  1097 

since  the  process  depends  solely  on  the  vessel  affected.  The  involve- 
ment is  sometimes  bilateral,  and  in  severe  cases  is  distributed  through 
several  segments,  especially  in  the  lumbar  cord.  As  may  easily  be 
anticipated,  disease  in  the  trophic  cells  of  the  lower  motor  neurone  must 
be  followed  by  degeneration  of  their  axis  cylinders,  nerve  roots,  peri- 
pheral nerves  and  muscles  (which  become  granular,  fatty,  and  later 
indurated).  In  old  cases,  macroscopic  inspection  shows  shrinking  of 
the  anterior  horns,  perhaps  also  of  the  contiguous  white  matter,  with 
lack  of  differentiation  between  the  gray  and  white  matter.  Micro- 
scopically, the  (formerly  inflamed)  vessels  are  thickened  and  pig- 
mented ;  groups  of  ganglion  cells  have  disappeared,  and  their  nerve  fibers 
are  degenerated  or  wholly  wasted,  which  led  Charcot  to  hold  that  the 
process  was  essentially  in  the  ganglionic  cells,  but  the  connective 
tissue  also  is  rich  in  cells  and  stains  deeply  with  carmine,  because  it  is 
thicker  than  normal;  in  other  words,  a  cicatrix  remains  from  the  pri- 
mary inflammation.  In  severe  cases,  identical  changes  have  been 
found  in  the  medulla,  pons,  and  centrum  ovale.  Acute  poliomyelitis 
differs  from  acute  myelitis  and  disseminated  myelitis  only  in  its  locali- 
zation, for  which  there  is  no  universally  accepted  reason;  the  gray 
substance  is  more  vascular,  and  Lamy's  experiments,  in  which  he 
injected  powder  into  the  abdominal  aorta,  always  showed  embolic 
softening  of  the  gray  matter  first. 

SjTnptoms. — There  are  three  clinical  'periods:  1.  The  acute  stage 
(including  prodromes) :  2.  The  stage  of  diffuse  paralysis,  when  degen- 
eration appears  and  regeneration  occurs:  3.  The  stationary  stage, 
with  some  improvement  and  determination  of  the  paralysis  to  given 
groups  of  muscles. 

1.  The  Acute  Stage. ^ — ^The  typical  onset  is  acute,  appearing  in  a 
child  previously  well,  with  fever  (75  per  cent.),  often  with  vomiting, 
headache,  somnolence,  and  sometimes  with  convulsions  or  coma, 
which  are  followed  by  a  sudden  complete  and  flaccid  paralysis  in  one 
limb  or  more  than  one  limb;  it  corresponds  to  the  acute  inflammation 
in  theanterior  horn.  The  fever  averages  101°,  may  reach  105°  or  more, 
and  lasts  about  24  hours.  Convulsions  are  not  as  common  as  in  the 
cerebral  type;  they  occur  mostly  in  younger  subjects  and  are  attributed 
perhaps  to  teething,  which  was  once  thought  the  cause  of  the  paralysis. 
The  simple  motor  paralysis  usually  reaches  its  maximum  in  twenty- 
four  to  forty-eight  hours;  it  is  not  progressive;  its  distribution  will  be 
considered  under  the  next  stage.  In  some  cases  prodromata  exist, 
which  are  not  characteristic;  they  are  malaise,  anorexia,  pain  in  the 
back  and  limbs  or  diarrhoea;  their  average  duration  is  one  to  two  days. 
Unusual  variations  in  the  onset  are  possible;  the  fever  may  last  one 
or  two  weeks  before  the  paralysis  develops,  it  may  be  short,  lasting 
for  a  few  hours  only,  or  may  be  absent  throughout  the  entire  course. 
The  paralysis  may  develop  during  the  night.  Abortive  cases  are  most 
exceptional  and  are  probably  often  due  to  neuritis;  the  paralysis  may 
follow  some  acute  infection,  as  measles  or  scarlatina.  Sometimes  par- 
alysis is  not  noticed  for  a  longtime,  until,  for  example,  the  child  fails 


1098  DISEASES  OF  THE  NERVOUS  SYSTEM  . 

to  walk.  In  some  cases  pain  is  the  first  symptom  in  older  children, 
and  is  referred  to  the  back  or  extremities.  Convulsions  involve  princi- 
pally the  extremities,  and  sometimes  occur  in  the  form  of  clonic  muscu- 
lar contractions;  Striimpell  observed  them  for  more  than  a  month 
before  the  paralysis  developed.  The  onset  may  simulate  acute 
rheumatism. 

2.  The  Stage  of  Degeneration. — This  results  from  localization  in  the 
anterior  horn,  which  produces  (a)  paralysis,  (b)  disturbed  nutrition,  (c) 
vasomotor  changes  and  (d)  loss  of  reflexes,  (a)  The  paralysis  is  motor 
only;  it  is  sudden,  complete,  flaccid  and  nonprogressive;  though  at 
first  diffuse,  it  usually  regresses,  although  incompletely,  leaving  some 
permanent  paralysis.  General  localization,  according  to  Starr's  com- 
bined statistics  of  about  600  cases  gives :  (i)  Paralysis,  most  frequently 
of  one  leg,  then  (ii)  of  both  legs,  and  (iii)  and  (iv)  of  all  four  limbs  or  of 
one  arm  (with  equal  frequency),  (v)  of  arm  and  leg  of  same  side  (spinal 
hemiplegia),  (vi)  of  arm  with  opposite  leg  (crossed  or  alternating 
paralysis),  (vii)  of  three  limbs,  and  least  often,  (viii)  of  both  arms. 
The  trunk  muscles  may  be  involved,  but  the  cranial  nerves  are  almost 
always  exempt,  save  in  severe  and  diffuse  foci.  The  bladder  is  usually 
unaffected,  except  in  the  early  stage,  from  general  toxsemia,  or  in  severe 
cases.  As  to  its  special  localization,  the  leg  is  paralyzed  in  75  per  cent, 
of  cases  (E.  Remak);  in  one  form,  the  lasting  paralysis  affects  the 
quadriceps  femoris  with  the  adductors  (upper  lumbar  lesion),  but 
the  sartorius  is  not  involved;  in  another  form,  the  muscles  below  the 
knee  supplied  by  the  peroneal  nerve,  are  involved,  as  the  tibialis 
anticus,  extensor  digitorum  communis,  ext.  longus  or  brevis,  ext.  hallucis 
longus,  peronei  (lower  lumbar  and  upper  sacral  lesion)  of  which  some 
muscles  may  escape  as  the  tibialis  ant.,  since  total  paralysis  is  rare. 
If  both  legs  are  involved,  the  paralj^sis  is  rarely  symmetrical.  Polio- 
myelitis usually  involves  several  segments,  because  of  the  arterial  dis- 
tribution. The  arm  is  paralyzed  in  25  per  cent.,  chiefly  in  the  form  of 
the  combined  shoulder  paralysis  of  Remak,  involving  the  deltoid 
(sometimes  alone),  biceps,  brachialis,  supinator  longus  with  the  supra- 
and  infra-spinatus  and  teretes  (lesion  in  upper  cervical  enlargement, 
fifth  to  sixth  segments);  in  some  cases  the  forearm  type  may  be  seen, 
with  involvement  of  the  flexors  or  possibly  of  the  extensors,  while  the 
supinator  longus  often  escapes  (lower  cervical  lesion,  seventh  and 
eighth  segments).  The  trunk  or  neck  muscles  usually  show^  improve- 
ment in  this  stage.  (6)  As  to  disturbed  nutrition,  the  muscles  and 
nerves  corresponding  to  the  level  of  the  poliomyelitis  rapidly  degenerate 
as  shown  by  early  reaction  of  degeneration  and  muscular  atrophy 
The  reaction  of  degeneration  consists  of  failure  of  the  nerve  and  muscles 
to  respond  to  the  faradic  current  and  usually  appears  in  one  or  two 
weeks  (Duchenne)  or  rarely  earlier;  it  also  includes  a  lack  of  response 
of  the  nerve  to  the  galvanic  current,  and  finally  too  prompt  a  response 
of  the  muscles  to  the  galvanic  current  and  more  quickly  to  the  positive 
than  to  the  negative  pole ;  this  latter  reaction  lasts  for  two,  three  or  six 
months  and  then  gradually  disappears  in  a  year  or  two.      Muscular 


ACUTE  POLIOMYELITIS  OF  CHILDREN  1099 

atrophy  may  be  apparent  in  two  weeks  and  is  more  clearly  seen  in  the 
arm  than  in  the  leg  or  trunk,  whose  adipose  deposit  may  obscure  it. 
Fibrillary  contractions  are  rather  frequent.  The  wasted  flaccid  mem- 
ber hangs  and  swings  in  a  lifeless  fashion,  (c)  Vasomotor  paralysis 
causes  the  low  temperature  (1  to  even  10°  below  normal)  and  the  livid 
cyanotic  or  sometimes  clammy  skin,  (d)  The  skin  and  tendon  reflexes 
are  abolished  in  the  limb  at  first;  the  skin  reflexes  usually  return 
later.  The  sphincters  are  almost  always  intact  and  sensation  is  very 
rarely  afi^ected.    True  trophic  changes  are  almost  unknown. 

3.  Stationary,  Chronic,  Residual  Stage. —  Some  improvement  may 
occur,  but  this  stage  is  generally  marked  (a)  by  accentuation  of  mus- 
cular  atrophy,  connective  and  sometimes  adipose  tissue  replacing  the 
contractile  substance;  it  is  most  marked  in  the  legs  in  old  cases,  and 
involves  also  the  nerves,  arteries,  and  tendons.  (6)  The  hones  become 
thin,  flexible,  friable,  arrested  in  development  and  therefore  shorter, 
since  the  bone  cortex  wastes  and  its  medulla  becomes  more  spongy; 
scoliosis  may  result,  (c)  There  may  be  pronounced  vasomotor  lividity. 
{d)  In  the  joints,  nodules  may  appear  as  in  cerebral  hemiplegia;  the 
joint  structures  are  relaxed,  and  the  "flail  joint"  may  develop  with 
luxation  or  subluxation,  (e)  Contractures  are  due  principally  to  the 
mechanical  influence  of  the  unopposed  antagonist  muscles  on  the 
posture  of  the  joint;  if  all  the  muscles  are  paralyzed  they  sometimes 
result  from  static  causes,  as  from  standing  or  attempting  to  walk,  i.  e., 
from  neglect;  trauma  and  malposition  of  the  luxated  joints  or  tendons 
may  also  cause  contracture  or  actual  deformity;  the  arm,  the  shoulder, 
wrist  and  fingers  are  usually  flexed  and  the  elbow  usually  escapes 
involvement.  In  the  leg,  deformity  (pes  equinovarus)  is  more  common 
than  in  the  arm. 

Diagnosis. — The  initial  vomiting,  fever  or  convulsions  are  usually 
misinterpreted  until  the  diffuse  purely  motor  paralysis  appears,  and 
consequently,  the  physician  is  unjustly  blamed  for  what  he  cannot 
anticipate.  The  age,  acute  paralysis,  rapid  atrophy,  reaction  of  degen- 
eration and  loss  of  reflexes  are  positive  diagnostics,  together  with  the 
absence  of  sensory  and  sphincter  disturbance.  Bedsores  "practically 
never  develop." 

Differentiation. — (a)  The  various  forms  of  muscidar  atrophy  in 
children  are  gradual  in  onset,  progressive,  symmetrical,  and  often 
familial.  The  atrophy  precedes  and  exceeds  paralysis,  and  there  is  no 
arrest  in  development.  The  neural  progressive  muscular  atrophy  of 
Hoffmann,  due  to  disease  of  the  nerves  or  nerve  roots,  may  produce 
paralysis,  atrophy  and  the  reaction  of  degeneration,  but  the  afi'ection  is 
progressive,  familial  and  involves  sensation.  (6)  Birth  palsies  are 
distinguishable  by  their  history,  and  more  favorable  course,  (c)  Mul- 
tiple neuritis  (q.v.)  has  several  distinctive  features.  Poliomyelitis  is  due 
to  a  local  inflammation,  is  unilateral  and  spinal  in  type — or  if  bilateral, 
it  is  asymmetrical.  Multiple  neuritis  is  hsematogenous  and  toxic,  and 
therefore  affects  the  spinal,  and  often  the  cranial  nerves  symmetrically 
and  bilaterally,  and  usually  involves  the  arms  and  legs;  ataxia,  sensory 


1100  DISEASES  OF  THE  XERVOUS  SYSTEM 

disturbance  and  local  tenderness  over  the  nerve  trunks  are  common, 
its  onset  is  more  subacute  and  convulsions  are  rare;  the  reaction  of 
degeneration  is  less  intense  and  the  issue  is  much  more  favorable. 

(d)  The  cerebral  palsies  of  children  {q.  v.  for  table)  affect  the  upper 
motor  neurone  and  therefore  never  produce  marked  degenerative 
atrophy,  or  loss  of  faradic  irritability.  Its  hemiplegic  form  involves 
the  face  and  its  paraplegic  form  is  spastic.  Disturbance  of  the  intellect, 
focal  or  general  convulsions  and  hemichorea  are  common.  In  rare 
cases,  the  cerebral  and  spinal  forms  of  infantile  paralysis  may  co-exist. 

(e)  Myelitis  also  begins  acutely,  but  usually  in  older  subjects.  Polio- 
myelitis may  be  confused  only  when  it  is  bilateral,  located  in  the  cer- 
vical or  lumbar  enlargement,  when  sensory  changes  occur  (2  per  cent.), 
when  the  sphincters  are  involved  or  when  the  poliomyelitis  reaches 
back  into  the  white  matter,  producing  a  flaccid  atrophic  paralysis  of 
an  arm  and  a  spastic  paresis  of  the  leg,  the  latter  of  which  is  only 
transitory.  Bed-sores,  which  are  common  in  myelitis,  are  "almost 
unknown"  in  poliomyelitis.  (/)  Painful  affections  causing  immobility 
of  a  joint,  hip-joint  disease.  Parrot's  syphilitic  pseudoparalysis  and 
infantile  scurvy  bear  a  superficial  resemblance  to  poliomyelitis.  Dif- 
ferentiation is  easy.  Westphal  noted  that  in  the  new-born  the  electrical 
reaction  normally  resembles  that  of  the  reaction  of  degeneration. 
(g)  Hysterical  contractures,  sometimes  with  atrophy,  disappear 
under  anaesthesia  and  show  no  reaction  of  degeneration. 

Prognosis. — (1)  Regarding  life;  there  is  little  danger  after  the 
fever  subsides;  life  is  very  rarely  threatened  from  extension  to  the 
medulla  oblongata.  In  exceptional  cases,  death  may  result  from 
antecedent  pneumonia.  (2)  Regarding  relapses;  second  attacks 
almost  never  occur.  (3)  Regarding  recovery;  improvement  is  the 
rule.  The  diffuse  initial  paralysis  usually  becomes  localized,  but 
complete  recovery  is  so  infrequent  that  it  may  be  disregarded.  A 
localized  initial  paralysis  may  show  but  little  improvement,  and  an 
extensive  initial  paralysis  may  diminish  greatly.  A  definite  prognosis 
of  the  ultimate  extent  of  the  paralysis  cannot  be  made  for  two  weeks 
and  then  only  by  the  electrical  examination.  Muscles  which  show 
no  reaction  of  degeneration  after  fourteen  days  will  probably  recover; 
those  showing  slight  loss  of  faradic  irritability  will  recover  in  great 
part;  after  six  weeks  only  those  muscles  are  paralyzed  which  will 
remain  paralyzed;  if  there  is  no  recovery  in  three  months,  there  will 
be  none  or  it  will  be  slight. 

Treatment. — In  the  acute  stage  rest,  a  light  diet,  laxatives,  diaphor- 
etics and  diuretics  are  indicated.  After  the  fever,  the  patient  should 
be  kept  in  bed  for  weeks,  and  should  be  given  hike  warm  baths. 
Electricity  is  contra-indicated.  As  the  paralysis  begins  to  recede,  a 
fuller  diet  and  careful  passive  movements  are  beneficial.  In  the 
chronic  stationary  stage,  with  its  inevitable  and  permanent  paralysis, 
fresh  air  and  liberal  nourishment  are  important.  Proof  is  lacking 
that  strychnine  is  valuable,  but  it  probably  is  because  of  its  general 
tonic  action,  and  its  almost  specific  physiological  action  on  the  motor 


SUBACUTE  AXD  CHROXIC  POLIOMYELITIS  1101 

elements  of  the  cord.  It  should  be  given  three  or  four  weeks  after  the 
paralysis  becomes  stationary.  Full  doses  may  induce  muscular 
spasm,  pain  and  irritating  parsesthesia.  Electricity  cannot  restore 
totally  destroyed  tissue,  but  it  hastens  recovery  in  partial  lesions;  if 
applied  to  the  spine,  it  is  useless,  but  the  constant  stream  to  the  muscles 
and  the  faradic  current  to  the  skin  are  helpful.  Contractures  may  be 
modified  as  well  as  deformities  due  to  neglect,  to  which  gymnastic 
movements,  massage  and  orthopedic  apparatus  are  essential.  The 
child  should  be  kept  in  bed  for  a  long  period.  In  some  cases  tenotomy, 
arthrodesis  and  tendon  transplantation,  by  attaching  the  tendons  of 
sound  muscles  to  those  of  paralyzed  muscles  (Vulpius,  Nicolodoni) 
are  indicated.  Nerve  transplantation  is  in  its  infancy,  but  is  proving 
very  successful. 


V.  Acute  Poliomyelitis  in  Adults. 

This  is  rare  in  comparison  with  the  infantile  form.  It  was  estab- 
lished by  Vogt  in  1858,  Moritz  Meyer,  in  1861,  and  anatomically  by 
Gombault,  in  1873.  The  etiology  is  practically  the  same  as  that  of  the 
infantile  variety;  most  cases  occur  between  the  twentieth  and  thirtieth 
years.  The  symptoms  and  course  are  essentially  the  same,  with  the 
following  variations:  fever  is  almost  always  present,  which  with  the 
prodromes  lasts  longer  than  in  children ;  it  often  lasts  a  week.  There 
is  the  same  flaccid  paralysis  with  atrophy  and  the  reaction  of  degenera- 
tion, but  it  regresses  less  and  results  less  frequently  in  contractures. 
The  types  of  Remak  are  more  clearly  developed  in  the  adult.  Pain  is 
a  more  prominent  symptom.  Friedlander  observed  mixed  cases  in 
which  there  was  early  although  transient  anaesthesia.  Though  the 
diagnosis  is  easy  in  children,  it  is  more  uncertain  in  adults,  chiefly 
because  multiple  neuritis  and  to  a  lesser  degree  myelitis  and  hsemato- 
myelia  are  more  difficult  to  exclude  but  in  all  three  affections  sensory 
alterations  are  usual. 


VI.  Subacute  and  Chronic  Poliomyelitis. 

Many  reported  cases  are  probably  multiple  neuritis,  although 
Oppenheim  has  published  perfectly  clear  cases.  Etiology. — Metallic 
poisons  and  syphilis  are  important  factors.  Pathologically,  two  main 
types  are  distinguished;  in  the  larger  group  there  is  no  inflammation, 
but  rather  a  seemingly  primary  atrophy  of  the  ganglionic  cells,  which 
heightens  its  resemblance  to  spinal  progressive  muscular  atrophy, 
than  which,  however,  it  runs  a  more  rapid  course;  in  a  smaller  group 
of  cases  there  is  early  perivascular  exudation  in  the  anterior  horn  and 
later  sclerosis,  wherein  it  resembles  acute  poliomyelitis,  although  it  is 
slower  in  its  course.  The  anterior  roots  are  involved  and  in  most 
cases  there  is  degeneration  in  both  pyramidal  tracts,  possibly  also  in 


1102  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  posterior  columns  or  roots,  in  Clarke's  columns  or  rarely  in  the 
medulla.  The  course  is  gradual,  for  one  extremity  becomes  slowly 
affected  (in  one  to  three  years),  sometimes  with  extension  to  others 
after  months  or  years.  There  is  paresis  with  atrophy,  fibrillary  tremors, 
partial  or  complete  reaction  of  degeneration,  decrease  or  absence  of 
the  reflexes  and  normal  sensation  and  sphincters.  Life  is  rarely 
immediately  threatened,  but  recovery  is  most  unlikely;  if  it  occurs, 
neuritis,  not  poliomyelitis,  is  probably  the  actual  lesion.  The  ultimate 
outcome  is  unfavorable.  Differentiation  is,  as  follows:  (a)  Multiple 
neuritis  (see  Acute  Poliomyelitis);  (b)  from  progressive  spinal 
muscular  atrophy,  even  an  anatomical  differentiation  is  not  easily 
made.  As  a  rule,  the  following  clinical  distinctions  hold;  in  progres- 
sive muscular  atrophy,  atrophy  precedes  and  exceeds  the  muscular 
weakness,  fiber  after  fiber  of  muscle  very  slowly  wastes,  the  atrophy 
is  especially  marked  in  the  distal  parts  as  in  the  hands  and  fingers, 
and  the  reaction  of  degeneration  is  usually  less  complete.  In  chronic 
poliomyelitis,  atrophy  always  rapidly  follows  paralysis;  it  is  an  out- 
right atrophy  {atrophic  en  masse),  it  occurs  more  often  in  the  proximal 
parts,  as  in  the  shoulder,  and  the  reaction  of  degeneration  is  marked. 
(c)  In  amyotrophic  lateral  sclerosis  the  paralysis  is  spastic  with  in- 
creased reflexes,  contractures  and  often  with  bulbar  symptoms. 
Treatment  is  the  same  as  that  of  the  chronic  stage  of  acute  poliomye- 
litis. 

VII.  Landry's  Paralysis. 

Landry's  paralysis  (acute  ascending  or  centripetal  paralysis)  was 
described  by  Landry  and  independently  by  Kussmaul  in  1859. 
Landry's  description  included  five  cases  of  his  own  and  five  others; 
the  famous  Cuvier  died  of  this  disease,  in  1832.  Acute  ascending 
paralysis  is  a  symptom  complex  rather  than  a  disease  in  itself  and 
may  be  conveniently  classified  under  infiammatory  affections  of  the 
cord.  The  etiology  is  vague.  The  affection  occurs  mostly  between 
twenty  and  forty  years  of  age  and  three  times  more  frequently  in  males 
than  in  females.  It  has  followed  acute  infections,  as  diphtheria, 
typhoid,  influenza  or  variola  and  also  chronic  infections  as  syphilis 
and  tuberculosis. 

Pathology. — In  the  early  and  in  many  recent  cases  no  anatomical 
findings  existed,  and  on  this  Westphal  (1876)  founded  his  three 
criteria:  (a)  that  the  disease  is  a  progressive,  ascending  and  finally 
fatal  affection  with  (6)  normal  electrical  reaction  and  (c)  negative 
findings  at  autopsy.  Though  negative  findings  are  frequent,  recent 
cases  have  given  definite  though  varying  postmortem  results,  as 
structureless  exudation  in  the  cord,  disseminated  foci  of  inflam- 
mation in  the  cord,  medulla  and  pons,  changes  in  the  pyramidal 
tracts,  anterior  horns  and  in  the  spinal  and  sometimes  in  the  cerebral 
peripheral  nerves.  By  some  writers  two  forms  are  distinguished: 
(a)  the  bulbar  or  medullary  form,  in  which  sensation  and  electrical  re- 


MULTIPLE  SCLEROSIS  1103 

actions  are  normal,  and  (6)  the  peripheral  neuritic  form,  with  sensory 
and  electrical  alteration.  The  parenchymatous  swelling  of  the  liver, 
spleen,  kidneys  and  lymphatics  indicates  a  general  infection  or  tox- 
semia.  Bacteriologically,  an  anthrax-like  bacillus  (Baumgarten),  the 
pneumococcus,  typhoid  bacillus,  bacilli  in  all  the  peripheral  nerves 
and  streptococci  (ffittinger  and  Marinesco)  have  been  found. 

Symptoms. — The  onset  is  acute  with  short  prodromes,  as  head- 
and  back-ache,  muscular  spasms,  and  parsesthesia,  or  it  is  without 
prodromes.  Paralysis  usually  commences  in  one  foot,  then  in  the 
other,  and  develops  in  the  legs,  thighs,  abdomen,  back,  arms,  even  in 
the  face  or  the  eyes,  possibly  with  optic  neuritis;  the  paralysis  is  pro- 
gressive and  ascending;  when  the  medulla  is  invaded,  dysarthria, 
dysphagia  and  paralysis  of  the  tongue  occur  and  finally  death  results 
by  respiratory  paralysis  or  in  atypical  cases  by  circulatory  paralysis. 
The  proximal  parts  of  the  limbs  are  more  involved  than  the  distal  and 
some  muscles  may  be  unaffected.  Fever  is  usually  absent;  the  sen- 
sorium,  sensation,  sphincters  and  electrical  reaction  are  usually  normal. 
There  are  no  tremors,  no  twitchings,  no  convulsions,  no  contractures, 
no  trophic  disturbance.  The  reflexes  are  variable,  but  are  usually 
decreased  or  absent.  In  rare  cases  there  may  be  partial  reaction  of 
degeneration  (which  usually  has  not  time  to  develop),  atrophy,  and 
moderate  disturbance  of  sensation  or  the  sphincters.  The  paralysis 
may  be  of  the  descending  type,  in  which  event  the  bulbar  involvement 
is  fatal  before  the  paralysis  in  the  legs  is  well  developed. 

Course  and  Prognosis. — The  disease  lasts  two  or  three  days  to  one 
or  two  weeks,  and  usually  terminates  with  a  respiratory  paralysis. 
Bulbar  symptoms  are  ominous,  but  not  necessarily  fatal.  The  central 
form  of  paralysis  is  fatal  and  the  peripheral  form  probably  includes 
most  of  the  recoveries.  In  rare  cases,  death  may  occur  in  a  few  hours 
or  only  after  months,  with  remissions  and  exacerbations.  In  the 
still  rarer  cases  of  recovery,  chronic  paralysis  of  some  part  may  re- 
main. If  recovery  ensue,  the  paralysis  regresses  in  an  order  inverse  to 
that  of  development.  A  diagnosis  is  usually  easily  made,  because  of 
the  ascending  motor  paralysis  with  loss  of  reflexes  and  without  marked 
mental,  sensory,  sphincter  or  electrical  alteration.  The  treatment  is 
that  of  myelitis  or  multiple  neuritis,  iid ministration  of  strychnia  and 
other  stimulation  is  indicated  if  the  bulbar  symptoms  are  manifested. 
C.  L.  Greene  reports  a  case  which  was  kept  alive  by  artificial  respira- 
tion forty-one  days  after  respiratory  failure  set  in;  he  advises  calomel, 
colonic  flushings  and  oxygen  inhalations. 


MULTIPLE    SCLEROSIS. 

Insular  or  disseminated  sclerosis,  sclerose  en  plaques  disseminecs,  was 
described  pathologically  by  Cruveilhier  and  Cars  well  (1838) ;  Frerichs, 
in  1849,  made  the  first  diagnosis,  and  Charcot  (and  Vulpian),  in  1863-64, 
gave  a  description  of  the  typical  case. 


1104  DISEASES  OF  THE  XERVOUS  SYSTEM 

Etiology. — In  fully  50  per  cent,  of  the  cases  no  cause  is  found,  and 
little  is  known  of  its  etiology.  It  occurs  equally  in  either  sex  and 
usually  commences  between  the  twentieth  and  thirtieth  years.  Cases 
resembling  multiple  sclerosis  (pseudosclerosis)  occurring  after  the 
fortieth  year  are  thought  to  be  arteriosclerotic.  Two  main  factors  are 
thought  to  exist:  (a)  Acute  infections,  as  typhoid,  pneumonia,  measles, 
smallpox,  etc.  Marie  adopted  this  theory,  but  Oppenheim  finds  that 
many  cases  can  be  traced  back  to  infancy,  a  view  vigorously  contested 
by  Striimpell  as  is  (b)  the  idea  that  chronic  intoxications  with  alcohol, 
lead,  etc.,  are  causal. 

Pathology. — Macroscopically,  the  sclerotic  foci  are  usually  seen 
with  ease  as  irregular  grayish-red  areas  as  large  as  a  pea  or  walnut; 
they  are  multiple  (numbering  even  over  100),  are  distributed  at 
random  and  occur  largely  in  the  white  substance,  although  recent 
studies  by  Oppenheim  and  Taylor  have  revealed  equal  involvement 
of  the  gray  matter.  In  most  cases  their  distribution  is  cerebrospinal, 
in  rarer  cases  in  the  cord  alone,  and  most  rarely  in  the  brain  only; 
the  brain  cortex  is  less  frequently  involved  than  the  centrum  ovale, 
central  ganglia,  corpus  callosum,  and  the  anterior  under  surface  of  the 
pons  and  the  crus.  The  medulla  is  quite  often  and  the  cerebellum 
rarely  involved.  The  white  matter  in  the  cord  is  more  frequently 
affected  than  in  the  brain.  On  section,  the  focus  is  a  trifle  sunken  and 
transparent,  is  fairly  well  demarked,  firm  save  in  the  freshest  foci,  and 
on  hardening  in  Miiller's  solution,  appears  light  green,  while  the  nor- 
mal tissue  is  a  darker  green  color.  Microscopically,  the  medullary 
sheaths  in  the  white  substance  are  thinner  or  absent  and  though  the 
axis  cylinders  are  somewhat  wasted  and  at  times  varicose,  their  re- 
markable persistence,  first  noticed  by  Charcot,  causes  the  incomplete 
character  of  the  symptoms  and  the  usual  absence  of  ascending  and 
descending  degenerations.  The  ganglion  cells  sufi^er  some  atrophy 
and  pigmentation,  though  in  general  they  resist  the  sclerosis  fairly 
well.  The  foci  stain  deeply  with  carmine,  are  not  sharply  demarked 
from  the  healthy  tissue  and  show  corpora  amylacea,  granule-bearing 
cells,  increase  of  the  fine  meshed  neuroglia  fibrils,  nuclear  proliferation 
and  sometimes  Deiter's  cells.  In  contrast  with  the  system-degenera- 
tions, the  primary  change  is  interstitial  with  secondary  changes  in  the 
nervous  tissue.  Some  pathologists,  as  Ribbert,  see  significant  changes 
in  the  bloodvessels  of  early  cases,  as  arterial  thrombosis,  followed  by 
exudation,  and  finally  neurogliar  proliferation;  this  theory  is  vigor- 
ously opposed  by  Striimpell.  The  cerebral  nerves  suffer  often, 
especially  the  optic  nerve,  in  which  proliferation  of  connective  tissue 
is  followed  by  loss  of  the  medullary  sheaths,  while  the  axis  cylinders 
are  unaffected.  The  nuclei,  roots  and  nerve  trunks  of  the  third,  eighth, 
seventh  and  other  cranial  nerves  may  suffer  similar  alteration.  The 
spinal  nerve  roots  are  not  infrequently  involved;  the  peripheral 
nerves  have  not  been  systematically  studied. 

Symptoms. — The  clinical  picture  is  so  variable  that  a  definite 
description  cannot  be  made  to  cover  all  cases.     Charcot's  description 


MULTIPLE  SCLEROSIS  1105 

included  the  intention  tremor,  the  nystagmus,  scanning  speech,  motor 
weakness  and  rigidity,  and  apoplectic  insults,  although  he  recognized 
atypical  forms   (formes  frustes). 

1.  Motor  Symptoms. — These  are  the  most  important,  (a)  Mus- 
cular weakness  is  very  common.  Paresis  is  more  frequent  than  paraly- 
sis, and  the  gross  muscular  power  is  lessened,  though  rarely  abolished, 
since  some  axis  cylinders  remain  intact.  The  movements  are  slow 
and  fatigue  rapidly  follows  their  repetition;  this  statement  applies  to 
isolated  rather  than  to  synergistic  movements.  The  paresis  is  most 
apparent  in  the  legs,  there  is  usually  some  in  the  arms,  and  frequently 
some  in  the  musculature  of  the  eyes,  head  and  speech.  It  sometimes 
does  not  develop  until  late  in  the  disease,  may  at  no  time  be  conspicu- 
ous, and  is  commonly  associated  with  increased  reflexes  and  spasticity. 
The  gait  is  spastic,  scuffling,  and  the  feet  seem  to  stick  to  the  ground; 
to  this  is  sometimes  added  a  cerebellar,  atactic  or  paretic  element. 
Muscular  atrophy  is  rare  but  may  result  from  an  adventitious  focus 
in  the  anterior  horn.  The  electrical  reactions  are  practically  normal. 
(b)  Muscular  rigidity  is  the  most  frequent  finding,  is  referred  to 
disease  of  the  lateral  columns  and  is  most  developed  in  the  legs.  It 
increases  with  successive  movements;  for  example,  each  step  becomes 
more  stiff  in  walking.  It  is  sometimes  slight  in  degree,  and  amounts 
only  to  a  sense  of  stiffness;  in  other  cases  the  spasticity  is  so  extreme, 
and  the  muscles  so  hard  that  the  limb  cannot  be  moved  even  with 
great  effort.  Contractures  develop,  which  usually  affect  the  adductors 
and  extensors  first  and  the  flexors  later,  and  draw  the  heels  up  to  the 
buttocks.  Contractures  often  affect  the  muscles  of  the  neck,  (c) 
Tremor  is  one  of  the  most  striking  phases  of  the  disease,  being  present 
in  75  per  cent,  of  cases.  It  is  caused  as  is  the  paresis,  by  the  loss  of  the 
medullary  sheaths  (Charcot)  which  allows  diffusion  of  nerve  impulses, 
by  foci  in  the  pons  or  thalamus  (Erb),  or  by  lack  of  coordination 
between  antagonistic  muscles  (Striimpell,  v.  Leyden);  the  axis  cylinders 
remain  intact.  There  is  no  tremor  during  rest,  but  it  appears  when 
voluntary  efforts  are  attempted,  whence  the  name  intention  tremor; 
it  develops  as  the  patient  reaches  for  an  object,  which  is  grasped 
only  after  jerking  and  unsuccessful  efforts.  The  hand  carrying  a 
glass  of  water  to  the  mouth  shakes  so  much  that  all  the  water  may  be 
spilled  by  the  rhythmic  tremor,  which  possesses  a  wide  range,  and 
occurs  five  or  six  times  to  the  second.  It  is  apparent  in  the  head  when 
the  patient  sits,  because  the  muscles  of  the  neck  are  in  constant  action 
to  support  the  head;  it  disappears  in  the  recumbent  posture.  Similar 
tremor  occurs  in  the  face,  larynx,  trunk  or  legs  on  changing  posture,  as 
rising;  in  the  fingers,  it  produces  handwriting  which  becomes  more 
erratic  with  each  word  written;  and  in  the  thoracic  muscles,  it  causes  a 
species  of  cog-wheel  respiration,  id)  X ijstagmiis  occurs  in  50  per  cent, 
of  cases,  and  is  elicited  by  having  the  patient  follow  with  his  eyes 
the  index  finger  when  moved  to  one  side  of  his  field  of  vision,  his  head 
remaining  stationary.  His  eyes  show  short,  jerking  lateral  movements. 
It  is  most  common  on  lateral  or  vertical   movements.     Spontaneous 

70 


1106  DISEASES  OF  THE  XERYOUS  SYSTEM 

nystagmus  is  rarer,  as  nystagmus  on  attempting  to  focus  the  eyes.  It 
must  be  remembered  that  it  may  occur  without  organic  disease,  as  in 
general  weakness  or  convalescence.  There  is  no  satisfactory  explana- 
tion; it  is  considered  a  tremor  or  an  incoordination,  (e)  The  speech  is 
scanning  (54  per  cent.)  syllabic  or  staccato;  it  is  slow,  monotonous, 
unmodulated  and  sometimes  explosive,  especially  for  the  letters  c,  p,  g 
and  d.  The  speech  muscles  become  fatigued  easily  and  the  end  of  a 
sentence  is  often  elided;  the  sounds  are  often  nasal,  interrupted  by 
yawning  inspiration,  or  by  expiration  at  the  beginning  of  each  syllable. 
Leube  observed  a  tremor  of  the  vocal  cords,  which  oscillated  during 
their  movement.  The  cause  of  the  peculiar  speech  is  not  clear;  it  may 
be  due  to  tremor,  or  ataxia  from  foci  in  the  pons  or  medulla.  (/) 
Paresis  of  the  eye  muscles  (in  17  per  cent.  Uhthoff)  affects  the  third  or 
sixth  nerves,  convergence  or  associated  movements.  About  50  per  cent, 
is  nuclear.  In  rare  cases  the  paralysis  is  progressive.  Transient 
diplopia,  unequal  pupils,  rhythmic  spontaneous  widening  and  narrow- 
ing of  the  pupils  (hippus)  and  strabismus  are  less  common,  (g) 
Apoplectiform  seizures  (in  20  per  cent.)  develop  without  prodromes, 
and  are  marked  by  partial,  rarely  by  complete  coma,  increased  pulse, 
high  temperature,  aphasia  and  hemiplegia,  which  is  usually  fugitive 
and  flaccid,  rarely  enduring  or  spastic.  They  may  recur.  In  most 
cases  negative  pathological  findings  exist,  but  Leube  and  Leyden  refer 
them  to  acute  encephalomyelitis.  Though  usually  hemiplegic,  they 
may  exceptionally  produce  paraplegia,  hemiansesthesia  or  ataxia, 
or  monoplegia.     Less  frequently,  unilateral  convulsions  occur. 

2.  Sensory  Symptoms. — These  are  less  frequent  (30  per  cent.)  and 
important,  because  the  sensory  fibers  are  more  resistant  to  disease, 
although  they  are  rarely  wholly  absent.  Freud  found  sensory  symp- 
toms in  80  per  cent,  of  his  cases.  Subjectively,  dull  pains,  formication, 
vertigo,  the  importance  of  which  is  "frequently  overestimated,"  and 
paroxysmal  moderate  headache  are  frequent,  and  lightning  pains, 
crises,  girdle  sensation,  trigeminal  neuralgia,  palpitation  and  dyspnoea 
are  very  uncommon.  Objectively,  any  species  of  sensation  may  be 
involved,  especially  in  distal  parts  of  the  extremities,  where  it  is  usually 
transient.  Ataxia  is  usually  referred  to  disease  of  the  posterior  columns 
or  sensory  tracts  of  the  pons  or  medulla;  it  is  marked  in  50  per  cent, 
of  cases  and  may  produce  a  typical  tumbling  cerebellar  gait. 

3.  Special  Senses. — The  optic  nerve  is  affected  in  45  per  cent., 
usually  as  a  pallid  partial  atrophy  involving  its  temporal  side,  and  less 
often  as  neuritis  or  complete  atrophy  with  total  blindness.  The  change 
is  more  conspicuous  pathologically  than  clinically.  Optic  neuritis  is 
transient  and  runs  a  rapid  course;  in  the  majority  (60  per  cent.)  of 
cases,  it  produces  central  scotomata,  although  at  times  it  narrows  the 
field  of  vision.  It  may  be  the  first  sign  of  the  disease.  Hearing  and 
taste  may  be  affected. 

4.  Psychical  Symptoms. — Slight  mental  impairment  is  common; 
the  patient  is  indifferent  and  singularly  complacent;  the  memory  is 
weak;  psychoses  are  rare.    Compulsory  or  forced  laughing  and  weep- 


MULTIPLE  SCLEROSLS  1107 

ing  are  partly  without  motive  and  partly  emotional;  they  are  sometimes 
referred  to  mental  alteration  but  probably  should  be  classed  among  the 
motor  symptoms  and  be  referred  like  the  analogous  compulsory  yawn- 
ing or  swallowing  to  lesions  in  the  medulla,  pons  or  crus. 

5.  Bulbar  Symptoms. — These  may,  in  rare  cases,  resemble  the 
symptoms  of  bulbar  palsy,  as  dysphagia,  anarthria,  and  tongue  atrophy. 

6.  Reflexes. — The  tendon  reflexes  are  increased,  most  markedly  in 
the  legs.  The  patellars  are  exaggerated,  there  is  ankle  clonus,  and 
tickling  of  the  sole  produces  dorsal  flexion  instead  of  the  normal  plantar 
flexion  of  the  foot  (Babinsky's  sign)  showing  disease  of  the  pyramidal 
tracts.  The  skin  reflexes  are  usually  said  to  be  normal,  but  Striimpell 
found  the  abdominal  reflexes  absent  in  70  per  cent,  of  his  cases.  The 
pupillary  reflexes  are  usually  normal  or  but  slightly  slow. 

7.  Sphincters. — Lasting  or  severe  symptoms  in  the  bladder  or  rectum 
are  uncommon,  though  slight  disturbance  and  weakness  occur  in  most 
cases.  The  bladder  is  often  hypertonic  and  irritation  is  frequent.  The 
sexual  power  is  variable. 

8.  Trophic  Symptoms. — These  are  rare;  they  consist  of  skin  erup- 
tions, oedema,  low  temperature,  sweating,  chronic  arthritis  and  ery- 
thromelalgia. 

Course  and  Prognosis. — The  onset  is  usually  gradual;  the  spinal 
symptoms  are  most  prominent  and  in  most  cases  the  weakness  in  the 
legs  appears  first  and  for  a  long  time  is  hard  to  interpret;  it  occurs 
without  pronounced  sensory  symptoms,  bladder  disorder  or  atrophy. 
Sometimes  the  onset  is  acute,  with  loss  of  consciousness,  transient 
hemiplegia,  vertigo,  headache,  eye  symptoms,  vomiting  and  optic 
neuritis.  In  the  average  case  the  leg  paralysis  is  followed  by  scanning 
speech,  nystagmus,  and  tremor,  which  covers  a  chronic  course  averag- 
ing three  to  six,  or  in  some  cases  even  more  than  twenty  years,  A 
rapid  course,  as  twenty-three  months,  may  occur  in  the  bulbar  form. 
The  symptoms  remit  and  recur.  Progression  to  a  fatal  ending  is 
inevitable.  Charcot  distinguished  three  stages  (a)  the  period  from  the 
development  of  the  first  symptoms  to  the  tremor  and  jjaresis,  (b)  the 
period  in  which  the  patient  is  hed-ridden,  and  (c)  the  terminal  stage  with 
dementia,  decubitus,  sphincter  paralysis,  cystitis  and  septicopy?emia. 

Diagnosis. — The  typical  case  is  unmistakable,  because  of  the  cardi- 
nal symptoms,  which  consist  of  (1)  intention  tremor;  (2)  spastic 
paresis;  (3)  nystagmus;  (4)  scanning  speech;  (5)  ataxia;  (6) 
increased  reflexes;  (7)  optic  atrophy;  (8)  the  slow,  uneven  course 
with  remissions  and  recurrences;  (9)  the  variability  of  the  symptoms; 
(10)  apoplectic  insults;  and  (11)  moderate  involvement  of  the  mental- 
ity, sensation,  bladder  and  rectum. 

Differentiation. — Transient  hemiplegia  may  suggest  hemorrhage, 
syphilitic  thrombosis,  embolism  or  tumor  (q.v.).  If  these  can  be 
excluded,  multiple  sclerosis  or  paretic  dementia  must  be  differentiated 
(q.v.).  Paralysis  agitans  is  usually  but  rather  uimecessarily  differen- 
tiated; the  absence  of  the  cardinal  signs  of  sclerosis  multiplex  and  the 
presence  of  a  constant  fine  tremor  of  the  hands  and  fingers  (not  of  the 


1108 


DISEASES  OF  THE  NERVOUS  SYSTEAI 


large  joints,  and  much  less  in  the  head)  which  is  not  increased  by  move- 
ment, its  persistence  during  rest,  the  mask-like  facies,  festinating 
speech,  peculiar  attitude,  gait,  propulsion,  retropulsion,  muscular 
rigidity  without  increased  reflexes,  and  the  advanced  age  are  clear  and 
characteristic  points. 


Multiple  Sclerosls. 

Occurs  in  the  medullary  substance. 

A  focal  disease. 

Nystagmus,  scanning  speech,  tremor. 


Transitory  amaurosis,   hemianopsia, 
complete  optic  atrophy,  choked  disk 
or  neuritis  are  very  rare. 

Partial  optic  atrophy  occurs. 

Mydriasis  1  per  cent.,  myosis  4  per  cent. 
Argyll-Robertson  pupil  practically 
never  present. 


Syphilis  . 

Occurs   in   the   periphery   of   the   cord 
(meningomyelitis    and   root    symp- 
toms). 

Diffuse. 

More  frequent  mental  obscuration,  in- 
sults, hemiplegia,  etc.;  speech  may 
be  disturbed  or  slow  in  pons  lesions 
but  is  not  scanning. 

Amaurosis,  etc.,  are  frequent. 


There  is  more  disturbance  of  vision. 
Mvdriasis  is  verv  common. 


Cortical  symptoms  may  be  present; 
rectum  and  bladder  more  frequently 
involved;  results  may  be  obtained 
in  early  stages  from  antisypliilitic 
remedies. 


Hysteria  more  than  any  other  disease  simulates  early  multiple 
sclerosis,  the  two  affections  often  occur  together,  and  in  both  the 
symptoms  are  changeable.  In  hysteria  sensory  symptoms  are  much 
more  prominent,  there  is  often  limitation  of  the  visual  fields,  monocular 
diplopia,  contractures,  and  convulsions,  but  there  is  no  optic  atrophy, 
nystagmus  is  extremely  rare  (Sougues)  as  is  the  scanning  speech;  and 
intention  tremor  may  occur,  but  is  not  so  wide.  The  movements  in 
hysteria  are  often  accompanied  by  contraction  of  the  antagonist 
muscles,  which  is  a  most  valuable  diagnostic  aid.  In  extremely  rare 
cases,  described  first  by  Westphal  as  pseudosclerosis,  similar  symp- 
toms prevail  though  the  autopsy  shows  nothing;  the  tremor  affects 
the  arms  chiefiy;  there  is  no  ataxia  or  nystagmus;  the  facies  is  some- 
what rigid  and  outbursts  of  anger  are  frequent;  syphilis  is  a  possible 
cause.  Birth  palsies  may  be  accompanied  by  jerky  movements, 
incoordination  of  the  legs  and  even  scanning  speech,  but  the  history  of 
very  early  onset  is  conclusive. 

Striimpell  groups  the  atypical  forms  as  (a)  the  latent  group;  (b) 
those  resembling  chronic  myelitis,  or  (c)  pure  spinal  spa.stic  paralysis, 
maybe  resembling  amyotrophic  lateral  sclerosis  if  the  anterior  horns 
are  involved,  or  chronic  bulbar  palsy  if  the  medulla  is  affected;   optic 


SYRINGOMYELIA  1109 

atrophy  in  such  cases  indicates  multiple  sclerosis,  (d)  Cases  resemb- 
ling tabes  with  ataxia,  and  pains,  which  are  probably  cases  of  com- 
bined system  disease  {v.  i.);  (e)  the  hemiplegic  form;  and  (/)  the 
psychical  form. 

Treatment. —  Treatment  is  futile.  Drugs  as  silver  and  arsenic  are 
inert,  and  hydro-  and  electro-therapeutic  measures  are  useless.  The 
patient  should  live  in  a  warm  climate  during  the  winter  months. 

(H).  SYRINGOMYELIA. 

The  term  refers  to  cavities  in  the  cord,  and  was  first  employed  by 
Ollivier  (1824).  The  affection  was  first  described  by  Morgagni. 
Syringomyelia  must  be  distinguished  from  hydromyelus  (hydrorrhachis 
interna),  which  is  a  dilatation  of  the  central  canal  due  to  develop- 
mental anomalies,  possibly  to  stasis  of  cerebrospinal  fluid  resulting 
from  pressure;  it  is  usually  an  accidental  finding  at  necropsy,  or  if 
symptoms  are  present  they  are  those  of  syringomyelia. 

Etiology.— Sixty-three  per  cent,  of  cases  occur  between  the  tenth  and 
thirtieth  years  and  70  per  cent,  of  them  in  males.  Other  factors  are 
wholly  uncertain,  as  trauma,  manual  occupations,  or  cold. 

Pathology  and  Pathogenesis. —  Gross  Pathology. — A  cavity  may 
be  seen  from  without.  The  cord  is  often  lax,  sometimes  fluctuating  or 
flat.  The  cavity  is  usually  localized  but  may  sometimes  extend  from 
the  medulla  to  the  filum  terminale;  it  is  most  often  found  in  the  lower 
cervical  or  upper  dorsal  regions,  less  frequently  in  the  dorso-lumbar 
segments  or  in  the  lower  brain;  in  size  it  ranges  from  a  narrow  slit  to 
a  cavity  as  wide  as  the  cord  itself;  it  is  not  absolutely  symmetrical  and 
may  be  unilateral;  it  may  communicate  with  the  central  canal,  may  be 
multilocular  from  septa  or  strands  of  tissue,  and  diverticula  may  be 
found.  Its  wall  is  smooth,  sometimes  pigmented  from  old  hemor- 
rhages. Sometimes  the  cord  is  normal,  but  it  usually  suffers  thickening, 
and  sclerosis  develops  from  the  ependyma,  posterior  commissure  or 
posterior  horns,  in  the  form  of  hard  or  soft,  tumor-like,  somewhat 
asymmetrical  neurogliar  proliferations,  especially  in  the  cervical 
region;  these  later  break  down  and  form  secondary  cavities.  The 
posterior  horns  and  columns  are  often  affected,  the  anterior  horns  and 
columns  less  frequently  and  the  lateral  columns  very  rarely.  Hemor- 
rhage into  the  gliomatous  tissue  or  the  cavity  may  result  from  rupture  of 
the  new  formed  bloodvessels. 

Minute  Pathology.— The  essential  finding  is  overgrowth  of  the 
neuroglia,  which  in  part  breaks  down  and  forms  cavities.  This  hyper- 
plasia is  most  probably  due  to  some  congenital  anomaly,  which  also 
explains  its  frequent  association  with  dilatation  of  the  central  canal 
(hydromyelus).  The  neurogliar  overgrowth  is  rich  in  fibers,  whereas 
the  ordinary  glioma  (gliomatosis)  especially  abounds  in  cells;  syringo- 
myelia and  gliomatosis  may  co-exist.  The  proliferation  is  seemingly 
embryonic  in  character,  contains  some  large  sharply  nucleated  cells, 


1110  DISEASES  OF  THE  XERVOUS  SYSTEM 

here  and  there  a  few  epithehal  cells,  is  firm  as  a  whole,  but  somewhat 
softer  towards  the  posterior  horns,  is  often  hyaline  nearest  the  cavity 
from  compression,  and  abounds  in  bloodvessels,  which  are  often 
hard  and  hyaline.  The  cavity  is  usually  lined  with  cylindrical  epithe- 
lium like  that  of  the  central  canal,  sometimes  only  with  neuroglia;  its 
contents  resembles  cerebrospinal  fluid,  but  is  occasionally  blood 
tinged  or  less  often  gelatinous,  mucoid  or  milky.  Degenerations  occur 
in  parts  actually  involved  and  at  times  in  distant  parts  as  in  the  medulla. 
The  nerve  fibers  are  not  much  involved,  although  secondary  degenera- 
tion may  occur  in  the  posterior  and  less  frequently  in  the  lateral 
columns. 

The  exact  pathogenesis  is  obscure.  Congenital  hydromyelus  (with 
primary  neurogliar  hyperplasia  and  secondary  cavity  formation), 
inflammation  and  hemorrhage  are  not  causal  factors. 

S3Tiiptoms. — There  are  three  cardinal  symptoms.  (1)  Partial  or 
dissociated  anoesthesia  occurs  in  the  typical  case,  in  which  the  sensation 
of  touch,  pressure  and  locality  is  preserved  while  heat  or  cold  and  pain 
are  not  recognized  as  such  but  as  simple  pressure.  Thermo-ancBsthesia 
usually  concerns  perception  of  both  heat  and  cold,  sometimes  of  only 
one  of  them,  or  one  in  one  place  and  the  other  in  another;  analgesia 
is  frequently  preceded  by  hyperalgesia;  it  concerns  the  superficial  or 
deeper  structures  and  usually  corresponds  with  the  thermo-ansesthesia 
which  however  may  exist  alone.  Thermo-ansesthesia  and  analgesia 
usually  begin  in  the  hands  and  fingers  and  are  later  found  on  the  upper 
trunk;  sometimes  the  entire  trunk,  the  legs,  mucous  membranes,  and 
face  may  be  affected,  depending  on  the  location  of  the  cavity.  The 
patient  may  suffer  burns  or  injuries  in  these  parts  without  pain.  Dis- 
sociated ansesthesia  is  most  probably  caused  by  disturbance  of  con- 
duction of  temperature  and  pain  in  the  gray  substance  of  the  cord, 
which  is  frequently  invaded  by  neurogliar  proliferation  and  the  cavity 
formation;  tactile  sensation  traverses  the  white  columns.  In  some 
cases  the  partial  anaesthesia  is  unilateral.  Anaesthesia  may  involve  all 
variaties  of  sensation.  Subjective  sensory  disturbances  include 
parsesthesia  and  burning,  tabes-like  pain  in  the  neck,  arms  or  trunk, 
and  sometimes  in  the  joints,  spine  or  legs. 

2.  Muscular  atrophy  is  due  to  involvement  of  the  anterior  horn 
and  affects  the  arms  mostly,  because  the  disease  is  largely  in  the  lower 
cervical  and  upper  dorsal  cord.  It  is  slow  in  onset,  more  marked 
than  the  attendant  fiaccid  paresis,  degenerative,  and  often  observed 
with  fibrillary  muscular  contractions  and  increased  myotatic  irrita- 
bility. It  usually  involves  the  small  muscles  of  the  hand  as  the  inter- 
ossei,  produces  flattening  of  the  thenar  and  hypothenar  eminences  and 
the  claw-like  hand  as  seen  in  the  Duchenne-Aran  type.  The  radial 
supply  is  first  affected,  then  the  ulnar  and  median  supply.  Sometimes 
the  scapulohumeral  type  is  observed,  especially  with  bulbar  symptoms. 
The  muscles  of  the  trunk,  and  much  less  often  of  the  legs,  may  be  af- 
fected. From  cervical  compression  of  the  pyramidal  tracts,  paraplegia 
results,   wath    increased  reflexes  and    spasticity,  in    12    per  cent,  of 


SYRIXGOMYELIA  1111 

cases.  Other  motor  symptoms  occasionally  occur,  as  tremor,  con- 
tractures, spasms,  opisthotonos  or  choreiform  movements.  The  gait 
is  normal,  spastic  and  paretic  or  sometimes  of  the  cerebellar  type. 
Romberg's  sign  and  ataxia  result  from  involvement  of  the  posterior 
columns  or  coincident  tabes. 

3.  Trophic,  secretory,  or  vasomotor  symptoms  may  occur.  Trophic 
symptoms  are  quite  frequent.  (a)  Phlegmons  and  felons  develop, 
particularly  on  the  fingers.  They  are  painless,  chronic,  often  recurrent, 
and  lead  to  necrosis  of  the  bone,  ankylosis  of  the  joints,  and  to  con- 
siderable deformity  or  mutilation,  (b)  The  joints  suffer  in  over  10 
per  cent.,  especially  in  males  (75  per  cent.),  and  this  is  probably  due 
to  loss  of  articular  sensation  (whereby  the  joints  are  used  inappro- 
priately) or  to  lack  of  the  nutritional  reflex.  These  arthropathies  are  of 
the  hypertrophic  form,  with  thickening  and  bony  formation,  like 
arthritis  deformans  or  of  the  atrophic  form  with  relaxation  of  ligaments 
or  flail  joint.  There  is  little  exudation,  no  fever,  no  pain.  On  the 
whole,  they  are  similar  to  the  tabetic  joints  but  are  more  chronic  and 
more  often  involve  the  upper  extremities  (shoulder  32  per  cent.,  elbow 
28  per  cent.,  hand  16  per  cent.,  hip  8  per  cent.,  ankle  8  per  cent.,  knee 
6  per  cent.),  (c)  Painless  bone  necrosis  and  spontaneous  fractures  may 
occur  late  in  the  disease;  moderate  scoliosis  is  frequent,  usually 
confined  to  the  dorsal  spine,  sometimes  with  kyphosis.  It  is  probably 
due  to  trophic  vertebral  changes  or  possibly  to  atrophy  of  the  back 
muscles;  perforating  ulcer,  thick,  friable  nails  and  clubbed  fingers  are 
less  common.  Morvan  (1883)  described  an  affection  as  paresie  anal- 
gesique  avec  panaris,  endemic  in  Brittany,  which  is  clearly  syringomy- 
elia. "Morvan's  disease"  is  marked  by  trophic  disorders,  excessive  or 
deficient  secretion  of  sweat,  oedema  especially  on  the  dorsum  of  the 
hands,  erythema,  urticaria,  more  rarely  local  asphyxia,  and  herpes 
zoster. 

There  may  be  other  symptoms,  (a)  The  reflexes  of  the  skin  are 
usually  normal,  although  the  abdominal,  cremasteric  and  plantar 
reflexes  are  sometimes  increased;  the  tendon  jerks  are  variable,  being 
often  decreased  in  the  upper  and  increased  in  the  lower  extremities. 
(6)  The  sphincters  are  not  involved,  or  may  be  only  late  in  the  disease. 
Retention  of  urine  and  constipation  are  more  frequent  than  incon- 
tinence, (p)  Bulbar  or  pontine  symptoms  are  not  infrequent,  are  usually 
unilateral,  and  appear  in  the  later  stages.  They  include  facial  hemi- 
atrophy or  paresis,  paresis  of  the  tongue  with  atrophy,  partial  dysphagia, 
paresis  of  the  palate  (nasal  speech),  paralysis  of  the  vocal  cords,  of  the 
external  branches  of  the  spinal  accessory  nerve  (trapezius  paralysis)  and 
trigeminus  (sensory  symptoms),  eye  paralyses  (abducens),  unequal 
pupils,  nystagmus,  tinnitus,  salivation,  apoplectiform  attacks,  polyuria, 
glycosuria  and  vagus  symptoms  (disturbed  pulse  or  respiration,  vomit- 
ing, and  singultus).  Complications  include  hysteria,  paretic  dementia, 
tabes,  pachymeningitis.  Graves'  disease,  and  epilepsy. 

Diagnosis. — An  almost  positive  diagnosis  can  be  made  from  the 
three  combined  cardinal  symptoms;    (1)  the  dissociated  anaesthesia 


1112  DISEASES  OF  THE  NERVOUS  SYSTEM 

(thermo-aneesthesia  and  analgesia  with  practically  normal  tactile 
sensation)  is  the  earliest,  most  constant  and  widely  distributed  sign. 
Grasset  has  collected  cases  of  twenty  or  more  nervous  diseases  (func- 
tional, traumatic,  neoplastic,  specific)  in  which  the  dissociation  of 
syringomyelia  has  been  found;  but  it  remains  liighly  distinctive  in 
conjunction  with  (2)  muscular  atrophy  of  the  upper  extremities  with 
paresis  and  (3)  trophic  disorders,  felons,  arthopathies,  and  scoliosis;  to 
which  three  cardinal  manifestations  may  be  added  the  spastic  paresis 
of  the  legs  and  bladder  symptoms.  Besides  the  classical  form,  various 
varieties  are  described  by  Schlesinger;  (a)  the  latent  form,  (b)  the  motor 
form,  simulating  amyotrophic  lateral  sclerosis,  (c)  the  sensory  type, 
possibly  resembling  hysteria,  (d)  the  trophic  and  (e)  the  tabetic  types. 

Differentiation. — -Progressive  spinal  muscular  atrophy  and  amyo- 
trophic lateral  sclerosis  may  resemble  syringomyelia  with  poorly 
developed  sensory  symptoms  (Clarke  and  Gull,  1862)  but  they  possess 
very  few  sensory  signs,  no  anaesthesia,  no  trophic  disturbance  and 
bulbar  symptoms  are  bilateral.  Juvenile  muscidar  dystrophy  may  be 
simulated  in  the  scapulohumeral  type  of  syringomyelia.  Peripheral 
neuritis  rarely  produces  dissociated  ansethesia  but  all  variations  of 
sensation  are  disturbed;  the  distribution  of  the  paralysis  is  peripheral, 
not  spinal  or  segmental,  and  there  is  the  reaction  of  degeneration; 
neuritis  of  the  upper  brachial  plexus  (Duchenne-Erb  paralysis)  pro- 
duces paralysis  of  the  shoulder,  arm  and  supinator  longus,  a  combination 
not  found  in  syringomyelia.  Focal  disease  of  the  anterior  and  posterior 
gray  substance,  as  multiple  sclerosis,  hemorrhage,  or  myelitis  may 
simulate  syringomyelia,  but  their  course  is  less  chronic  and  there  is  less 
tropliic  disorder.  The  signs  of  irritation  produced  by  tumor  of  the  cord 
are  lacking.  Located  in  the  dorsolumbar  region,  syringomyelia  may 
closely  simulate  tabes,  from  the  lancinating  pains,  crises  and  ataxia, 
but  the  Argyll-Robertson  pupil  is  lacking  and  the  sensory  impairment 
is  typical.  The  anaesthetic  form  of  leprosy  has  caused  difficulty  but  its 
ansesthesia  is  peripheral,  not  spinal,  in  type;  in  the  lesions  of  the  skin, 
ulcers,  and  nasal  secretions,  the  Henssen  bacillus  is  often  found;  if 
there  are  no  lesions  in  the  skin,  thickness  and  tenderness  of  the  nerves 
indicate  leprosy. 

Course  and  Prognosis. — The  onset  is  very  gradual  and  the  course 
chronically  progressive,  for  years  or  even  for  decades.  When  recog- 
nized, the  affection  is  well  advanced  and  recovery  is  impossible.  The 
first  symptoms  are  pain  and  dissociated  anaesthesia,  followed  by 
atrophy  and  paresis,  with  trophic  changes  in  the  advanced  course. 
Death  occurs  from  intercurrent  disease,  cystopyelitis,  septicaemia  and 
bulbar  complications. 

Treatment. — Treatment  is  unavailing,  being  confined  to  hygienic 
and  symptomatic  measures.  The  danger  of  self  injury,  as  a  result  of 
the  peculiar  anaesthesia,  should  be  borne  in  mind. 


TABES  DORSALIS,    LOCOMOTOR  ATAXIA  1113 

I.   SYSTEM  DISEASES. 

These  constitute  a  small  group  of  very  important  diseases  and  involve 
structures  or  systems  having  a  common  junction,  thus  differing  from 
such  indiscriminate  or  random  disease  as  myelitis  or  multiple  sclerosis. 
The  essential  change  is  a  'primary  slow  degeneration  of  the  nerve 
elements,  followed  by  secondary  proliferation  of  connective  tissue  (sclero- 
sis). The  pathogenesis  of  these  degenerations  is  not  clear,  although 
hereditary  weakness  causing  nutritional  failure  at  a  certain  age  (the 
familial  form),  and  the  selective  action  of  toxins  in  the  blood  acting  on 
certain  nervous  structures,  have  been  thought  causes. 

System  Disease  of  the  Sensory  Tract. 

The  sensory  type  of  system  disease  is  locomotor  ataxia  in  which  the 
peripheral  sensory  neurone  is  affected,  in  the  posterior  roots  and 
columns,  while  the  motor  types  are  spastic  paraplegia,  involving  the 
upper  motor  neurone  (pyramidal  tracts),  and  muscular  atrophy  due  to 
lesions  in  the  lower  neurone  (anterior  horns  and  roots). 

Tabes  Dorsalis,  Locomotor  Ataxia  (Duchenne). 

Definition. — ^A  disease  characterized  (a)  etiologically,  by  syphilis;  (b) 
pathologically  by  lesions  in  the  posterior  spinal  roots  and  posterior 
columns,  in  the  cutaneous  and  muscular  sensory  and  also  the  cerebral 
nerves;  and  (c)  clinically  by  incoordination  (ataxia),  sensory  symp- 
toms (pains  and  defective  sensation),  loss  of  myotatic  irritability  (of 
the  tendon  reflexes),  loss  of  the  pupillary  reflex  to  hght  and  trophic 
disturbances. 

It  is  the  best  known  and  most  frequent  chronic  disease  of  the  cord. 
Horn  in  1827  partly  described  the  affection,  although  Todd  in  1847 
gave  the  first  accurate  account,  eliminated  paralysis,  and  found  the 
posterior  columns  diseased  at  autopsy.  Stanley  first  (1840)  referred 
the  affection  to  the  posterior  columns  and  peripheral  sensory  nerves. 
Tiirck  first  examined  the  tissues  microscopically  and  Romberg  (1851), 
and  especially  Duchenne  (1858),  popularized  the  disease;  it  is  still 
known  in  France  as  Duchenne's  disease. 

Etiology. — Syphilis  is  the  essential  causal  factor  (Fournier  and 
Erb)  in  75  per  cent.  (Gowers),  90  per  cent.  (Erb  and  Striimpell),  or 
100  per  cent.  (Mobius).  In  about  10  per  cent,  of  cases  the  syphilitic 
history  and  stigmata  are  lacking,  whence  it  is  sometimes  attributed  to 
other  causes,  as  trauma,  heredity,  concussion,  exposure,  toxins  of 
soft  chancres  (Hitzig  and  Buzzard),  and  ergotism  (Tiiczek);  but  it  is 
most  probable  that  these  are  only  apparent  or  incidental  factors  and 
that  syphilis  is  the  sole  cause.  The  following  etiological  data  of  tabes 
are  practically  those  of  syphilis;    age,  50  per  cent,  in  the  thirtieth  to 


1114  DISEASES  OF  THE  XERVOUS  SYSTEM 

fortieth  year;  25  per  cent,  in  tlie  fortieth  to  fiftieth  year;  less  than 
25per  cent,  in  the  twentieth  to  thirtieth  year  (Gowers);  cases  may  occur 
in  persons  over  fifty,  under  twenty,  or  even  ten  years  of  age,  the  latter 
of  which  are  probably  due  to  hereditary  syphilis.  Forty-seven  juvenile 
cases  were  collected  by  Hirtz  (1905);  of  these,  the  parents  in  thirteen 
instances  had  syphilis,  tabes  or  dementia.  Sex :  as  in  syphilis  and  paretic 
dementia,  ten  cases  occur  in  males  to  one  in  females.  Syphilis  is  more 
difficult  to  diagnosticate  in  women  and  more  often  runs  a  latent  course. 
Like  syphilis,  tabes  is  sometimes  familial;  Nonne  (1904)  saw  tabes  in 
a  mother  and  two  daughters.  It  prevails  largely  in  cities,  and  among 
the  higher  classes  ("syphilization  and  civilization").  It  is  uncommon 
in  the  negro  though  Hecht  has  seen  cases.  The  reason  that  syphilis  is 
not  considered  causal  by  some  is  the  fact  that  tabes  does  not  occur 
during  its  florid  or  even  its  tertiary  stage;  tabes  is  meta-  or  para- 
syphilitic,  a  degenerative  lesion  occurring  on  an  average  six  to  twelve 
years  after  the  chancre  or  even  later.  Dalous  (1904)  collected  21  cases 
with  active  syphilis. 

Pathology. — The  gross  changes  are  usually  visible  to  the  unaided 
eye;  the  posterior  columns  are  smaller,  outwardly  flattened  instead  of 
rounded,  and  appear  gray  from  loss  of  the  medullary  sheaths  and  trans- 
lucent from  primary  loss  of  nerve  fibers  and  secondary  increase  of  con- 
nective tissue.  The  pia  may  be  secondarily  opaque  and  thickened. 
The  degenerated  areas  are  somewhat  sunken  on  section.  The  posterior 
horns  and  roots  are  always  somewhat  atrophied  and  gray  or  grayish- 
red  in  color.  As  to  minute  changes,  the  toxins  (Striimpell)  bring 
about  a  very  slow  degeneration  of  the  peripheral  sensory  neurone,  its 
fibers,  and  the  processes  of  the  spinal  ganglia  cells,  which  themselves 
suffer  much  less  and  later  obvious  changes  than  their  processes.  These 
processes  run  in  two  directions :  to  the  periphery  and  to  the  posterior 
roots  and  posterior  columns,  (a)  The  peripheral  spinal  sensory  nerves 
are  often  degenerated  (Westphal,  Pierret,  Dejerine),  less  in  large 
trunks  (sciatic  or  crural  nerves)  than  in  the  peripheral  filaments  of 
the  skin,  joints  and  muscles  which  are  important  in  the  sensory,  trophic 
and  atactic  symptoms  of  tabes ;  their  white  substance  wastes  and  then 
their  axis  cylinders.  The  trophic  centres  for  these  fibers  are  largely 
in  the  root-ganglion  but  there  is  some  evidence  that  there  are  also 
some  peripheral  trophic  cells.  (6)  The  fibers  running  from  the  ganglia 
to  the  posterior  roots  are  more  early,  regularly  and  obviously  changed. 
In  the  cord  the  degenerated  tracts  stain  deeply  with  carmine  and 
include  only  structures  derived  from  the  posterior  roots  and  their  col- 
laterals, all  others  escaping  involvement.  The  posterior  root  fibers 
run  (i)  to  the  posterior  columns,  whence  there  occurs,  low  down  in  the 
cord,  degeneration  in  Burdach's  and  then  higher  up  in  Goll's  columns, 
into  which  the  root  fibers  are  pushed  as  new  and  higher  root  fibers 
enter  the  cord.  The  location  of  the  degenerated  fibers  therefore  differs 
at  successive  levels  and  the  degeneration  is  an  ascending  one.  In  the 
lumbar  cord  the  posterior  columns  are  most  intensively  and  extensively 
diseased,  especially  in  their  middle  and  posterior  parts,  nearest  the 


TABES   DORSALIS,    LOCOMOTOR   ATAXIA  1115 

posterior  roots  and  surface  of  the  cord.  Early  and  marked  degener- 
ation is  found  in  the  fine  fibers  of  Lissauer's  zone  which  hes  just  back 
of  the  posterior  horn.  The  anterior  part  of  the  post.  ext.  cohimn  and  the 
central  part  of  the  post.  int.  cohimn  are  shghtly,  if  at  all,  diseased  as 
they  are  not  derived  from  the  post,  ganglia.  In  the  dorsal  cord  the  post, 
columns  are  degenerated  save  in  the  post.  ext.  part  and  in  the  ant.  part. 
In  the  cervical  co7'd  the  'post.  int.  columns  are  diseased  (representing  the 
root  fibers  of  the  lumbodorsal  cord)  and  also  some  areas  in  the  post.  ext. 
column  where  degenerated  root  fibers  have  just  entered.  There  is 
some  pathological  as  well  as  clinical  variation  in  different  cases ;  Marie 
holds  that  one  set  of  sensory  fibers  after  another  is  involved,  and  that 
degeneration  develops  by  segments.  Tabetic  changes  are  usually  most 
developed  in  the  lower  cord,  but  in  the  rare  "cervical  tabes"  the  upper 
cord  suffers  severely  and  perhaps  exclusively,  (ii)  From  the  post, 
roots  a  second  series  of  fibers  run  to  Clarke's  column.  They  and  their 
collaterals  are  degenerated  but  the  cells  of  Clark's  column  (and  their 
ascending  fibers  to  the  cerebellum)  usually  remain  intact,  (iii)  The  post, 
horns  degenerate,  because  they  contain  fine  root  fibers,  (iv)  The  reflex 
collaterals  to  the  ant.  horns  also  degenerate. 

As  already  stated,  pronounced  or  early  atrophy  in  the  cells  of  the 
post,  ganglia  is  rare.  Degenerative  changes  may  involve  other  analo- 
gous neurones,  as  the  auditory,  trigeminus,  optic,  visceral,  sympathetic 
or  ocular  nerves,  or  less  often  the  peripheral  motor  nerves,  the  pyra- 
midal tracts,  the  muscles  themselves,  the  medulla  and  the  brain  cortex. 
In  old  cases,  corpora  amylacea  are  found. 

The  exact  pathogenesis  is  still  disputed:  (i)  Obersteiner  believes  the 
initial  changes  are  in  the  pia  through  which  the  dorsal  nerve  roots  pass ; 
(ii)  Marie  contends  that  there  is  a  lymphangitis  of  the  post,  columns ; 
(iii)  Edinger  believes  the  toxins  (admittedly  those  of  syphilis)  attack 
those  nervous  structures  most  in  use,  and  therefore  most  easily  fatigued ; 
these  are  the  sensory  tracts  of  the  lumbar  cord,  pupil,  bladder  and 
intestine. 

Symptoms. — The  symptoms  vary  chiefly  as  to  their  intensity, 
duration  and  order  of  succession.  In  general  three  stages  are  described. 
1.  The  initial,  neuralgic  or  pre-atactic  stage,  lasting  sometimes  for  years 
(usually  6  to  8,  or  even  10  to  20).  The  earliest  symptoms  are  usually 
sensory  and  irritative,  as  pains  which  are  either  lancinating  or  rheu- 
matic, perhaps  neuralgic  or  like  migrane  or  parsesthesia.  The  knee 
jerk  is  lost  in  nearly  all  cases,  usually  very  early  and  the  pupil  reacts  to 
accommodation  but  not  to  light.  2.  These  symptoms  usually  exist  years 
before  the  ataxy  of  the  second  stage  appears.  Much  less  often  optic 
atrophy,  sexual,  sphincter,  ocular,  articular  or  visceral  symptoms  first 
attract  attention.  The  atactic  stage  may  last  many  years;  muscular 
movements  become  incoordinate,  especially  in  the  legs,  but  sometimes, 
though  later,  in  the  arms.  The  tabetic  gait  develops,  the  patient  sways 
when  his  eyes  are  closed  (Romberg's  sign),  sensation  is  obtunded, 
especially  the  muscular  sense,  urinary  and  sexual  disorders  develop 
and  in  some  cases  diplopia.    The  gross  muscular  power  is  unimpaired. 


1116    ;  1     ;         DISEASES  OF  THE  NERVOUS  SYSTEM 

Trophic,  joint,  bone  and  skin  lesions  and  visceral  disturbances  (crises) 
occur.  3.  The  terminal  stage,  improperly  called  paralytic,  is  much  like 
that  of  other  chronic  affections  of  the  cord.  The  patient  is  bed-ridden, 
helpless  from  extreme  ataxia  and  rarely  from  motor  weakness,  and  bed- 
sores, lesions  in  the  medulla,  and  cystitis  lead  to  a  fatal  issue. 

Special  Symptoms  in  Detail.— 1.  Of  the  motor  symptoms,  (a) 
ataxia  (incoordination)  is  of  such  importance  that  the  disease  is  named 
locomotor  ataxia.  It  is  present  in  75  to  88  per  cent,  of  cases  but  may 
develop  slowly,  only  after  years  or  perhaps  not  at  all ;  it  is  less  common 
at  the  present  time  than  formerly  (Brissaud);  itoccured  in  barely  10  per 
cent,  of  Babinsky's  cases,  who  explains  this  decrease  by  his  use  of  mer- 
cury. Ataxia  is  a  disturbance  of  harmonic  efficient  muscular  contrac- 
tion and  arises  not  only  from  tabes  but  also  from  lesions  in  the  upper 
sensory  neurones  of  the  cord,  medulla,  cerebellum,  pons  and  cerebrum. 
The  cause  of  tabetic  ataxia  is  probably  disease  of  the  afferent  muscular 
fibers  (muscular  anaesthesia,  Reynolds  1855),  intensified  by  sensory 
impairment,  disturbance  in  the  reflex  collaterals  and  sometimes  by  atro- 
phy of  the  optic  nerve.  Duchenne  first  made  the  valuable  distinction 
between  ataxia  and  loss  of  muscular  power  which  is  preserved  until  late 
in  the  disease.  Ataxia  is  frequently  first  observed  by  the  patient  when 
he  walks  in  the  dark  or  closes  his  eyes,  as  in  washing  the  face.  When 
he  closes  his  eyes  or  looks  well  upward  or  when  the  heels  and  toes  are 
brought  closely  together,  the  body  sways  {Romberg's  sign)  and  he 
perhaps  falls,  because  vision  is  one  of  the  sensory  factors  in  equili- 
bration. Later,  incoordination  occurs  even  when  the  eyes  are  open, 
and  the  patient  can  walk  only  with  the  support  of  a  cane.  It  is  often 
increased  by  removing  the  shoes,  which  support  the  feet.  The  ataxia 
is  marked  when  the  patient  attempts  to  "about  face,"  to  walk  back- 
ward (Althaus),  to  stand  on  his  tiptoes  (Rosenbach)  or  to  stand  with 
the  knees  half  flexed  (Brissaud).  In  women  marked  ataxia  is  less  fre- 
quent than  simple  awkwardness.  Ataxia  is  also  seen  when  the  patient, 
with  the  eyes  closed,  attempts  to  place  his  heel  on  the  opposite  knee,  or 
perform  with  one  limb  those  movements  made  by  the  physician  in 
another  limb.  The  gait  is  atactic,  the  feet  are  lifted  too  high,  are  thrown 
too  far  forward  and  outward  (wide-legged  gait)  and  are  brought  sud- 
denly and  forcibly  down  in  a  "stamping"  fashion.  It  has  been  called 
the  "rooster  gait."  A  tumbling  cerebellar  gait  is  less  frequent, 
observed  later  in  the  disease  and  referable  to  involvement  of  the 
trunk  or  hips.  Movement  in  tabetics  is  characterized  by  excessive 
excursion,  rapidity,  irregularity  and  uncertainty  of  execution.  The 
arms  usually  escape  or  are  involved  less  markedly  and  later,  save  in 
cervical  or  brachial  tabes.  The  patient  cannot  execute  finer  move- 
ments, such  as  writing  or  buttoning  the  clothes.  Ataxia  is  rare  in  the 
head,  eyes,  face  and  tongue,  although  in  exceptional  cases  it  has  been 
observed  in  masticatory  movements.  (6)  Muscular  power  may  be 
normal  even  with  the  extreme  ataxia.  The  muscles  are  hypotonic,  and 
this  loss  of  tone  allows  hyperextension  and  hyperflexion  of  the  joints; 
it  is  due  to  loss  of  centripetal  sensory  conduction.    There  is  a  feeling  of 


TABES  DORSALIS,    LOCOMOTOR   ATAXIA  1117 

weakness  in  the  legs  in  two-thirds  of  the  cases.  Attacks  of  transient 
muscular  weakness  are  frequent  (62  to  92  per  cent.)  as  in  the  eye 
muscles.  Paralysis,  though  usually  transient,  may  be  permanent  from 
disease  of  the  pyramidal  tracts,  ant.  horns  or  peripheral  nerves,  (c) 
Atrophy  is  not  common,  but  may  affect  the  arm  (type  of  Duchenne- 
Aran),  the  leg  (the  tabetic  club  foot,  usually  due  to  neuritis),  or  most 
rarely  the  face  (hemiatrophy),  (d)  The  electrical  reactions  are  usually 
normal.  Sometimes  muscular  contractures  occur,  due  to  abnormal 
sensation.  Associated  movements,  in  which  one  leg  moves  when  its 
fellow  moves,  and  spontaneous  movements,  taking  place  without 
volition  or  consciousness  of  them  and  due  to  the  slight  unnoticed 
reflexes,  may  occur. 

2.  Sensory  symptoms  are  prominent.  In  the  majority  of  cases  the 
disease  begins  with  irritative  sensory  phenomena,  (a)  Spontaneous 
pains  occur  in  80  to  90  per  cent.,  are  sudden,  paroxysmal,  lightning-like, 
lancinating,  and  often  nocturnal.  They  are  usually  severe,  but  may  be 
agonizing,  though  sometimes  only  dull,  burning  or  like  those  of 
muscular  rheumatism;  they  may  be  increased  by  damp  and  cold.  They 
last  from  a  few  hours  to  a  day  or  two.  The  legs  are  the  most  common 
seat  of  pain,  then  the  back,  trunk,  arms  especially  in  the  ulnar  distri- 
bution, and  sometimes  the  head  (occipital  nerves)  and  face  (trigeminus, 
whose  ascending  branch  represents  the  sensory  parts  of  most  of  the 
other  cranial  nerves);  Collet  found  migraine-like  attacks  in  40  per 
cent.;  their  bilateral  occurrence  is  very  suggestive.  The  pains  are 
more  often  deep  than  superficial  and  are  more  often  irregular  than 
exactly  conforming  to  a  nerve's  course.  The  pain  in  the  trunk  may 
assume  the  "girdle  form"  (31  per  cent.)  over  a  narrow  or  broad  zone. 
Sometimes  the  area  affected  shows  local  trophic  changes,  as  herpes, 
ecchymoses  or  friable  hair,  (b)  Parcesthesioe  are  common,  as  creeping 
sensations  (formication),  "pins  and  needles"  sensations,  a  sense  of 
heat  or  especially  of  cold.  They  occur  in  the  legs  in  66  per  cent,  of 
cases.  If  in  the  arms,  the  ulnar  distribution  is  especially  involved  (17 
per  cent.).  The  ulnars  at  the  elbows  are  often  insensitive  to  pressure 
(Biernacki's  sign)  and  show  lessened  appreciation  of  pain,  temperature 
and  tactile  impressions.  In  the  face  a  perverted  feeling,  as  of  a  mask, 
may  be  noted  {"Hutchinson's  mask"),  (c)  In  the  early  stages  hyper- 
sesthesia  (probably  from  nerve  irritation)  may  be  noted.  In  86  per 
cent,  of  developed  cases  sensation  is  reduced;  it  is  most  often  of  the 
spinal  or  segmental  type,  though  sometimes  peripheral.  Tactile 
sensation  is  often  disturbed,  especially  in  the  legs  and  soles  of  the  feet. 
Hypsesthesia  may  be  observed  on  tiie  buttocks,  scrotum,  perinivum, 
penis  (the  cause  of  early  decreased  sexual  power)  or  on  the  trunk  as  a 
zone  (80  per  cent.)  which  is  hypiesthetic  especially  to  light  touch  (Ilit- 
zig  and  Liihr).  It  is  not  usually  found  higher  than  the  third  rib, 
although  there  may  be  occasional  occipital  or  trigenuiial  anaesthesia. 
If  the  arms  are  affected,  it  is  mostly  in  the  hands  and  palms.  Some- 
times a  touch  to  one  member  is  referred  to  another  (allocheiria). 
Occasionally     a     single    contact    feels    like    several     fpolvivsthesia). 


1118  DISEASES  OF  THE  XERVOUS  SYSTEM 

Perception  of  pain  is  lessened  in  30  to  70  per  cent,  of  the  cases,  occurring 
alone  or  with  hypsesthesia;  a  short  stab  with  a  pin  is  often  felt  merely 
as  a  touch.  Pain  conduction  is  often  retarded  (36,  even  90  per  cent,  of 
cases) ;  the  sharp  stick  of  a  pin  is  felt  at  once  as  a  touch,  but  the  pain  is 
perceived  only  after  7  to  15,  even  35  seconds.  When  asked  to  state  his 
sensations,  the  patient  says  "now"  when  stuck,  and  later  "ouch"  as 
he  feels  the  pain.  Analgesia  may  be  the  cause  of  severe  injuries  as  in 
syringomyelia.  Sometimes  the  testicles  are  insensitive  to  pressure,  and 
inflammations  such  as  pleurisy  may  run  a  painless  course.  The  sense 
of  temperature  is  rarely  affected  alone  or  completely  and  is  usually 
associated  with  analgesia;  tabetics  are  often  oversensitive  to  cold. 
The  muscle  sense  is  disturbed  not  only  as  regards  the  location,  but  also 
as  to  active  or  passive  movements  of  the  muscles,  especially  of  the  legs. 
A  change  of  angle  of  one  or  two  degrees  in  the  joints  and  tendons  is 
noted  by  normal  individuals,  while  in  tabetics  much  wider  movements 
are  not  perceived,  especially  those  in  the  small  distal  joints;  the  toes 
may  be  moved  unnoticed  by  the  patient,  perhaps  in  the  later  stages  the 
fingers  also. 

3.  The  reflexes  are  also  involved,  (a)  The  skin  reflexes  may  be 
increased  early  in  the  disease.  Later  the  plantar  and  gluteal  reflexes 
are  somewhat  decreased.  The  abdominal  and  cremasteric  may  long 
remain  normal.  (6)  Of  the  tendon  reflexes,  the  knee  jerk  is  lost  early 
(Westphal's  sign);  this  is  a  most  constant  finding  in  tabes  (98  to  100 
per  cent.)  and  is  due  to  disease  of  the  afferent  nerves  (and  collateral 
reflex  paths  in  the  cord).  These  reflexes  should  be  examined  by  having 
the  patient  sit  on  the  edge  of  a  table,  with  his  eyes  closed,  and  excluding 
cerebral  inhibition  of  the  reflexes  by  having  him  pull,  in  an  outward 
direction,  the  locked  fingers  ( Jendrassik's  reinforcement).  The  patellar 
reflexes  are  rarely  present  save  in  exceptional  cases  of  cervical  tabes. 
They  are  sometimes  simulated  by  a  reflex  movement  which  occurs  after 
tapping  the  patellar  tendon  but  in  this  case  the  interval  is  longer  before 
the  reaction,  and  the  same  reaction  may  follow  a  simple  pin  prick. 
The  knee  jerk  has  been  known  to  return  after  a  cerebral  hemiplegia. 
The  Achilles  reflex  is  often  lost,  though  less  frequently  than  the  pateflar 
(or  equally  frequently,  according  to  Frankel).  The  tendon  reflexes  of 
the  arms  are  sometimes  decreased. 

4.  The  Eyes  and  Special  Senses. — (a)  The  pupils  contract  to  accommo- 
dation but  not  to  light  in  85  to  97  per  cent.  (Argyll-Robertson,  1869). 
In  testing,  the  patient  must  look  to  a  distance,  and  one  eye  must  be 
tested  at  a  time  lest  accommodation  be  confused  with  contraction  to 
light.  The  cause  of  the  Argyll-Robertson  pupil  is  not  known,  but  it 
may  depend  upon  a  degeneration  of  fibers  connecting  the  optic  nerve 
with  the  oculomotor  muscles  (see  Progressive  Paralysis  of  Insane). 
The  tabetic  pupil  rarely  dilates  on  pinching  or  sticking  the  skin  of  the 
neck  (Erb),  especially  if  the  pupil  is  small.  In  about  50  per  cent,  it  is 
small  (spinal  myosis) ;  the  pupils  are  often  unequal  in  size  and  irregular 
in  contour.  (6)  The  eye  muscles  are  affected  in  40  to  50  per  cent,  of 
cases.    Mobius  holds  that  ocular  paralyses  are  almost  as  important  as 


TABES   DORS  A  LIS,    LOCOMOTOR   ATAXIA  1119 

the  pupillary  changes,  especially  when  they  are  painless  wherein  they 
differ  from  the  rheumatic  and  syphilitic  forms;  he  holds  that  the 
majority  of  all  eye  paralyses  in  the  adult  are  tabetic.  Diplopia  (in  16 
per  cent.)  is  common  and  usually  unilateral.  The  order  of  frequency 
of  involvement  is  the  sixth,  third  (lev.  palpebrarum),  sup.  rectus  and 
fourth  nerves.  When  one  muscle  is  paralyzed  the  others  are  usually 
weak.  The  early  form  of  paralysis  is  usually  transitory;  the  late  form 
is  often  permanent.  Nuclear  degeneration  is  the  most  probable  cause. 
(c)  Optic  atrophy  (10  per  cent.)  is  generally  an  early  symptom.  The 
disk  is  pale  and  shrunken,  especially  on  its  temporal  side  and  at  the 
edges,  which  are  sharp.  The  process  is  always  bilateral;  central 
scotoma  and  actual  neuritis  are  rare.  The  process  is  usually  progressive 
and  blindness  results.  When  optic  atrophy  occurs  early,  ataxia  may 
not  appear;  this  is  known  as  "tabes  arrested  by  blindness."  When  it 
develops  later  it  has  no  effect  on  the  ataxia,  (d)  Deafness  may  develop 
gradually  or  suddenly,  sometimes  with  vertigo  or  Meniere's  complex. 
It  may  be  permanent  or  transient.  Auditory  defects  are  present  in  80 
per  cent,  of  cases.  Atrophy  of  the  auditory  and  olfactory  nerves  has 
been  found. 

5.  The  Sphincters  and  Genital  Sphere. — (a)  The  bladder  is  frequently 
affected  (45  to  80  per  cent.),  possibly  as  the  first  symptom  of  the  disease. 
The  bladder  is  slowly  or  imperfectly  evacuated,  because  its  centripetal 
sensory  fibers  are  diseased.  There  may  be  overflow,  incontinence,  and 
in  the  later  stages  cystitis  frequently  results  from  decomposition  of  the 
residual  urine,  followed  in  turn  by  pyelitis,  nephritis  and  septicaemia. 
(b)  The  sphincter  ani  is  somewhat  w^eak;  there  is  rarely  incontinence. 
Constipation  is  the  rule,  (c)  The  sexual  appetite  and  power  are 
reduced  (58  to  76  per  cent.),  often  early.  Labor  is  not  interfered  with 
and  is  sometimes  painless. 

6.  Trophic  Disorders. — The  general  nutrition  sometimes  suffers,  but 
local  trophic  changes  are  much  more  common,  (a)  Trophic  alter- 
ations in  the  bones  and  joints,  described  by  Cruveilhier  and  ^Mitchell, 
were  first  thoroughly  studied  by  Charcot,  after  whom  they  are  named, 
Charcot's  disease.  They  usually  appear  late  and  develop  in  2  per  cent, 
of  cases.  The  onset  of  articular  changes  is  usually  gradual,  sometimes 
acute  with  marked  swelling,  or  may  seem  to  be  traumatic.  Two  forms 
are  observed;  first  and  more  frequently  the  atrophic  form,  especially 
in  the  hip  and  shoulder,  in  which  the  cartilages  are  eroded,  the  articular 
surfaces  waste  and  crepitate,  foreign  bodies  sometimes  develop,  and 
the  joint  becomes  too  lax,  and  dislocation  of  the  hip  or  knee  (genu 
recurvatum)  results;  second,  the  hypertrophic  form  with  bony  for- 
mation, ossification  of  the  ligaments,  and  rigidity  resembling  arthritis 
deformans  but  more  acute,  extreme  and  ett'usive.  The  adjacent 
muscles  atrophy — the  arthropathic  muscular  atrophy.  The  large 
joints  are  usually  involved,  as  the  knee  (45  per  cent.),  hip  (20  per  cent.), 
shoulder  (11  per  cent.),  elbow  (5  per  cent.),  or  ankle  (4  per  cent.),  but 
smaller  articulations  may  be  affected,  as  the  tarsus  (S  per  cent.)  or  less 
often  the  jaw,  spine,  thumb,  etc.    The  tabetic  joint  is  painless.    The 


1120  DISEASES  OF  THE  XERVOUS  SYSTEM 

cause  is  the  same  as  in  syringomyelia;  the  anaesthetic  joints  are  moved 
inappropriately  and  the  nutritional  reflex  (which  normally  depends  on 
centripetal  influences)  is  lacking  (Marinesco  and  Serieux).  The  tabetic 
foot  is  characterized  by  thickness  and  roundness  of  its  inner  border  and 
arch,  flattening  of  the  sole,  decreased  motility  and  pathologically  by 
erosion  and  atrophy  of  its  bones.  It  must  be  distinguished  from  the 
tabetic  club  foot  due  to  muscular  atrophy  of  the  calf  muscles  with  con- 
tractures. The  bones  are  friable  and  break  easily  but  painlessly,  as  first 
described  by  Wier  IMitchell.  Fracture  is  due  to  rarefying  osteitis, 
which  renders  the  medullary  substance  more  porous,  the  cortex  thinner 
and  the  inorganic  base  less  in  amount.  If  a  callus  develops,  it  is  often 
exuberant.  The  tendons  sometimes  rupture,  probably  from  trophic 
changes.  (6)  The  perforating  ulcer  of  the  foot  {mat  per  for  ant  du  pied) 
is  more  frequent.  It  is  "punched  out"  in  appearance,  and  thickening 
precedes  ulceration;  it  is  usually  painless,  secretes  but  little  pus  and  is 
due  to  nerve  degeneration.  Similar  ulcerations  resembling  syphilis 
may  occur  in  the  nose,  ear,  buccal  mucosa,  palate  or  uvula,  (c)  In  the 
skin,  local  sweating,  ecchymoses,  herpes,  blebs,  alteration  of  the  hair  or 
nails,  gangrene  and  ichthyosis  may  occur.  Decubitus  is  not  common 
save  in  the  last  stages,  and  it  may  not  develop  even  after  years  in  bed. 
There  may  be  painless  falling  out  of  the  sound  teeth  with  analgesia  of 
the  gums  or  there  may  be  dental  caries,  referred  to  changes  in  the 
fourth  ventricle  (Demange). 

7.  Of  the  visceral  symptoms,  the  most  important  are  the  painful 
crises  described  by  Delmarre  but  first  correctly  interpreted  by  Charcot. 
(a)  Gastric  crises  occur  in  5  per  cent,  of  the  cases.  There  is  severe 
sometimes  excruciating  epigastric  pain,  which  often  radiates  into  the 
back,  vomiting  (with  or  without  nausea)  of  food,  then  fluid,  finally 
bile  or  even  some  blood;  this  is  often  attended  by  restlessness,  epi- 
gastric retraction,  hiccough,  fever  and  a  slow  or  rapid  and  irregular 
pulse.  A  test  meal  gives  varying  results;  hyperacidity  is  less  frequent 
than  hypacidity.  The  urine  is  alkaline,  contains  indican,  and  the 
chlorides  are  decreased.  The  crisis  lasts  several  hours  to  several 
days  (even  8  or  10)  and  may  greatly  reduce  the  general  nutrition;  it 
recurs  and  is  sometimes  the  first  evidence  of  tabes.  The  cause  of  the 
crisis  is  hard  to  explain;  it  is  usually  considered  nervous,  but  Pal  thinks 
it  is  due. to  increased  arterial  tension,  (b)  Laryngeal  crises  are  next 
in  frequency  but  are  shorter  in  duration.  They  are  due  to  spasm  of  the 
laryngeal  muscles,  and  are  often  dangerous.  In  some  instances  only 
a  hoarse  cough  like  that  of  pertussis  is  noted;  in  others  there  is  collapse 
or  death  (ictus  laryngis).  Anatomically,  the  ascending  branch  of  the 
fifth  nerve  and  the  glossopharyngovagus  nucleus  or  its  branches  are 
degenerated,  (c)  Other  crises  are  far  less  common,  as  intestinal  crises, 
which  are  characterized  by  colic,  diarrhoea  and  sometimes  rectal 
tenesmus;  the  author  saw  one  case  with  severe  constipation  lasting 
12  days,  which  was  immediately  relieved  by  morphine  gr.  V;  renal 
crises  with  scant  urine,  transient  albuminuria  or  even  hsematuria,  and 
less    often    nasal,    pharyngeal,    hepatic,    cardiac,    bronchial,   vesical. 


TABES   DORSALIS,  LOCOMOTOR   ATAXIA  1121 

urethral  or  vulvovaginal  crisesoccur.  (d)  The  pulse  in  tabes  frequently 
reaches  a  rate  of  100  or  120.  Lachrymation,  salivation,  polyuria  or 
glycosuria  aj-e  sometimes  noted. 

8.  Cerebral  symptoms ,  other  than  the  eye  changes  noted  above,  are 
not  frequent;  they  are  unilateral  atrophy  of  the  tongue;  paralysis  of 
the  vocal  cords,  especially  of  the  abductors;  vagus  and  accessorius 
symptoms  other  than  those  already  noted,  such  as  rapid  pulse,  palatal 
weakness  or  rarely  paralysis  affecting  the  trapezius  and  sternomastoid, 
which  is  probably  neuritic;  and  very  rarely  facial  or  bulbar  paralysis. 

Complications. — These  include  hysteria,  neurasthenia.  Graves' 
disease,  paralysis  agitans;  true  cerebrospinal  syphilis;  other  meta- 
syphilitic  maladies,  as  arteriosclerosis,  aneurysm  (10  to  20  per  cent.), 
valvular  disease,  arteriosclerotic  aortic  regurgitation  (2  to  9  per  cent.) 
and  especially  dementia  paralytica,  which  is  maintained  by  some  to  be 
a  cerebral  tabes  but  more  correctly  held  to  be  an  independent  although 
closely  correlated  affection;  myelitis;  general  or  local  muscular 
atrophy,  particularly  the  symmetrical  form  (Dejerine)  due  to  neuritis; 
cerebral  thrombosis  due  to  concomitant  arterial  disease;  and  apoplec- 
tiform seizures  which  occur  as  in  paretic  dementia. 

Course  and  Prognosis. — The  typical  progress  of  the  disease  by  stages 
(v.  s.)  may  be  altered.  According  to  Sarbo,  pain  is  the  first  symp- 
tom in  68  per  cent,  while  no  other  single  early  symptom  is  the  first  in 
more  than  3  per  cent.  The  disease  in  rare  cases  begins  acutely.  Not 
over  50  per  cent,  are  progressive  (Gowers).  Optic  atrophy  or  insanity 
may  arrest  tabes.  In  the  early  stages  or  in  rudimentary  forms,  there  is 
a  slight  chance  that  the  symptoms  may  become  stationary,  but  not  after 
ataxia  fully  develops.  Tabes  is  incurable.  Leube  mentions  an  instance 
of  a  man  who  worked  hard  for  forty  years  after  the  onset  of  tabes; 
tabetics  may  live  for  twenty  years  in  the  last  stages  of  the  disease. 
Crises,  especially  the  gastric  crisis,  alcoholism,  traumatism,  acute  on- 
set, intercurrent  affections  which  may  be  unnoticed  because  of  their 
painlessness,  typhoid,  and  affections  of  the  bladder  and  kidney  with 
sepsis  are  unfavorable  prognostics.  In  1,960  well-observed  cases  (out 
of  4,000)  40  per  cent,  followed  a  long  course  with  exacerbations,  30  per 
cent,  were  steadily  progressive,  19  per  cent,  halted  for  three  years  or 
more,  6  per  cent,  ran  a  severe  rapid  course,  and  5  per  cent,  almost 
recovered  (Belugou  and  Faure,  1903). 

Diagnosis. — The  diagnosis  is  usually  very  easily  made  and  is  based 
on  the  following  signs  in  various  combinations: — (a)  The  Argyll- 
Robertson  pupil,  which  according  to  Mobius  is  practically  indicative 
of  tabes,  paretic  dementia  or  rare  lesions  in  the  corp.  quadrigemina. 
(6)  The  most  common  and  early  symptom,  Westphal's  sign,  loss  of  the 
patellar  reflex  (which  most  rarely  fail  in  health,  marasmus,  old 
individuals  or  as  an  hereditary  lesion),  (c)  Lightning  pains,  "tabetic 
neuralgia,"  girdle  sensation,  gastric  and  other  crises,  (d)  Sensory 
changes,  subjective  and  objective,  including  bladder  disturbance,  (e) 
Optic  atrophy.  (/)  Painless  ocular  paralysis,  particularly  in  the  adult 
and  of  the  nuclear  form,  producing  ptosis,  and  diplopia,     (g)  Ataxia, 


1122 


DISEASES  OF  THE  NERVOUS  SYSTEM 


which  usually  does  not  develop  early,  with  Romberg's  sign  and  the 
tabetic  gait,  is  practically  pathognomonic  after  exclusion  of  peripheral 
neuritis. 

In  less  than  1  per  cent,  of  cases  (Dejerine)  the  disease  is  located 
in  the  cervical  region ;  and  in  this  cervical  tabes,  the  sensory  changes, 
pains,  and  ataxia  are  most  manifest  in  the  arms,  or  even  in  the  face. 
The  arm  reflexes  are  sometimes  abolished,  and  the  patellars  may 
rarely  be  normal  or  increased.  The  characteristic  pupils  are  almost 
always  present,  and  gastric  crises  appear  early  and  very  frequently. 
The  diagnosis  oi  atypical  tabes  may  long  remain  uncertain,  as  in  cases 
in  which  ataxia,  Westphal's  sign,  and  the  Argyll-Robertson  pupil  are 
absent,  or  in  those  with  unusual  symptoms,  as  marked  motor  weakness, 
atrophy,  or  paralysis. 

Differentiation. — In  the  earliest  stage,  confusion  with  neurasthenia, 
hypochondriasis  and  nosophobia  is  possible,  from  common  symptoms, 
as  pains,  parresthesia,  girdle  sensation,  and  weakness  of  the  legs,  but 
close  continued  observation  usually  determines  the  diagnosis;  the  tabes 
of  Hippocrates  was  probably  neurasthenia.  One  of  the  forms  of  peri- 
pheral  {multiple)  neuritis,  (q.  v.),  viz.  acute  ataxia,  or  pseudotabes,  may 
require  differentiation.  Cerebrospinal  syphilis,  especially  of  the  roots 
and  the  membranes,  mav  sometimes  cause  confusion. 


Tabes 

Gradual  onset;    very  slow  progress. 

Blindness  often  complete ;  marked 
ophthalmoscopic  changes.  Hemian- 
opsia not  common;  rarely  central 
scotoma.     Argyll-Robertson  pupil. 


Symptoms  bilateral. 

Oculomotor  nerve  symptoms  may  cause 
the  greatest  difficulty,  since  the 
closest  r3lati6n  (Erb)  exists  between 
the  two  diseases  as  regards  this  nerve, 
yet  painless  in  tabes  and  nuclear  in 
origin. 

Crises  and  anaesthesia  of  the  fifth  nerve, 
laryngeal  paralysis. 


Sensory  nerves  most  involved. 

Paralysis  very  rare. 

Knee  jerk  absent. 

Ataxia. 

In  .syphilis  and  parasyphilitic  diseases 
(tabes),  lumbar  puncture  shows  pre- 
dominance of  mononuclear  cells. 


-Syphilis. 


More  rapid. 

Blindness  rarely  total;  ophthalmo- 
scopic changes  may  be  few  or  none, 
yet  with  great  disturbance  of  func- 
tion. Amaurosis,  etc.,  acute  or  sub- 
acute, "in  installments";  central 
scotoma  with  free  periphery.  No 
Argyll-Robertson  pupil. 

Often  unilateral. 

Oculomotor  symptoms  with  headache 
(meningitis  and  nerve  trunk  involve- 
ment). 


Crises,  anaesthesia  of  the  fifth  nerve,  etc., 
rare.  Anaesthesia  of  the  fifth  is  for 
all  varieties  of  sensation,  while  tabetic 
anaesthesia  is  for  pain. 

Motor  nerves  mostly. ,;-    . 

Paralysis  frequent  at  some  period. 

Knee  jerk  variable,  increased. 

Rare. 

Remissions  frequent  witli  greater  Aari- 
ability  and  brusqueness  tiian  in 
tubes. 


TABES    DORS  A  LIS.    LOCOMOTOR   ATAXL4.  1123 

Tabes  and  paretic  dernentia  have  a  common  etiology  but  in  the  latter 
the  pyschical  alteration  is  characteristic.  For  differentiation  from 
Friedreich's  ataxia,  see  page  1135.  In  cereheUar  tumor,  the  ataxia 
usually  ceases  when  the  eyes  are  closed,  and  is  not  characterized  by  the 
excessive  excursion  or  rapidity  of  tabes;  in  most  cases  the  patellar 
reflexes  are  increased,  there  is  no  anaesthesia,  and  signs  of  tumor  are 
often  present.  In  multiple  sclerosis  there  may  in  exceptional  cases  be 
crises,  pains,  and  sensory  disturbance,  but  the  Argyll-Robertson  pupil, 
ataxia,  marked  sensory  and  bladder  disturbances  are  most  rare.  The 
reflexes  are  increased,  there  is  nystagmus,  scanning  speech,  intention 
tremor  and  central  scotoma,  and  functional  oculomotor  involvement 
is  more  frequent.  Paraplegias  are  not  difficult  to  differentiate,  since 
true  motor  disturbance  is  rare  and  of  late  occurrence  in  tabes;  the 
reflexes  are  increased  and  spastic  rigidity  is  marked,  even  in  atactic 
paraplegia.  Tabetic  pain  is  often  misinterpreted;  pain  as  a  rule 
suo-orests  disease  of  the  vertebrse  and  membranes  rather  than  of  the 
cord  itself,  but  in  vertebral  disease  or  cord  tumor  the  pani  is  hxed, 
and  is  jDften  increased  on  pressure  and  movement.  Tabes  may  be 
confused  (but  only  on  hasty  or  partial  examinations)  with  rheumatism, 
intercostal  or  trigeminal  neuralgia,  and  gastric,  renal  or  other  visceral 
disease.  Bilateral  sciatica  always  suggests  tabes,  diabetes,  or  nephritis. 
Strlimpell  describes,  among  workers  in  tobacco,  a  nicotine  tabes,  in 
which  pain,  pupillary- alteration,  atactic  gait  and  absence  of  knee  jerks 
are  observed,  but  which  presents  a  characteristic  tremor  and  increased 
cutaneous  reflexes  in  the  legs. 

Treatment. — Since  the  disease  is  incurable,  no  therapy  is  especially 
efficacious. 

1.  Etiological  Treatment. — Antisyphilitic  remedies  are  at  first 
indicated,  but  their  frequent  and  almost  regular  failure  has  led  some 
writers  to  erroneously  deny  the  causal  connection  between  syphilis  and 
tabes.  Tabes  is  not  active  syphilis;  it  is  a  late  degenerative  para- 
syphilitic  affection.  Mercury  and  iodides  are  therefore  advantageous 
chiefly  either  in  early  cases  or  in  those  in  which  gummatous  changes 
co-exist  with  tabes.  They  apparently  arrest  some  cases  of  optic  atrophy. 
Mercury  is  thought  by  Erb  to  be  beneficial  if  it  is  used  carefully;  it 
may  be  administered,  but  should  be  discontinued  at  once  if  untoward 
symptoms  develop. 

2.  Hygienic  Tre.\tment. — Overwork,  overexercise,  worry,  fatigue, 
trauma,  exposure,  and  excess  in  tobacco,  alcohol  or  in  sexual  indulgence 
should  be  avoided.  Tabetics  should  not  marry.  The  diet  should  be 
regulated,  since  dyspepsia  promotes  pain.  If  possible,  the  patient 
should  live  in  a  warm  climate  and  at  a  moderate  altitude. 

3.  Drug  Treatment. — There  is  no  specific  remedy.  Silver,  strych- 
nia, and  nitroglycerine  give  uncertain  results.  Gowers  considers 
arsenic  beneficial. 

4.  Balneotherapy. — Warm  baths  are  injurious;  lukewarm  baths 
are  best,  but  exert  no  specific  influence  on  the  disease.  The  same  is 
true  of  (o)  electrotherapy,  and  (6)  massage. 


1124  DISEASES  OF  THE  NERVOUS  SYSTEM 

7.  Symptomatic  Therapy.— (a)  If  'pain  is  superficial,  sinapisms, 
chloroform  liniments,  cocaine  (hypodermatically)  or  the  galvano- 
cautery  should  be  tried;  if  moderate,  acetanilide  or  cannabis  indica, 
are  beneficial,  but  morphia  should  be  avoided  as  long  as  possible, 
because  the  habit  is  readily  acquired.  Peripheral  faradization  is  often 
efficacious.  Gowers  recently  described  cases  in  which  pain  was  a 
salient  symptom  and  existed  without  ataxia  or  loss  of  the  patellar 
reflexes:  for  this  "tabetic  neuralgia,"  differing  from  the  ordinary  pains 
of  tabes,  he  recommends  salicylates  and  aluminium  chloride,  gr.  v-x 
t.  i.  d.  (6)  Crises  resist  milder  therapy  and  usually  necessitate  the  use 
of  hypodermics.  Laryngeal  crises  often  respond  to  nitroglycerine 
hypodermatically,  chloroform  by  inhalation  or  cocaine  locally.  Stretch- 
ing the  jspine  and  cord  probably  relieves  pain;  the  patient  sits  on  the 
floor  with  the  legs  extended;  without  other  movement,  the  body  is 
carefully  pushed  forward  as  far  as  possible,  (c)  For  vesical  affections, 
catheterization  for  residual  urine  is  indicated,  but  under  most  rigid 
antisepsis;  belladonna  and  faradization  are  often  beneficial.  Cystitis 
is  treated  by  lavage,  {d)  Secondary  infection  should  be  avoided. 
Corns  should  never  be  cut  but  always  rubbed  off. 

8.  Ataxia. — ^This  may  be  relieved  by  H.  G.  Frankel's  systematic 
exercises,  "a  reeducation  of  the  central  nervous  system  by  repeated 
exercises,"  which  teaches  that  carefully  and  persistently  executed 
muscular  movements,  not  forceful  movements,  are  desirable.  (The 
nerve  stretching  of  Langenbuch  and  the  suspension  method  of  Mitchell 
are  useless  and  even  injurious). 


II.  System  Diseases  of  the  Motor  Tract. 

The  centrifugal  or  motor  paths  may  be  diseased  (1)  in  the  upper 
neurone,  as  in  spastic  spinal  paralysis;  (2)  in  their  entirety;  this 
affects  both  neurones,  as  amyotrophic  lateral  sclerosis;  (3)  in  the 
peripheral  neurone,  as  spinal  muscular  atrophy  or  its  cerebral  analogue, 
progressive  bulbar  paralysis;  (4)  in  the  peripheral  motor  nerves,  as  the 
neuritic  muscular  atrophy  and  finally  (5)  in  the  muscles  themselves, 
as  the  muscular  dystrophies.  These  forms  are  probably  more  or  less 
correlated  and  some  of  the  types  blend,  but  separate  descriptions  are 
necessary  in  order  to  bring  out  clearly  the  classical  symptoms  and 
physiology  (though  the  classification  of  cases  into  those  with  and 
without  disease  of  the  spinal  gray  matter,  is  more  simple). 


1.  Spastic  Spinal  Paraplegia. 

Lateral  sclerosis,  tabes  dorsal  spasmodique,  was  described  first  by  Erb 
in  1875,  and  later  by  Tiirck  and  Charcot.  Though  amyotrophic  lateral 
sclerosis  affects  both  neurones  and  the  muscular  atrophies  the  lower 
neurone  in  the  cord,  nerves  or  muscles,  this  malady  concerns  only 


SPASTIC  SPINAL   PARAPLEGIA  1125 

the  upper  motor  neurone,  especially  that  part  which  is  in  the  cord, 
although  it  has  been  traced  at  times  to  the  cortex. 

Etiology  and  Pathology. — The  disease  represents  a  clinical  symptom 
complex  rather  than  a  pathological  entity.  The  causal  factors  are 
uncertain,  as  syphilis,  or  occasionally  an  hereditary  tendency.  In  75 
per  cent,  of  cases  it  occurs  between  the  twentieth  and  fortieth  years. 
It  was  thought  that  there  was  a  primary  sclerosis  of  the  lateral  pyra- 
midal tracts,  especially  in  their  lower  parts,  for  which  unequivocal 
confirmation  is  still  lacking,  for  the  cases  of  Erb,  Charcot,  Striimpell, 
Dreschfeld,  and  Minkowski  were  not  wholly  confined  to  these  tracts 
and  there  were  some  changes  in  other  neurones, as  in  the  post,  columns. 

Symptoms. — There  are  three  cardinal  findings,  (a)  Motor  weak- 
ness, which  is  usually  paraplegic;  (6)  muscular  rigidity,  and  (c) 
increased  reflexes,  (a)  Motor  weakness  is  usually  the  first  sign;  it 
begins  slowly  and  is  evidenced  by  weakness,  fatigue  or  stiffness  in  the 
flexors  of  the  hips  especially  but  also  of  the  knees  and  ankles.  Every 
gradation  from  paresis  to  paralysis  may  be  noted  in  different  cases  or 
in  different  stages.  The  arms  rarely  are  first  affected.  Unilateral 
paresis,  as  of  one  arm  and  one  leg,  is  very  exceptional.  Striimpell 
attributes  the  loss  of  finer  synergistic  movements  to  involvement  of  the 
lateral  pyramidal  tracts;  he  holds  that  the  coarser  movements  for 
groups  of  muscles  are  possible,  via  the  anterior  pyramidal  tracts.  The 
muscles  are  large  and  well  nourished.  (6)  Muscular  rigidity  (hyper- 
tonicity)  results  also  from  disease  of  the  lat.  pyram.  tracts,  which  lessens 
the  inhibition  and  is  proportionate  to  the  loss  of  power.  The  muscles 
resist  passive  efforts  at  flexion,  especially  quick  efforts,  but  yield  to  slow, 
gradual  flexion  and  remain  in  the  position  given  them;  this  is  the  "  lead 
pipe  contraction"  of  Wier  Mitchell.  The  knees  are  rigidly  extended, 
even  when  the  patient  sits  on  the  edge  of  the  bed;  the  great  toe  is 
strongly  flexed  dorsally;  when  one  leg  is  lifted  as  he  lies  in  bed,  the 
other  comes  with  it;  the  specially  tense  adductors  prevent  abduction 
of  the  thighs.  The  muscles  are  stiff  in  the  morning;  painful  spasms 
may  occur  during  the  night;  hypertonicity  may  lead  to  contractures 
which  are  largely  active  in  character  and  patients  sometimes  complain 
of  the  "tendons  getting  too  short."  In  active  movements  rigidity  is 
manifest;  the  gait  is  paretic  and  spastic,  the  knees  are  extended 
and  closely  apposed,  the  steps  are  short,  the  balls  of  the  feet  seem 
to  cleave  to  the  ground,  and  the  feet  scuffle,  (c)  Increase  of  the 
reflexes  is  also  due  to  lateral  pyramidal  sclerosis.  The  knee  jerks  are 
most  excessive;  ankle  clonus  and  Babinsky's  reflex  are  present;  a 
strong  clonic  contraction  of  the  quadriceps  follows  depression  of  the 
patella,  and  the  gait  may  be  hopping;  in  short,  this  is  the. so-called 
*' spinal  epilepsy,"  (Brown-S^quard).  The  arms  are  often  normal  but 
may  show  weakness;  there  may  be  rigidity  like  that  of  a  late  hemi- 
plegia, although  less  in  degree,  in  which  the  arms  hug  the  chest,  the 
forearm  is  pronated  and  partly  flexed  and  the  fingers  are  flexed;  there 
may  be  clonic  spasm  of  the  fingers,  and  increased  tendon  and 
periosteal  reflexes.     In  the  trunk,  there  sometimes  is  weakness  in  the 


1126  '  DISEASES  OF  THE  NERVOUS  SYSTEM 

back  and  painful  contractions  of  the  chest  and  back  muscles  with  dull 
aching.  The  cranial  nerves  are  rarely  diseased,  although  the  jaw-jerk 
may  be  increased.  Sensation,  the  electrical  reactions,  the  sphincters, 
muscular  nutrition,  and  the  eyes  are  usually  cpiite  normal.  If  there  are 
sensory  symptoms  they  are  rarely  objective;  the  sphincters  are  usually 
affected  late. 

Clinical  Forms  and  Diagnosis. — Diagnosis  concerns  (a)  the  paresis, 
(6)  hypertonicity,  (c)  increase  in  the  reflexes,  {d)  gradual  onset,  andCe) 
absence  of  sensory,  trophic  and  other  symptoms.  Six  clinical  forms 
may  be  described.  (1)  There  is  rigidity  and  spasticity  in  the  legs,  arms 
and  perhaps  the  face,  sometimes  with  compulsory  laughing  or  weeping,, 
as  in  amyotrophic  lateral  sclerosis,  but  without  muscular  atrophy. 

2.  The  hereditary  or  familial  form  (Erb,  Bernhardt,  Striimpell, 
Spiller)  commences  in  persons  between  twenty  and  thirty  years  of  age; 
the  paresis  develops  late;  this  form  is  characterized  anatomically  by 
sclerosis  of  the  (congenitally  weak)  lateral  pyramidal  tracts,  and  also  by 
sclerosis  of  the  cerebellar  and  GoU's  columns  (this  would  be  more 
properly  classified  under  combined  system  disease). 

3.  In 'infantile  forms  (see  Cerebral  Paralysis  in  Children),  the 
rigidity  is  less;  foot-clonus  less  common;  tonic  spasms  are  rare;  athetoid 
movements,deficient  mentality  and  epileptiform  convulsions  are  common. 

4.  In  the  syphilitic  form  of  Erh,  there  is  paresis  and  slight  spasti- 
city, plus  urinary  incontinence,  retention,  and  impotence. 

5.  There  are  forms  which  are  symptomatic  of  brain  disease  (tumor, 
syphilis,  paretic  dementia,  encephalitis,  hydrocephalus),  cord  disease 
(tumor,  myelitis,  compression,  syringomyelia,  multiple  sclerosis),  and 
hysteria  (which  may  closely  simulate  spastic  paraplegia) ;  hysteria  has 
not  the  peculiar  extensor  spasm,  loss  of  power  is  rarely  complete,  and 
ankle  clonus  is  rare,  although  a  spurious  half  voluntary  contraction 
of  the  calf  muscles  may  be  noted. 

6.  Westphal,  Charcot,  Schachnowitch,  but  especially  Goldflam, 
have  described  periodic  familial  paralysis,  which  affects  the  legs  and 
less  often  the  arms,  is  flaccid,  and  results  in  decrease  of  the  patellar 
and  absence  of  the  plantar  reflexes,  decreased  faradic  irritability, 
sleepiness,  but  without  sensory  symptoms;  it  lasts  one  to  three  days. 
The  prognosis  is  good. 

Prognosis. — The  disease  may  be  stationary  for  years  and  its  course  is 
chronic.  "It  is  perhaps  the  least  dangerous  to  life  of  any  chronic 
spinal  lesion."     Recovery  or  arrest  is  rare. 

Treatment. — Much  exercise,  fatigue,  electrotherapy  and  strychnia 
are  to  be  avoided.  ^lassage  and  warm  baths  relieve  the  spasticity. 
Otherwise  the  therapy  is  expectant. 


2.  Amyotrophic  Lateral  Sclerosis. 

This   was  often   called  the   Maladie  dc   (liarcoi,   because   Charcot 
(18(55)  with  Joifroy  first  described  it. 


AMYOTROPHIC   LATERAL   SCLEROSIS  1127 

Etiology. — It  occurs  mostly  between  the  twenty-fifth  and  forty-fifth 
years,  more  frecjuently  in  males,  but  its  exact  causes  are  not  known, 
although  cold,  trauma,  and  overexertion  are  possible  factors. 

Pathology. — Changes  may  be  found  from  the  cerebral  cortex  to  the 
muscles  themselves,  but  the  name  amyotrophic  lateral  sclerosis,  left 
to  us  by  Charcot,  designates  the  leading  changes,  which  are,  amyoiro- 
phy,  muscular  wasting,  from  atrophy  of  the  anterior  horns  and  scleras i.s 
of  the  lateral  columns,  (a)  The  lateral  pyramidal  tracts,  and  to  a  lesser 
extent  the  anterior,  show  symmetrical  primary  degeneration  of  the 
nerve  fibers,  followed  by  interstitial  overgrowth  (secondary  sclerosis) 
which  is  most  marked  in  the  cord,  i.  e.,  the  lower  part  of  the  upper 
neurone,  but  extends  upward  (Charcot,  ^Nlarie)  in  some  cases  to  the 
medulla,  pons,  crus  or  even  to  the  very  central  convolutions,  the 
ganglionic  cells  of  which  may  be  atrophied.  Charcot's  belief  that  the 
disease  starts  in  the  pyramidal  tracts  and  is  followed  by  changes  in  the 
anterior  horns  (v.  i.)  is  not  proven.  In  some  cases  similar  but  un- 
important changes  may  be  found  in  the  cerebellar  tracts  or  indeed  in  the 
posterior  columns.  (6)  The  ganglionic  cells  of  the  anterior  horn  are 
degenerated,  so  that  the  anterior  motor  part  of  the  cord  is  'distinctly 
smaller  and  flatter,  particularly  in  the  cervical  region.  Likewise  the 
nerve  fibers  from  the  pyramidal  fibers,  anastomosing  with  the  pro- 
cesses of  the  ant.  horn,  are  degenerated.  With  these  changes  in  the 
trophic  centre  of  the  second  motor  neurone,  the  atrophic  changes  in  the 
anterior  roots,  motor  nerves  and  muscles,  are  easily  explained.  Certain 
muscles  are  wasted  to  a  varying  degree,  and  show  degeneration  or 
complete  atrophy,  as  in  the  purely  spinal  progressive  muscular  atrophy, 
next  to  be  described,  (c)  The  bulbar  nuclei,  with  their  nerves  and  mus- 
cles, show  identical  changes,  for  they  are  the  analogues  of  the  ant. 
horns. 

Symptoms. — The  symptoms,  like  the  lesions,  are  strictly  motor. 

Stage  1  of  Charcot. — The  disease  begins  with  weakness  and 
atrophy  of  the  muscles  of  the  hand,  first  in  one  and  then  in  the  other; 
they  are  most  marked  in  the  thenar,  hypothenar  and  interosseal 
muscles,  and  are  followed  by  wasting  and  weakness  in  the  forearm 
extensors,  deltoid  and  triceps,  while  other  muscles  of  the  arm  and 
forearm  escape  or  are  involved  later.  There  may  be  some  tingling  in 
the  parts  affected,  but  sensory  symptoms  are  absent.  The  decreased 
power  of  unwasted  muscles  is  often  manifest  before  they  atrophy. 
Other  symptoms  of  disease  of  the  lower  neurone  appear,  as  fibrillary 
contractions;  the  reaction  of  degeneration  is  present  in  those  muscles 
which  are  wholly  atrophied,  while  in  others  the  response  is  reduced 
proportionately  to  the  atrophy;  the  nerve  trunks  respond  normally. 
Evidences  of  involvement  of  the  upper  neurone  also  a})pear;  paralysis 
often  precedes  the  wasting  and  accentuates  the  weakness  from  ant. 
horn  involvement;  there  is  increase  of  the  refie.rcs  (which  never  occurs 
in  muscular  atrophy  due  to  disease  of  the  ant.  horns  alone),  increased 
bice])s,  triceps,  and  periosteal  forear?n  reflexes,  ami  there  is  often  rigid  if // 
and  ronfracfiire  in  which  the  arm  hugs  the  chest,  the  forearm  is  flexed 


1128  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  pronated,  and  the  wrist  and  fingers  are  flexed.  Sometimes  the 
neck  is  rigid  and  even  trismus  is  observed. 

Stage  2. — In  less  than  a  year  the  legs  are  involved;  indeed  they  show 
symptoms  during  the  first  stage.  The  legs  are  weak,  especially  in  the 
flexors  of  the  hip,  knee  and  dorsal  flexors  of  the  foot.  Spastic  symptoms 
prevail.  The  legs  resist  passive  movement,  because  of  increased 
muscle  tonus  and  the  increased  reflexes.  The  gait  is  spastic  and  paretic 
(see  above.  Spastic  Spinal  Paealysis)  and  walking  finally  becomes 
impossible  because  of  the  rigidity  and  the  twitching  tetanic  movements 
of  the  extensors.  The  patellar  reflexes  are  exaggerated;  ankle  clonus  is 
frequent;  when  the  patient  attempts  to  flex  the  thigh  while  the  exam- 
iner holds  the  ankle,  there -is  a  visible  contraction  of  the  tibialis  anticus 
(the  tibialis  phenomenon);  Babinshy's  reflex  is  present  (dorsal  instead 
of  plantar  flexion  on  stroking  the  sole);  there  are  evidences,  in  short, 
of  pyramidal  disease,  which  dominate  the  leg  symptoms,  because 
symptoms  referable  to  the  lower  neurone,  as  atrophy,  are  much  less 
frequent,  less  marked  and  less  early  in  the  legs  than  in  the  arms.  In 
exceptional  cases  the  leg  symptoms  develop  first. 

Stage  3. — This  stage  occurs  in  one  or  two  years  with  bulbar  symp- 
toms, dysphagia,  atrophy  of  the  lips  and  tongue  with  fibrillation,  as  in 
primary  bulbar  paralysis  {q.  v.).  On  tapping  the  jaw,  a  marked  jerk 
is  elicited,  analogous  to  the  increased  reflexes  in  the  arm  and  leg.  A 
tonic  tension  of  the  facial  muscles  may  occur  as  in  spastic  spinal 
paralysis.  Spasmodic  laughing  or  weeping  almost  always  occurs  and  is 
due  to  loss  of  inhibitory  innervation.  The  mind  is  clear.  Death  results 
from  respiratory  failure,  aspiration  pneumonia  or  intercurrent  disease. 
In  rare  cases  the  bulbar  symptoms  antedate  atrophy  in  the  arms  and 
spasticity  in  the  legs. 

Course  and  Prognosis. — In  some  cases  the  spinal,  in  others  the 
atrophic,  symptoms  develop  first  and  are  dominant.  The  entire  course 
is  rapid  compared  with  other  diseases  of  the  group ,  covers  one  to  four 
years,  and  is  always  fatal. 

Diagnosis.— The  involvement  of  both  motor  segments,  muscle 
atrophy  with  increased  reflexes,  rigidity,  absence  usually  of  sphincter  or 
sensory  alteration  (except  rarely  some  pains)  and  the  final  bulbar 
symptoms  make  the  disease  easy  of  diagnosis. 

The  treatment  is  that  of  spinal  muscular  atrophy  {v.  i.),  but  avails 
little. 


3.  Progressive  Spinal  Muscular  Atrophy. 

Duchenne  and  Aran  (1849-50)  gave  us  the  first  full  clinical  descrip- 
tion of  this  disease,  while  Clarke,  Luys,  (1860)  and  then  Charcot, 
discovered  changes  in  the  anterior  horns. 

Etiology. — The  ultimate  causes  are  not  known.  Seventy-five  per 
cent,  of  cases  occur  in  males,  mostly  between  the  twenty-fifth  and 
forty-fifth  years.    Hereditary  factors,  which  are  often  observed  in  the 


PROGRESSIVE  SPIXAL   MUSCULAR   ATROPHY  1129 

muscular  dystrophies  (v.  i.)  are  infrequent,  although  Werding  (1891), 
Hoffman  (1894),  Bruce,  Osier  and  Thompson  have  described  familial 
infantile  forms.  Hard  work,  mental  distress,  syphilis,  trauma,  acute 
infections  and  acute  poliomyelitis  are  possible  factors. 

Pathology. — In  the  cord,  especially  in  the  cervical  region,  (a)  the 
ant.  horns  are  small  and  flattened;  their  ganglion  cells  are  shrunken, 
deformed,  their  processes  lost;  they  are  wholly  wasted  in  advanced 
cases.  Any  interstitial  changes  are  wholly  secondary.  (b)  The 
anterior  roots,  especially  the  cervical,  are  somewhat  degenerated,  and 
often  also  the  peripheral  nerves,  although  changes  in  them  are  most 
difficult  to  distinguish,  (c)  The  muscles  are  small,  stringy  and  pale, 
having  lost  their  normal  redness.  Microscopically  their  individual 
fibers  are  small,  although  a  few  normal  or  even  hypertrophic  fibers  may 
be  seen.  Their  transverse  striation  persists  remarkably,  and  waxy, 
fatty  or  granular  degeneration  and  longitudinal  splitting  are  not 
common;  sometimes  the  empty  sheaths  alone  are  seen.  The  muscle 
nuclei  multiply,  round  cells  may  wander  in,  and  there  is  usually  increase 
of  connective  tissue  and  sometimes  fatty  deposit.  Just  where  the  process 
begins  is  disputed.  No  close  distinction  can  be  drawn  between  this 
disease  and  amyotrophic  lateral  sclerosis,  although  changes  in  the 
upper  neurone  are  absent  in  spinal  muscular  atrophy.  Gowers  and 
v.  Leyden  consider  them  identical;  Kahler  and  Pick  held  that  both 
these  diseases  and  bulbar  paralysis  are  one  affection. 

Symptoms. — (a)  The  essential  symptoms  are  those  of  the  motor 
nerves,  and  all  others  are  accessory.  The  earliest  symptom  is  muscular 
atrophy  with  weakness  in  the  upjper  extremity  (90  per  cent.),  especially 
in  the  muscles  of  the  (right)  thenar  and  hypothenar  eminences.  The 
abductor  and  opponens  pollicis  are  first  involved,  then  the  flexor  brevis 
and  adductor,  the  wasting  of  which  brings  closer  together  the  meta- 
carpi  of  the  thumb  and  index  finger  (the  "ape  hand").  It  is  finally 
impossible  to  appose  the  thumb  to  the  fingers.  The  interossei  on  the 
dorsum  waste  and  leave  marked  furrows,  producing  the  "claw  hand," 
Tnain  en  griffe,  from  contraction  of  antagonist  muscles,  the  ext. 
digitorum  communis,  the  tendons  of  which  stand  out  prominently. 
The  wasting  lumbricales  make  the  palm  more  hollow.  Wasting  as 
above  described  is  known  as  the  Duchenne-Aran  type,  in  which 
"individual  muscles"  are  selectively  involved  (Charcot).  The  onset 
and  progress  are  always  very  gradual,  and  the  muscles  become  lax, 
soft,  thin  and  flat.  The  atrophy  long  exceeds  the  paresis.  The  forearm 
may  be  next  involved,  first  the  extensors,  especially  those  below  the  int. 
condyle  and  later  the  supinators  and  flexors.  A  deep  depression 
between  the  ulna  and  radius  eventually  occurs.  Later,  often  after 
several  years,  the  shoulder  muscles,  the  posterior  and  middle  third  of 
the  deltoid,  the  biceps  and  brachialis  waste,  and  much  later  the  triceps. 
Sometimes  the  wasting  of  the  muscles  of  the  shoulder  and  arm  immedi- 
ately follows  the  involvement  of  the  hand,  or  perhaps  the  disease 
begins  in  the  shoulder.  The  bones  of  the  shoulder  stand  out  clearly, 
covered   only  by   the   skin;    these  cases  are   "the  living  skeletons" 


1130  DISEASES  OF  THE  XERVOUS  SYSTEM 

seen  in  museums.  The  trunk  muscles  are  involved  in  this  order; 
trapezius  in  its  middle  and  lower  parts  (rarely  in  its  upper  third,  which 
is  the  ultimum  moriens  of  Duchenne);  pectoralis,  latissimus  dorsi, 
rhomboidei  (causing  the  shoulder  to  droop)  and  extensors  of  the  head, 
(allowing  the  head  to  fall  forward).  Scoliosis  may  develop,  lordosis  is 
common  in  involvement  of  the  extensors  of  the  trunk  and  hip,  and  the 
spine  stands  out  distinctly  in  cases  of  extreme  atrophy.  The  platysma 
and  face  almost  always  escape.  In  most  instances  the  respiratory 
muscles,  intercostals  or  even  the  diaphragm  are  involved,  and  this 
is  a  not  infrequent  source  of  danger  to  life.  The  abdominal  muscles  are 
sometimes  weakened.  In  the  leg  the  muscles  are  affected  late  and  to  a 
lesser  degree,  as  the  glutei,  quadriceps,  and  the  peronei.  In  very 
exceptional  cases  the  disease  first  develops  in  them.  In  the  fully 
developed  case  there  is  extreme  helplessness  in  which  an  added  misery 
in  the  form  of  the  sister-process,  bulbar  paralysis,  may  develop. 

(6)  In  the  wasted  and  weak  muscles  there  are  usually  fihrillary  con- 
tractions; they  are  involuntary  twitchings,  tremor-  or  even  wave-like  in 
character,  which  are  sometimes  incessant,  and  again  are  initiated  only 
by  cold,  or  tapping;  they  show  increased  mechanical  irritability.  They 
may  appear  in  muscles  not  yet  wasted  and  are  not  to  be  confused  with 
the  similar  neurasthenic  fibrillation,  (c)  The  electrical  reaction  depends 
on  the  degree  of  wasting.  In  the  nerves  it  is  normal.  In  the  muscles 
there  is  usually  only  cjuantitative  reduction,  and  the  voltaic  excitability 
remains  long  after  the  faradic  is  lost;  in  the  last  stages  there  is  a 
partial  reaction  of  degeneration,  id)  The  reflexes  are  weakened  or 
abolished;  they  are  roughly  proportionate  to  the  atrophy  and  due  to 
disease  in  the  motor  side  of  the  reflex  arc.  They  are  never  increased. 
The  sphincters  are  intact,  but  sexual  power  is  often  lost,  (e)  Sensation 
shows  no  objective  change,  and  even  subjective  parsesthesia  is  rare; 
in  some  instances  there  are  dull  aching  pains  in  the  muscles  or  joints. 
(/)  Vasomotor,  secretory  and  trophic  symptoms  are  lacking.  The 
coolness  of  wasted  parts  is  due  to  lack  of  motility. 

Diagnosis. — The  diagnosis  i^  based  on  (a)  the  slow  course;  {h)  the 
involvement  of  the  muscles  of  the  hand  and  its  slow  "individualiza- 
tion"; (c)  fibrillation;  (d)  partial  reduction  in  electrical  irritability 
or  partial  reaction  of  degeneration ;  (e)  absence  of  increased  reflexes 
and  (/)  of  any  sensory  signs. 

Difjerentiation  is  necessary  (1)  from  disease  in  which  muscular 
atrophy  is  but  one  among  several  symptoms.-  (a)  Syrincjomi/elia  is 
marked  by  its  trophic  characteristics,  its  analgesia,  thermo-an?es- 
thesia  and  less  symmetrical  wasting.  (//)  Meningitis,  pachymeningitis, 
spondylitis,  tumors  and  myelitis,  are  manifestetl  by  aujiesthesia,  pain, 
tenderness,  and  rigidity,  (c)  In  root  neuritis  or  multiple  neuritis  there  is 
a  clearer  reaction  of  dejjeneration,  more  sensorv  signs  and  more 
tenderness  in  the  nerve  trunks,  id)  The  atrophies  caused  by  an  indi- 
vidual's occupation  are  distinguished  by  the  history  and  slight  sensorv 
(listnrl)ance. 


XEURiriC   MUSCULAR  ATROPHY  1131 

(2).  Other  muscular  atrophies  must  be  dift'erentiated.  (a)  Subacute 
and  chronic  poliomyelitis  causes  paralysis  first  and  atrophy  afterward; 
it  affects  grcaips  of  muscles  at  once,  its  course  is  not  gradual  l)ut  rapid 
and  fil)rillary  contra.ctions  are  infrequent,  (h)  The  myopathic  atrophies 
must  be  distinguished  (see  p.  11 35).  (c)  Amyotrophic  lateral  sclerosis  is 
an  allied,  perhaps  an  identical  affection;  Charcot  held  that  the  atrophy 
is  not  "individualized,"  but  occurs  en  masse;  the  distinguishing- 
features  are  the  increase  of  the  reflexes,  spasticity,  and  a  much  more 
rapid  course.  Gowers  has  never  seen  a  case  of  progressive  spinal 
atrophy  without  anatomical  change  in  the  pryamidal  tracts;  in  describ- 
ing the  two  affections  together,  he  distinguishes  three  varieties  (i) 
extreme  atonic  atrophy,  (ii)  muscular  spasm  and  weakness  with  little 
or  no  atrophy,  and  (iii)  moderate  tonic  atrophy  with  increased  mvotatic 
irritability,  {d)  Arthritic  muscular  atrophy,  probably  due  to  reflex 
influences,  or  direct  extension  of  inflammation  to  the  muscles  or  nerves, 
may  be  acute  or  chronic,  and  involves  chiefly  the  extensors  in  a  moder- 
ate wasting;  diffuse  wasting  suggests  a  nervous  cause;  the  history  or 
evidence  of  joint  disease  is  distinctive.  The  electrical  reactions  are 
normal  or  show  only  slightly  decreased  excitability.  There  is  usually 
distinct  increase  in  myotatic  irritability  and  reflex  action. 

Course  and  Prognosis. — The  onset  between  the  twenty-fifth  and 
forty-fifth  years  is  gradual,  the  course  is  slowly  progressive,  remissions 
infrequent,  arrest  very  rare,  and  death  usually  results  from  intercurrent 
disease,  respiratory  affections  (tuberculosis)  or  bulbar  palsy.  Gowers 
observed  arrest  but  rarely,  and  then  chiefly  in  cases  marked  by  sym- 
metry and  synchronous  involvement  of  both  hands;  arrest  occurs, 
unhappily,  chiefly  late  in  the  disease. 

Treatment. — Drugs  are  of  uncertain  value.  Gowers  gives  strychnia 
hypodermatically ;  he  has  seen  7  consecutive  cases  of  arrest  of  which 
6  were  permanent;  it  has  little  effect  by  mouth.  Arsenic  and  iodides 
are  employed.  ^Massage,  active  and  passive  gymnastics  and  electricity 
are  alwavs  indicated  but  do  not  stav  the  disease. 


4.  Neuritic  Muscular  Atrophy. 

Charcot-]\larie  type.  Peroneal  fanu'ly  type  (Tooth).  Xeuritic  type 
(Hofl'mann). 

Etiology. — It  is  often  hereditary,  even  through  five  generations;  it 
is  usiuilly  familial.  It  occurs  in  the  second  half  of  childhood,  and 
rarely  after  the  twentieth  year.    Sixty-six  per  cent,  of  cases  are  in  males. 

Pathology  and  Symptoms. — The  pathological  characteristic  is 
ueuritis,  which  Hoft'mann  thought  might  ascend  to  the  post,  roots; 
secondary  changes  have  been  seen  in  (toll's  column.  Early  atrophy 
occurs  in  the  small  )UN.scle.s  of  the  feet  and  may  not  attract  attention  until 
bilateral  symmetrical  peroneal  paralysis  and  atrophy  develop,  together 
with  paralysis  in  the  long  toe  extensors,  and  club  feet  (pes  equinus 
or  raro-ccjuiuus).    The  calf  nuiscles  are  the  next  (o  suffer  and  the  thigh 


1132  DISEASES  OF  THE  NERVOUS  SYSTEM 

is  involved  still  later.  Then  after  years,  paralysis  and  atrophy  of  the 
hands,  as  in  progressive  spinal  atrophy,  develop,  with  the  "claw  hand"; 
in  involvement  of  the  forearm,  the  extensors  suffer  more  than  the 
flexors.  The  shoulder,  neck,  trunk  and  face  are  seldom  diseased. 
Fibrillation  is  infrequent;  the  reaction  of  degeneration  is  generally 
present,  sensory  manifestations  are  common  as  pains  or  anaesthesia 
(especially  plantar),  and  reflex  action  is  decreased  or  abolished,  though 
the  patellar  reflexes  may  long  persist. 

The  diagnosis  is  based  on  the  hereditary  or  family  history,  the  age, 
localization  and  signs  of  slow  neuritis.  Treatment,  as  in  other  forms  of 
muscular  atrophy,  is  unsuccessful. 


5.  Muscular  Dystrophy. 

The  progressive  muscular  dystrophies  (Erb)  or  myopathies  (Charcot) 
are  often  classed  with  diseases  of  the  muscles,  which  indeed  show  the 
sole  constant  pathological  lesions.  They  are  so  closely  related  clinically 
to  the  less  frequent  spinal  atrophies  that  they  are  here  considered. 
Their  status  is  provisional,  since  changes  in  the  cord,  nerve  trunks  and 
nerve  filaments  have  been  found  in  some  cases  of  each  type.  In  all 
types  (y.  i.),  with  few  exceptions,  there  are  certain  common  character- 
istics; (a)  heredity  is  an  obvious  cause  in  56  per  cent,  of  cases;  though 
this  factor  may  be  absent,  a  familial  incidence  is  often  observed;  the 
muscular  system  seems  deficient  in  nutrition,  development  or  vitality. 
(6)  It  usually  occurs  in  childhood  or  pubescence,  rarely  in  adult  life. 
(c)  The  pathology  is  practically  the  same  in  all  types;  the  muscles 
waste,  with  or  without  hypertrophy,  or  with  increase  of  fat  or  interstitial 
growth,  (d)  Being  strictly  a  muscular  affection,  fibrillation  and  the 
reaction  of  degeneration  are  very  rare,  (e)  In  localization,  certain  mus- 
cles are  involved,  as  those  of  the  face  (orbicularis  oculi  et  oris),  shoulder 
(pectoralis,  latiss.  dorsi,  serrat.  magnus,  rhomboidei,  trapezius),  arm 
(biceps,  brachialis,  supin.  long.,  triceps),  trunk  (erector  spinse),  glutei 
and  thigh.  Others  are  usually  exempt,  as  the  deltoid,  supra-  and  infra- 
spinatus, small  muscles  of  the  hands  and  feet,  leg  muscles  (gastro- 
cnemius), and  those  of  the  tongue  and  pharynx.    There  are  three  forms. 

Pseudohypertrophic  Muscular  Paralysis. — Lipomatous  muscular 
atrophy  is  the  least  frequent,  but  is  the  longest  and  best  known 
type.  (Bell  1830,  Partridge  1837,  Meryon  1852,  Duchenne  1861.)  It 
occurs  in  males  (80  per  cent.),  and  is  less  marked,  less  early  in  life,  and 
less  fatal  in  women.  It  is  often  transmitted  by  healthy  mothers,  the 
males  being  impotent,  and  may  be  seen  in  five  generations.  It  begins 
early  (75  per  cent,  under  ten  years),  and  but  rarely  after  twenty  years 
of  age. 

1.  Impaired  motility  is  the  earliest  symptom.  The  weakest  muscles 
are  the  invisible  hip  flexors.  Weakness  of  the  hip  and  knee  extensors 
makes  climbing  of  stairs  difficult,  causes  the  waddling  gait  (paresis  of 
glutei)  and  interferes  with  rising  from  the  floor,  so  that  the  child  must 


MUSCULAR   DYSTROPHY 


1133 


Fia.  7G. 


rise  by  resting  on  all  fours,  and  then  by  "climbing  his  own  legs  with  his 
hands  "  (Gowers).  Paresis  of  the  back  muscles  and  hip  extensors  causes 
lumbar  lordosis  and  abdominal  protrusion.  The  ankle  extensors  also 
weaken.  The  child  stands  with  legs  far 
apart.  The  depressors  of  the  shoulders 
are  weakened  early  in  the  disease,  later 
the  shoulder  muscles,  then  the  biceps  and 
triceps,  but  the  hand  remains  normal 
for  a  long  time,  or  is  permanently  un- 
affected. The  weak  muscles  show  nuclear 
increase,  atrophy  and  division  of  their 
fibers,  which  are  usually  undersized,  ir- 
regular in  width,  pale  and  narrow;  fatty 
degeneration  and  loss  of  striation  are 
rare.  Increase  of  connective  tissue  is  a 
later  but  most  characteristic  change. 

2.  Certain  muscles  show  apparent  in- 
crease in  size  (pseudohypertrophy) ,  which 
is  due  largely  to  early  adipose  deposit  or 
rarely  to  actual  muscular  hypertrophy. 
The  muscles  are  lax.  The  calf  muscles 
are  especially  enlarged,  then  the  glutei, 
knee  extensors,  or  infraspinatus  which 
contrasts  strongly  with  the  wasted  latis- 
simus  and  deltoid;  the  muscles  of  the 
face,  neck  and  forearm  seldom  show  en- 
largement. 

3.  As  to  other  symptoms,  the  electrical 
irritability  is  lowered,  but  there  is  no 
reaction  of  degeneration.  The  deep  re- 
flexes decrease  and  disappear,  from  the 
muscular  lesion.  Mentality,  sensation 
and  the  sphincters  are  normal.  Con- 
tractures, such  as  the  pes  equinus,  may 
occur  late  in  the  course.  Cardiac  hyper- 
trophy was  observed  by  Glotz  in  60  per 
cent,  of  his  cases.  The  course  is  pro- 
gressive, the  patient  becomes  bed-ridden, 
arrest  is  rare,  and  death  occurs  after 
years  from  intercurrent  disease  or  from 
respiratory  inflammation. 

Infantile  Atrophic  Form,  with  or  with- 
out Facial  Involvement. — ^Thereis  usually 
no  hypertrophy,  but  wasting  occurs  from  the  beginning.  It  may  be 
combined  with  the  first  form,  and  the  legs  then  show  pseudo- 
hypertrophy and  the  arms  simple  atrophy.  The  pathology  is  that  of 
pseudohypertrophic  muscular  paralysis,  save  that  there  is  no  hyper- 
trophy, true  or  false;    increased  connective  tissue  characterizes  this 


Typical  pseudohypertrophic  muscuhir 
paralysis.     (Dercum.) 


1134  DISEASES  OF  THE  XERVOUS  SYSTEM 

type  of  atrophy   and    also   that    of   the   juvenile    form    (see    below). 

The  face  may  be  involved,  as  was  first  observed  by  Duchenne  and 
later  emphasized  by  Landouzy  and  Dejerine.  The  lids  droop  and 
cannot  be  wholly  closed,  the  forehead  is  smooth,  the  cheeks  are  flaccid 
and  droop,  the  lips  part  and  functionate  poorly,  as  in  whistling,  the 
lower  lip  protrudes,  the  nasolabial  fold  disappears,  the  face  becomes 
expressionless,  (the  "fades  myopathica").  Sometimes  the  buccinator 
muscles  are  implicated  but  rarely  the  masseters  or  those  of  the  tongue, 
palate,  larynx,  pharynx,  or  eyeball.  Simultaneously  or  more  often 
later,  the  shoulder  girdle  wastes  as  in  the  first  type;  this  is  the  facio- 
sca'pulo-humeral  form  of  Landouzy  and  Dejerine;  the  latissimus  and 
lower  part  of  the  pectoralis  are  usually  first  affected,  but  in  the  biceps, 
triceps  and  often  in  the  supinator  longus,  wasting  and  paresis  are  more 
conspicuous;  the  wasting  is  usually  symmetrical.  The  forearm  save 
for  the  supinator  longus  and  the  hand  usually  escapes.  The  neck  is 
seemingly  lengthened  (Brissaud),  because  of  the  drooping  of  the 
shoulders  and  clavicles.  The  leg  muscles  then  waste,  especially  the  hip 
flexors,  knee  extensors  and  less  often  the  glutei ;  lordosis,  the  waddling 
gait  and  symptoms  observed  in  the  next  type  {v.  i.)  may  develop.  The 
order  given  may  be  altered,  for  facial  wasting  may  follow  that  of  the 
arms.  The  course  is  usually  progressive,  very  chronic  (ten  to  fifty 
years)  and  the  disease  in  itself  rarely  causes  death,  which  results  from 
intercurrent  infections  or  respiratory  catarrhs,  tuberculosis,  etc.  In 
the  second  and  third  types,  the  prognosis  is  more  favorable  than  in  the 
first  form  and  the  outlook  is  better  when  the  face  is  unaffected. 

The  Juvenile  Form  of  Erb. — This  type  begins  after  puberty,  possibly 
later  (twentieth  to  fortieth  year),  and  is  more  frequent  in  women  than 
the  above  forms.  It  begins  more  often  in  the  shoulders  and  arms,  than 
in  the  legs.  The  pectorals,  latissimus,  trapezius,  serratus  mag.,  rhomboi- 
dei,  sacrolumbalis,  longiss.  dorsi,  supinator  longus  and  later  the  triceps 
are  wasted,  while  the  sternomastoid,  supra-  and  infraspinatus,  lev. 
anguli  scapulse,  coracobrachialis,  teretes,  deltoid,  and  the  hand  and 
forearm  (except  the  supin.  long.)  are  almost  always  exempt.  If  we 
lift  the  patient  with  our  hands  beneath  his  shoulders,  he  tends  to  "slip 
through";  this  is  due  to  "loose  shoulders"  (Erb).  The  scapulse  stand 
out  prominently  from  weakness  of  the  serrati.  In  the  lower  limbs,  the 
glutei,  quadriceps  and  less  often  tibiahs  ant.  and  peronei  become 
atrophied.    The  lordosis  and  gait  are  as  above  described. 

Diagnosis  of  Myopathic  Atrophies.— (a)  Atrophy  from  cerebral 
lesions  is  less  marked  than  myopathic  atrophy  and  more  often  follows 
the  marked  loss  of  power.  (&)  Spinal  muscidar  atrophy  (according  to 
Leube)  is  differentiated  as  on  page  1135. 

(c)  Congenital  spastic  paraplegia  occurs  in  children  with  weak  legs 
and  contractures  in  the  calves  but  the  history,  increased  reflexes,  and  a 
regressive  rather  than  a  progressive  tendency  easily  distinguish  it. 
{d)  As  to  peripheral  neuritis,  the  hereditary  neurotic  (neuritic)  muscular 
atrophy  {q.  v.)  is  easily  recognized.  Multiple  neuritis  (</.  v.)  is  usually 
toxic,  more  acute  and  shows  sensory  symptoms  and  local  tenderness 


COM  BIX  ED  SYSTEM  DISEASES  '  1135 

Spinal  Progressive Myopathic  Progressive 

Muscular  Atrophy.  ^  '  Muscular  Dystrophy. 

Begins  in  small  hand  muscles.  In  trunk,  shoulder,  or  pelvic  girdle,  leg 

and  upper  arm. 

Extends  upward  (face  free).  Progresses  downward;    face  sometimes 

affected. 

Muscular  atrophy.  Frequently  with  hypertrophy. 

Fibrillation  the  rule.  Very  exceptional. 

Tendon  reflexes  may  be  increased  in  the         Never  increased. 

legs,  if  we  include  the  amyotrophic 

lat.  sclerosis. 
Reaction  of  degeneration,   partial,  Practically  never  present. 

perhaps  complete. 

Age:  usually  begins  after  thirtieth  year.         Usually     in     childhood;      rarely     after 

twentieth  year. 

Heredity — rare.  Frequent. 

Bulbar  symptoms  not  uncommon.  Never  present. 

over  the  nerves  and  muscles,     (e)  In  congenital  defects  in  the  pectoral 
muscles  and  trapezius,  any  progression  is  naturally  absent. 

Treatment. — Electricity  is  recommended,  but  a  current  sufficiently 
strong  to  excite  the  wasted  muscles  causes  too  much  pain.  Massage, 
but  especially  reasonable  exercise,  is  advisable,  because  the  patients 
begin  to  fail  when  they  cannot  walk.  In  advanced  cases  the  respiratory 
tract  must  be  watched,  since  catarrh  predisposes  to  tuberculosis. 


Under  diseases  of  the  motor  neurones,  ophthalmoplegia,  Landry's 
paralysis,  bulbar  palsy,  myasthenia,  acute  poliomyelitis,  etc.,  might  also 
be  described;  these  affections,  however,  are  treated  elsewhere  for 
anatomical  or  differential  reasons. 


III.  Combined  System  Diseases. 

In  1807  Westphal  described  these  affections  in  paretic  dementia,  but 
Kahler  and  Peck  in  1877  brought  to  more  general  attention  this  group 
of  cases  with  simultaneous  disease  in  several  systems  of  neurones.  Von 
Leyden  and  Goldscheider  consider  them  diffuse  or  even  myelitic  affec- 
tions rather  than  true  system  diseases,  of  which,  in  their  opinion,  there 
are  but  two  examples,  tabes  and  progressive  muscular  atrophy. 

1.  Hereditary  Ataxia,  Friedreich's  ataxia  (Friedreich,  1861). 
— Etiology. — 'J'his  affection  is  hereditary  in  33  per  cent,  and  in  the 
other  instances  it  is  usually  familial,  although  isolated  cases  are  seen. 
Most  cases  occur  in  boys.  It  is  held  by  some  to  be  a  congenital  hypo- 
plasia  of  the   pyramidal   and   other  tracts,   tending   to  degeneration 


1136  DISEASES  OF  THE  XERVOUS  SYSTEM 

(Friedreich,  Schultze,  Striimpell),  though  others  regard  it  as  a  com- 
bined system  disease  (Kahler,  Pick.)  Cerebellar  atrophy  has  been  held 
as  causal  (Senator,  Mentzel)  but  this  is  more  striking  in  the  hereditary 
cerebellar  ataxy,  described  below. 

Pathology. — The  cord  or  medulla,  and  even  the  pons  are  small. 
The  earliest  and  dominant  change  is  atrophy  with  secondary  sclerosis 
of  the  'post,  roots  and  post,  columns,  and  this  occurs  in  Goll's  more  than 
in  Burdach's  columns.  Lissauer's  "root  zone"  is  less  affected  than  in 
tabes,  but  more  than  in  ataxic  paraplegia.  The  direct  cerebellar  tract 
and  Clarke's  gray  columns  share  clearly  in  the  atrophy,  as  does  the  ant. 
lat.  ascending  tract  of  Gowers.  The  lat.  pyramidal  tract  suffers  in  most 
cases,  its  inner  portion  being  usually  normal;  the  ant.  pyramid,  tract 
is  less  altered  and  principally  in  the  cervical  region.  Chronic  lepto- 
meningitis, sometimes  with  annular  sclerosis  of  the  cord,  is  occasional. 

Symptoms. — (a)  The  cardinal  sign  and  the  one  first  observed  is  ataxia, 
which  is  less  rapid,  excessive  and  stamping  (as  to  gait)  than  tabetic 
ataxia,  and  more  closely  resembles  cerebellar  ataxia  in  its  tumbling 
character  and  involvement  of  the  trunk.  Static  ataxia  appears  later 
but  to  a  marked  degree,  and  the  head  oscillates  as  it  does  in  multiple 
sclerosis,  or  the  arms  show  jerky  movements.  Romberg's  sign  is 
usually  present,  and  the  subject  leans  over  to  watch  his  feet;  this 
leads  to  some  kyphosis.  Testing  the  sense  of  location  elicits  ataxia,  as 
in  the  knee-ankle  test.  The  arms  become  atactic  after  a  few  years. 
Nystagmus  develops  in  most  cases,  though  it  is  a  late  symptom;  it  is 
elicited  chiefly  on  lateral  (or  upward)  movements  and  is  atactic,  as  is 
also  the  disturbance  of  speech,  which  develops  in  three  to  ten  years ; 
the  speech  is  monotonous,  irregular,  unclear,  slightly  scanning,  slow 
and  strained;  syllables  are  often  ehded,  the  tongue  may  tremble  and  a 
nasal  twang  may  be  noticed. 

(6)  Regarding  the  reflexes,  the  knee  jerks  are  decreased  early  or 
are  abolished,  being  present  only  in  rare  atypical  cases.  The  skin, 
pupillary  and  sphincter  reflexes  are  usually  normal.  In  some  (possibly 
syphilitic)  cases  the  pupil  reflex  may  disappear,  (c)  Other  signs 
embrace:  Club  foot  (pes  equino-varus)  is  common,  and  is  best  seen 
in  the  dorsal  decubitus;  the  foot  is  shortened  and  widened,  the  arch  is 
exaggerated  (pes  cavus),  the  great  toe  is  strongly  flexed  dorsally 
(extended).  Scoliosis  and  kyphosis  are  common.  Muscular  paralysis 
or  wasting  is  rare,  although  late  paraparesis  may  develop.  Sensory 
signs  are  few;  tactile  and  muscle  sensation  are  sometimes  blunted;  the 
pain  sense  is  but  rarely  impaired;  pareesthesise,  crises,  lancinating 
pains,  and  trophic,  vasomotor  and  sensory  disturbances  are  lacking. 
General  or  sexual  development  may  be  retarded  at  puberty.  The 
pulse  is  often  increased  and  hsemic  murmurs  may  be  heard.  Cerebral 
symptoms,  as  mental  dulness,  develop  late,  if  at  all. 

Course  and  Prognosis. — About  33  per  cent,  develops  before  the 
sixth  year,  33  per  cent,  between  the  sixth  and  tenth,  and  33  per  cent, 
after  the  tenth  year.  The  atactic  gait  is  the  first  sign,  then  speech  is 
involved,  possibly  then   the  kyphosis  and   club    foot    develop,    and 


COMBINED  SYSTEM  DISEASES  1137 

later  the  arms  are  affected ;  the  course  is  steadily  progressive,  possibly 
with  remissions,  and  the  patient  becomes  bed-ridden  in  twenty  to 
thirty  years.    Death  follows  from  acute  infections,  cystitis  and  sepsis. 

Diagnosis. — The  diagnosis  is  based  (a)  on  the  hereditary  or  familial 
etiology;  (6)  the  age;  (c)  the  ataxia;  (d)  absent  knee  jerks;  and  (e) 
disturbance  of  speech. 

Differentiation. — 1 .  In  tabes,  there  are  also  ataxia  and  absent  knee 
jerks  but  in  hereditary  ataxia,  the  syphilitic  stigmata  or  history,  the 
immobile  pupil,  eye  paralysis,  optic  atrophy,  pains,  crises,  and  vesical, 
trophic  and  marked  sensory  disturbances  are  absent. 

2.  Multiple  sclerosis  (in  which  there  is  also  speech  alteration, 
nystagmus,  ataxia  and  tremor),  is  differentiated  by  the  history  of 
antecedent  acute  infections,  the  presence  of  spasticity, increased  reflexes, 
optic  atrophy,  compulsory  laughing  and  other  psychical  signs,  apoplecti- 
form insults,  a  distinctly  intentional  tremor  and  slow,  scanning  speech. 

3.  In  cerebellar  disease  the  ataxia  is  similar,  but  in  tumors  there  is 
optic  neuritis,  headache,  and  vomiting.  Marie,  Londe  and  Nonne 
described  a  clinically  similar  affection,  hereditary  cerebellar  ataxia, 
which  is  probably  due  to  simple  congenital  atrophy  of  the  cerebellum 
(middle  lobe),  degeneration  in  Clarke's  columns,  cerebellar  tracts  and 
posterior  columns,  is  also  hereditary  or  familial,  but  develops  later, 
between  the  twentieth  and  thirtieth  years.  The  ataxia  is  cerebellar. 
The  reflexes  are  increased  (which  Patrick  thinks  is  the  sole  differentiat- 
ing point),  often  with  spasticity;  quite  frequently  there  is  optic 
atrophy,  limitation  of  the  visual  field  for  objects  and  color,  eye  paralysis 
and  sometimes  an  immobile  pupil,  nystagmus,  choreiform  movements,, 
and  moderate  sensory  and  speech  disturbance,  which  may  be  nasal  and 
marked  by  unequal  inspiration  and  expiration.  The  club  foot,  scolio- 
sis and  Romberg's  sign  are  absent.  Sanger  Brown  has  reported  25 
and  J.  H.  Neff,  13  cases. 

4.  Cerebral  diplegia  of  children,  and  ataxic  paraplegia  are  dis- 
tinguished by  reflex  increase  and  spasticity. 

5.  "Amaurotic  family  idiocy"  (Sachs,  Peterson,  Hirsch)  is  char- 
acterized by  paresis  or  paralysis,  idiocy,  optic  atrophy,  marasmus, 
and  a  rapidly  fatal  course  before  the  third  year  of  life.  At  autopsy 
hypoplasia,  microgyria,  decreased  pyramidal  cells,  tangential  and  other 
fibers  are  noted.  Sachs  observed  27  cases  in  Jews,  and  Haveroch  (190^1) 
collected  36  cases. 

Treatment  is  wholly  symptomatic. 

2.  Ataxic  Paraplegia  (Gowers). — Most  cases  occur  in  males  between 
thirty  and  forty;  cold  and  concussion  are  possible  causes;  syphilis  is 
a  rare  cause.  Pathologically,  there  is  a  lateroposterior  sclerosis;  in 
the  lat.  column  the  degeneration  is  not  wholly  systematic,  symmetrical 
or  pyramidal;  it  may  invade  the  mixed  zone;  in  the  post,  column  the 
process  is  not  more  intense  in  the  lumbar  cord,  and  is  less  intense  in  the 
root  zone  than  is  the  case  in  tabes.  Sometimes  the  process  is  so  diffuse 
that  it  suggests  myelitis  or  arterial  obstruction  (Marie).  The  early 
symptoms  are  those  of  a  gradual  spastic  paraplegia  (muscular  weakness, 

72 


1138  DISEASES  OF  THE  NERVOUS  SYSTEM 

exaggerated  reflexes,  moderate  rigidity),  followed  by  ataxia  (mostly 
in  the  legs,  with  Romberg's  sign).  The  arms  are  involved  later, 
though  to  a  less  degree.  In  the  last  stages  the  ataxia  is  obscured  by  the 
spastic  paraplegia;  vesical  or  rectal  tenesmus  and  muscle  cramps  are 
fairly  common.  Cranial  involvement  is  infrequent,  though  sometimes 
suggested  by  slightly  disturbed  articulation,  nystagmus,  tremulous 
facial  movements,  and  increased  jaw-jerk.  The  mind  is  usually  clear, 
though  in  some  cases  late  dementia  develops.  Sexual  activity  is  often 
lessened,  and  the  sphincters  are  sometimes  moderately  disturbed. 
Dull  sacral  pain  is  sometimes  observed. 

Differentiation  is  necessary  (a)  from  tabes.  Certain  tabetic  symptoms 
are  absent,  as  the  high-stepping  and  sudden-stamping  gait,  the  immo- 
bile pupils,  optic  atrophy,  eye  paralysis,  lancinating  pains,  crises, 
other  sensory  disorders  and  absent  knee  jerks.  (6)  Friedreich's  ataxia  is 
distinguished  by  t4ie  age,  heredity,  speech,  and  absence  of  patellar 
reflexes,  (c)  Myelitis  is  more  acute,  diffuse  and  later  is  regressive. 
(d)  From  simple  spastic  paraplegia  it  is  recognized  by  the  ataxia. 

The  prognosis  and  treatment  are  those  of  spastic  spinal  paraplegia. 

3.  Other  Combined  System  Diseases. — Combined  sclerosis  may 
be  (a)  exogenous,  as  in  pellagra  (q.  v.)  with  degeneration,  and  then 
sclerosis  of  the  posterior  lateral  columns;  as  in  ergotism  (q.v.),  the 
longest  known  variety,  and  in  lathyrism  (q.v.),  or  it  may  be  (6) 
endogenous,  as  in  multiple  neuritis,  diabetes  (Williamson),  pernicious 
anaemia  (Lichtheim),  cachexia,  icterus,  leukaemia  (Minnich),  brain 
tumor,  plumbism,  or  diphtheria.  Some  toxin  causes  degeneration 
which  is  followed  by  sclerosis.  It  was  found  by  Putnam  in  enfeebled 
middle  aged  persons,  especially  in  women.  Dana,  Bastianelli,  Batten, 
Russel,  and  Collier  have  described  similar  cases. 

Pathologically,  there  is  posterolateral  sclerosis  with  diffuse  or  at 
times  discrete  degenerative  foci.  All  the  columns  may  be  affected.  The 
most  diffuse  changes  are  in  the  cervical  and  the  least  in  the  lumbar 
cord,  and  sometimes  changes  exist  in  the  ant.  horns  and  Clarke's 
columns.  There  are  sensory  symptoms  (lancinating  pains,  parsesthesia, 
ansesthesia,  ataxia),  motor  symptoms  (paresis,  paraplegia,  choreiform 
movements)  or  reflex  symptoms  (the  patellars,  for  instance,  being 
exaggerated  or  even  lost,  the  sphincters  incompetent);  optic  neuritis 
and  oedema  are  occasional  findings. 


DISEASES  OF  THE  PERIPHERAL  NERVES  1139 


IV.  DISEASES  OF  THE  PEEIPHERAL  NERVES. 

1.  Mononeuritis. — Inflammation  of  a  single  nerve  trunk. 

Etiology. — (a)  Injuries,  wounds,  fractures,  dislocations,  delivery ,  vio- 
lent muscular  contractions  as  in  blacksmiths;  exhaustion  or  disturbed 
metabolism;  anaesthesia  (ether)  paralyses,  the  arms  being  held  over  the 
head  (in  the  Trendelenberg  position),  the  legs  bound  in  holders,  or 
when  Esmarch's  bandage  is  applied;  ether  hypodermatically,  malpo- 
sitions of  the  arm  during  sleep,  and  the  use  of  crutches,  are  causes. 
(&)  Contiguous  disease  (pleurisy,  pelvic  inflammation,  compression 
by  tumors,  or  aneurysm)  may  produce  neuritis,  (c)  Cold  (rheumatic 
paralysis)  causes  inflammation  in  the  sheath,  whence  extension  to  the 
nerve,  {d)  Toxic  causes,  as  plumbism  and  alcoholism,  and  acute  or 
chronic  infections  (v.  i.  Multiple  Neuritis)  are  factors. 

Pathology. — In  acute  cases,  the  nerve  is  red,  swollen,  soft,  and 
sometimes  the  seat  of  punctate  hemorrhages  or  extravasation  of 
white  cells  in  the  sheath  or  between  it  and  the  nerve  fibrils.  In  some 
cases  inflammation  involves  the  sheath  chiefly  {'perineuritis),  and  in 
others  the  interstitial  tissue  {interstitial  neuritis),  in  which  the  included 
nerve  fibrils  are  readily  compressed.  The  process  is  either  disseminated 
or  focal  (where  the  nerve  divides  or  enters  the  fascia  or  bone).  In  many 
cases  the  nerve  fibrils  are  most  affected  {parenchymatous  neuritis).  It 
is  often  difiicult  to  distinguish  between  inflammation  and  degeneration ; 
in  both  processes  there  is  nuclear  multiplication  and  protoplasmic  swell- 
ing in  the  neurilemma;  this  compresses  the  myelin  sheath,  which 
becomes  varicose,  granular,  fragmented,  shows  nuclear  increase  and 
finally  becomes  emulsified.  The  axis  cylinder,  composed  of  thirty  to 
fifty  primitive  fibrils,  becomes  granular,  divided  and  may  largely  or 
wholly  disappear.  Regeneration  is  probably  accomplished  from  the 
spinal  or  cerebral  centres  but  also  from  the  periphery. 

Symptoms. — Symptoms  vary  with  the  intensity,  extent  and  seat  of 
the  neuritis  (see  Individual  Nerves).  Constitutional  disturbance 
may  attend  acute  cases. 

1.  Sensory  Symptoms. — The  chief  local  symptom  is  pain,  ex- 
perienced largely  in  the  sensory  nerves,  either  locally  or  eccentrically 
over  their  area  of  distribution;  it  is  increased  by  tension  or  movement, 
is  usually  intense  and  is  sometimes  increased  at  night.  Tenderness  is 
referable  to  involvement  of  the  nervi  nervorum  (Wier  Mitchell). 
Hypersesthesia,  hypsesthesia  and  paraesthesia  may  be  noted,  but  com- 
plete anaesthesia  is  rare  except  for  relatively  small  areas.  Sometimes 
the  swollen  nerve  or  perhaps  nodules  {n.  nodosa.)  may  be  felt. 

2.  Motor  Symptoms. — The  muscles  supplied  are  tender  to  touch, 
painful  on  movement,  paretic  or  paralyzed,  and  atrophied  (separation 
from  their  trophic  centres  or  loss  of  reflex  connections) .  They  are  nar- 
rower, less  clearly  striated,  granular  and  finally  indurated.  Muscular 
contractures  may  result  reflexly,  especially  in  traumatic  and  professional 
or  occupation  neuritis.     The  reaction  of  degeneration  is  present.     The 


1140 


DISEASES  OF  THE  NERVOUS  SYSTEM 


normal  nerve  is  stimulated  by  the  faradic  (induced)  and  by  a  stronger 
degree  of  the  voltaic  (constant)  current ;  the  faradic  produces  a  contin- 
ouus  muscular  contraction  and  the  voltaic  produces  a  contraction  when 
the  circuit  is  made  or  broken, — the  cathode  closing  contraction,  which 
is  first  to  appear  and  stronger  than  the  anode  closing  contraction.  In 
disease,  the  following  changes  from  normal  occur  (Church),  (a)  "  The 
muscle  responds  weakly,  sluggishly  and  deliberately  to  faradism,  and 
tends  to  maintain  contraction  after  the  current  is  withdrawn.  This 
is  the  modal  change,  the  most  essential  element  in  the  reaction.  (6)  "The 
nerve  trunk  loses  progressively  and  equally  its  responsiveness  to  both 
galvanism  and  faradism — a  quantitative  change,  (c)  "The  muscle 
becomes  much  more  excitable  by  galvanism  and  much  less  excitable  by 
faradism;  the  latter  reaction  and  the  responses  in  the  nerve  trunk  are 
completely  lost  after  two  or  three   weeks.     This   is   the  qualitative 


Fig.  77. 
1 

ATROPHY  AND  NUCLEAR 
PROLIFERATION  OF   MUSCLE 


REGENERATtON 


1^    WEEK 


DEGENERATION 


SIO         100    WEEK 

(Erb, 


1  3  10         20         30         40         50         60  70 

1,  paralysis  with  eaily  return  of  motion;    2 ,  incurable  paralysis  with  complete  degeneration 

modified  by  Church). 

change,  id)  "A  'polar  change  appears  in  the  muscle  about  the  second 
week  when  directly  stimulated  by  galvanism;  the  muscle  is  not  only 
more  readily  caused  to  contract  by  the  constant  current,  but  the  normal 
mastering  strength  of  the  negative  closing  contraction  over  the  positive 
has  disappeared  and  the  positive  closing  contraction  is  equal  to  or 
greater  than  the  negative"  (A.  Church). 

In  the  middle  or  mixed  form  of  Erh  there  is  a  normal  reaction  in  the 
nerves  and  increased  voltaic  response  in  the  muscles. 

3.  Trophic  Symptoms. — The  skin  is  sometimes  red,  "glossy," 
oedematous  or  more  rarely  thickened.  Increased  secretion  of  sweat, 
eruptions  as  herpes,  erythema  or  pemphigus,  inflammation  or  adhesions, 
in  the  joints,  and  perforating  ulcers  are  less  common. 


MULTIPLE  NEURITIS  1141 

Neuritis  may  sometimes  ascend  to  the  cord  or  its  membranes  as  in 
traumatic  cases  or  in  bladder  disease.  In  rare  instances  the  corre- 
sponding opposite  nerves  may  become  involved  without  disease  of  the 
cord;  this  is  the  so-called  syiwpathetic  neuritis.  The  progressive 
hypertrophic  interstitial  neuritis  of  childhood  (Dejerine  and  Sottas, 
1893)  is  a  rare  affection,  in  which  there  is  anatomically  sclerosis 
and  hypertrophy  of  the  nerves,  ant.  and  post,  nerve  roots,  and  sclerosis 
of  the  post,  columns  as  in  tabes,  and  clinically,  muscular  atrophy, 
pains,  anaesthesia,  nystagmus,  pupils  immobile  to  light,  and  kypho- 
scoliosis. 

Diagnosis. — Diagnosis  depends  on  (a)  localization  of  symptoms  to  a 
nerve  trunk  and  its  distribution;  (b)  pain,  tenderness  and  objective 
sensory  alteration;  (c)  muscular  atrophy  or  paralysis;  and  (d)  trophic 
changes.  The  early  diffuse  pain  may  simulate  disease  of  the  bones  or 
joints.  Chronic  (sensory)  forms  may  resemble  neuralgia,  in  which  the 
pain  is  paroxysmal,  the  tender  points  more  localized,  the  initial  tender- 
ness less,  and  objective  sensory  alteration  absent.  Disease  of  the  cord 
or  nerve  roots  usually  paralyzes  several  muscles  and  affects  sensation 
segmentally. 

The  prognosis  depends  on  the  cause  and  intensity  of  the  process. 
Acute  cases  last  for  weeks;  chronic  cases,  for  months.  The  outlook  is 
usually  good  in  traumatic  cases,  and  bad  when  they  are  due  to  con- 
tiguous suppuration. 

Treatment. — The  treatment  is  (a)  that  of  the  cause.  (6)  Absolute 
rest  is  indicated.  Exertion  increases  just  as  it  may  initiate,  neuritis, 
(c)  Pain  should  be  relieved.  The  salicylates  and  iodides  are  of  un- 
certain value.  Local  heat  may  relieve,  but  sometimes  causes  burns 
and  ulcerations,  for  the  anaesthetic  skin  may  not  perceive  its  intensity. 
Coal-tar  products  should  be  given  in  preference  to  morphine,  cocaine  or 
Schleich's  infiltration  anaesthesia,  because  habits  may  be  contracted; 
opiates  are  necessary  in  severe  cases.  The  positive  pole  of  the  voltaic 
current,  just  strong  enough  to  be  felt,  may  relieve  pain,  (d)  Paralysis 
should  be  treated  only  after  the  acute  stage.  The  weak  interrupted 
voltaic  current  (not  the  faradic)  is  indicated.  Massage  and  later 
passive  motion  are  beneficial  largely  because  the  veins  from  the  nerves 
empty  into  the  muscle  veins  and  surround  the  muscle  arteries. 


2.  Multiple  Neuritis;  Polyneuritis,  Peripheral  Neuritis.  This 
affection  was  described  by  James  Jackson  (1822)  and  Ladd  (1854), 
but  the  first  accurate  and  pathological  description  was  given  by  Dumeil 
in  1864,  while  Joffroy,  1879,  Leyden,  1880,  and  Stewart,  1881,  made 
important  contributions. 

Definition. — Neuritis  (or  nerve  degeneration)  due  to  the  selective 
action  of  toxic  substances  on  the  less  resistant  peripheral  nerves, 
causing  (a)  multiple,  symmetrical,  bilateral,  flaccid,  or  atrophic 
paralysis  with  (b)  the  reaction  of  degeneration,  (c)  sensory  and  (d) 
often  trophic  disturbances. 


1142  DISEASES  OF  THE  NERVOUS  SYSTEM 

Etiology. — The  causes  are  (a)  poiso7is;  alcohol  is  the  most  important; 
lead,  arsenic  (in  beer),  mercury,  phosphorus,  carbon  monoxide,  silver, 
aniline  and  ergot  may  also  produce  the  disease,  (b)  The  infections, 
(i)  acute,  as  diphtheria,  typhoid,  sepsis,  and  also,  occasionally,  almost 
every  active  infection,  and  (ii)  chronic,  as  beri-heri,  leprosy,  tuberculosis 
or  syphilis,  are  etiological  factors,  (c)  Intoxications ,  as  auto-intoxica- 
tions, diabetes,  nephritis,  digestive  disorders,  cachexias  and  pregnancy, 
may  be  causal,  {d)  Other  causes  include  the  seemingly  primary  cases. 
Cold  and  rheumatism  may  produce  it ;  our  present  knowledge  cannot 
explain  their  mode  of  action;  probably  these  cases  should  be  classified 
as  infectious,  for  spontaneous  multiple  neuritis  has  occurred  epidem- 
ically. Arteriosclerosis  (of  the  nerve  vessels)  is  a  rarer  cause.  It  may 
occur  with  tabes.  It  is  a  disease  of  adults  (twentieth  to  fiftieth  year) ;  in 
children  it  may  occur  with  poliomyelitis. 

Pathology. — In  acute  cases  the  nerve  may  be  red,  swollen  and  the 
seat  of  punctate  hemorrhage,  exudation  of  leukocytes  or  albuminous 
exudation  in  the  connective  tissue,  but  usually  parenchymatous  degen- 
eration predominates.  It  appears  first  and  most  markedly  in  the 
smaller  nerves.  As  in  mononeuritis,  the  axis  cylinders  waste  and  the 
medullary  sheaths  disintegrate.  The  symmetry  and  multiplicity  of 
degeneration  in  the  nerve  endings  is  caused  by  the  altered  condition 
of  the  blood  by  toxins  or  poisons.  Acute  polymyositis  of  similar 
origin  may  accompany  neuritis  multiplex.  In  cases  which  are  chronic 
from  the  beginning,  there  is  slow  degeneration  of  the  nerves.  The  con- 
nective tissue  is  increased  in  certain  forms,  as  gouty  or  leprous  neuritis. 
The  toxic  cause  may  also  produce  degeneration  of  the  cord  or  brain 
and  changes  in  the  liver  (alcoholic  cirrhosis),  kidneys  (alcohol  and 
lead),  and  lungs. 

Symptoms. — The  symptomatology  varies  considerably  mth  the 
cause.  In  acute  cases  it  may  begin  vnih  chills,  fever,  delirium,  headache, 
diarrhoea,  icterus,  bronchitis,  acute  splenic  tumor,  albuminuria  or 
other  toxsemic  symptoms;  these  are  followed  by  prodromal  numbness, 
tingling,  pains,  cramps  or  vasomotor  symptoms,  while  in  chronic  cases 
the  symptoms  develop  slowly. 

1.  Sensory  symptoms  are  usually  -first  to  appear,  the  last  to  disappear, 
and  are  throughout  the  most  vexing  manifestations.  Paresthesia 
precedes  pain  and  pain  precedes  paralysis.  The  muscles,  nerve  trunks 
and  skin  are  the  seat  of  spontaneous  pain,  tenderness  to  pressure  and 
pain  on  movement.  The  palms  of  the  hands  and  soles  of  the  feet  are 
especially  hypereesthetic  in  the  tabetic,  diabetic  and  diphtheritic  forms. 
Sensation  is  often  blunted,  perverted  or  less  often  completely  suspended ; 
the  most  marked  findings  exist  below  the  elbows  and  knees,  although 
higher  extension,  even  to  the  face,  is  possible.  Sensory  dulness  may 
concern  pain,  temperature,  tactile  or  muscular  sensation.  Some  sen- 
sory disturbance  is  rarely  absent.  Delayed  conduction  may  occur. 
The  joints  may  be  painful  and  swollen,  especially  in  the  hand,  causing 
thickening  and  limitation  of  movement. 

2.  Motor  symptoms  occur  chiefly  in  the  peripheral  distribution  of 


MULTIPLE  NEURITIS  1143 

the  spinal  nerves;  they  develop  first  and  are  most  marked  in  the 
extensors  of  the  leg  and  foot,  forearm  and  hand,  and  produce  the  ankle 
and  wrist  drop  (ext.  popHteal  and  musculospiral  nerves).  The  foot  is 
also  inverted.  The  paralysis  is  flaccid,  being  rarely  attended  by 
muscular  spasm.  If  the  paralysis  is  only  moderately  severe  in  the  legs, 
the  " steppage' '  gait  (Charcot)  is  noted,  and  the  patient  lifts  the  legs 
high  to  clear  the  pendant  toes  ("turkey-gobbler  walk").  The  paralysis 
later  involves  the  flexors  and  the  muscles  of  the  arm  and  thigh.  The 
muscles  may  show  an  early  increased  irritability  to  both  the  galvanic 
and  faradic  currents ;  this  is  followed  by  some  or  all  of  the  elements  of 
the  reaction  of  degeneration  (sometimes  before  paralysis  appears, 
Popoff).  The  muscles  rarely  fail  to  respond  to  the  galvanic  current, 
even  in  the  extreme  cases.  Then  the  muscles  atrophy,  chiefly  in  distal 
parts,  i.  e.,  where  the  sensory  and  motor  changes  predominate.  Other 
motor  manifestations  are  cramps,  tremor,  fibrillation,  ataxia  and 
contractures.  The  patient  either  lies  on  the  back  with  the  members 
extended  or  on  the  side  with  flexor  contractures,  which  draw  the  heels 
to  the  buttocks  and  the  thighs  to  the  abdomen.  The  trunk  muscles  may 
be  affected  as  well  as  those  of  the  neck  and  eyes,  face,  tongue,  or  indeed 
those  supplied  by  any  cranial  nerve;  rapid  pulse,  palpitation,  dys- 
pnoea, and  vocal  disturbance  indicate  involvement  of  the  vagus ;  optic 
neuritis  and  amblyopia  may  occur.  Involvement  of  the  cranial  and 
spinal  nerves  is  observed  in  the  neuritic  form  of  Landry's  paralysis. 
The  tendon  and  skin  reflexes  decrease  and  disappear  although  initial 
increase  or  exceptional  persistence  has  been  noted.  The  organic 
reflexes  are  almost  always  preserved.  Involvement  of  the  bladder  and 
rectum,  which  is  very  rare,  is  referable  to  the  mental  state  or  to  neuritis 
of  the  pudendal  plexus. 

3.  Trophic  symptoms  may  be  present.  The  skin  is  cold,  turgid, 
harsh,  sometimes  glossy;  eruptions  (herpes,  erythema),  ulceration, 
bed-sores,  and  trophic  changes  in  the  nails  or  hair,  are  uncommon; 
oedema  over  the  wrists  and  ankles  may  occur,  especially  in  alcoholics, 
and  is  trophic  or  vascular  in  origin. 

4.  There  may  be  general  symptoms.  Mental  symptoms  and  mal- 
nutrition may  result  from  the  antecedent  toxaemia  or  cachexia,  pain  or 
disturbed  circulation.  Korsakow  and  others  have  described  the 
"neuritic  psychosis,"  marked  by  amnesia,  delirium,  and  hallucina- 
tions, which  are  probably  due  to  the  causes  just  mentioned.  Recovery 
is  the  rule.  Some  visceral  symptoms  have  been  referred  to  involvement 
of  the  cardiac,  sacral  or  pudendal  plexuses,  although  mostly  without 
positive  evidence. 

Course  and  Prognosis. — Whether  the  disease  begins  acutely  or 
slowly,  the  common  order  of  symptoms  is  paresthesia,  pain,  paralysis, 
amyotrophy,  trophic  and  mental  symptoms.  The  distal  parts  are 
involved  more  early  and  intensely  than  the  proximal.  In  most  cases 
recovery  requires  about  a  year.  Paralysis  of  the  vagus  may  cause 
death.  The  prognosis  depends  in  part  on  the  cause.  It  is  good  in 
sensory  types,  and  in  forms  of  slow  evolution,  when  the  sensorium. 


1144 


DISEASES  OF  THE  XERVOUS  SYSTEM 


arms  and  trunk,  cranial  nerves  and  sphincters  escape  involvement,  and 
when  visceral  disease  as  liver  cirrhosis,  cord  or  brain  complications  and 
oedema  are  absent.  The  prognosis  must  regard  the  possibility  of 
recurrence  (recurrent  type)  and  cover  the  progress  of  the  disease, 
which  is  inevitably  slow,  despite  treatment. 

Diagnosis. — Early  diagnosis  is  important,  in  order  that  etiological 
therapy  may  be  instituted.  The  cardinal  signs  are  (a)  the  motor  and 
sensory  symptoms,  which  correspond  in  function,  peripheral  distribu- 
tion and  symmetry;  (b)  the  reaction  of  degeneration;  (c)  tenderness  of 
the  nerves  and  muscles;   (d)  loss  of  reflexes  and  (e)  the  etiology. 

Diagnosis  OF  Type, — (a)  The  a/co/io/ic  form  is  the  most  frequent;  70 
per  cent,  of  cases  occur  in  women;  the  legs  are  often  involved;  there  is 
the  "steppage "  gait ;  sensory  and  mental  symptoms  are  most  marked; 
the  atactic  form  is  not  infrequent  {v.i.);  recurrence  is  probable.  (6) 
When  due  to  lead  poisoning,  the  occupation,  lead  line,  colic  and  con- 
stipation are  characteristic;  the  arms  alone  are  involved  as  a  rule; 
there  is  little  or  no  sensory  participation;  the  involvement  rarely  extends; 
the  wasting  is  conspicuous,  (c)  Diphtheritic  form  (q.v.).  (d)  In  the 
toxcBmic  form  there  is  fever,  and  constitutional  reaction;  it  begins  in 
the  legs  or  in  all  members  simultaneously,  involves  equally  the  flexors 
and  is  attended  by  slight  sensory  symptoms  (Gowers).  (e)  When  due 
to  heri-heri  (q.  v.),  vagus  symptoms,  dropsy  and  cardiac  failure  are 
frequent.  (/)  Leprous  neuritis,  erythromelalgia  and  Dercum 's  disease 
are  considered  elsewhere. 

Differentiation. — Atactic  polyneuritis  (pseudotabes  peripherica, 
Dejerine)  with  little  or  no  motor  disturbance,  may  resemble  locomotor 
ataxia : 

Locomotor  Ataxia. vs. Multiple  Neuritis. 


History  or  stigmata  of  syphilis. 

Argyll-Robertson  pupil. 

Optic  atrophy,  10  per  cent. 

Eye  paralysis  frequent. 

Early    girdle    sensation    and    lightning 

pains. 
Muscular   sense   early    and    frequently 

disturbed;   ataxia. 
Gait  ataxic,  stamping,  striking  heel  first. 

Sensory  symptoms  predominate. 

Paralysis,  reaction  of  degeneration  and 
amyotrophy  rare. 

Nerve  trunks  often  insensitive. 

Arthropathies,  osteopathies,  mal  per- 
forant. 

Crises. 

Sphincters  early  and  frequently  in- 
volved. 

Clinical  evolution  very  slow. 

Disease  incurable. 


Rare:  history  of  infection  or  intoxica- 
tion. 

Absent  (loss  of  accommodation  in 
diphtheria). 

Rare,  but  toxic  amaurosis  is  frequent. 

Much  more  rare. 

Very  rare. 

Rare. 

Gait  due  to  motor  more  than  sensory 
disturbance.     Striking  toe  first. 

Motor  predominate. 

In  nearly  all  cases;  rapid  in  develop- 
ment and  symmetrical. 

Tender,  as  are  muscles. 

Unknown;    glossy  skin  more  common. 

Almost  unknown  ;toxsemicvomiting,etc. 
Very  rarely,  if  ever,  and  from  delirium, 

etc. 
Rapid. 
Recovery  usual,  if  not  early  death. 


NEUROMA  1145 

Poliomyelitis. vs. Multiple  Neuritis. 

Usually  in  children.  In  adults. 

More  sudden  onset.  Less  acute. 

Embraces  whole  limb ;  random  distribu-  Peripheral  and  symmetrical. 

tion. 

Muscles  functionating  together.     Reac-  Dissimilar  muscles  involved. 

tion    of    degeneration   in    both,    but 

strong  galvanic  current  not  required  Muscles  respond  only  to  strong  galvanic. 

(during    first    months)    to    produce 

muscular  contraction. 

Pain  and  tenderness  most  rare.  Comnion  in  nerves  and  muscles. 

Sensory  disturbance  rare.  Usually  (but  not  invariably)  present. 

Immediate  tendency  to  regress,  but  al-  Tendency  to  progress. 

ways  some  deformity.  Total  recovery  the  rule. 

In  acute  myelitis,  the  onset  is  acute,  there  are  girdle  pains,  paraplegia, 
with  corresponding  anaesthesia,  bed-sores,  disturbance  of  the  bladder 
and  rectum;  there  is  no  tenderness  of  the  nerves  or  muscles,  little  or  no 
ataxia,  and  recovery  is  unusual.  Landry's  'paralysis  often  cannot  be 
distinguished  (which  is  natural,  as  one  form  of  Landry's  disease  is 
neuritic);  sensory,  trophic  and  sphincter  changes  are  absent. 

Treatment. — In  the  etiological  therapy,  alcohol  must  always  be 
considered  and  deception  guarded  against ;  it  should  be  withdrawn  at 
once.  In  sepsis,  Gowers  gives  full  doses  of  iron.  For  treatment  of 
pain  see  Neuritis.  iVbsolute  rest  should  be  enforced.  A  full  diet, 
rich  in  fats,  should  be  given  if  the  stomach  can  tolerate  it;  tonics 
should  be  given  to  maintain  nutrition,  but  arsenic  shoidd  be  avoided. 
When  the  lower  cranial  nerves  are  affected,  feeding  by  the  nasal  tube 
or  by  rectum,  measures  to  avoid  hypostasis  as  in  typhoid,  and  cardiac 
stimulants  are  indicated.  To  overcome  contractures  from  ankle-  or 
wrist-drop,  splints  or  sand-bags  should  be  employed  when  they  do  not 
cause  excessive  pain.  The  weight  of  the  bedclothes  on  the  feet  may 
promote  contractures,  whence  frames  to  lift  the  bedding  should  be  used. 
Gentle  massage  and  voltaism  may  be  tolerated  after  the  acute  stage, 
may  prevent  contractures,  and  may  aid  the  return  venous  flow.  Bro- 
mides and  chloral  are  the  most  certain  somnifacients  but  chloral  must 
be  used  with  care  in  chronic  alcoholism.  Orthopedic  measures  are 
indicated  in  neo^lected  contractures. 


3.  Neuroma. — Two  varieties  exist,  the  true  and  the  false  neuroma. 
The  true  neuroma  may  be  medullated,  or  non-medullated,  though 
ganglion  cells  are  exceptional  (only  3  cases  are  recorded);  they  are 
usually  multiple,  .sometimes  very  numerous  (3,020  in  one  case),  and 
have  been  found  in  instances  on  every  cranial,  spinal,  and  sym- 
pathetic nerve.  They  may  undergo  sarcomatous  degeneration. 
The  tubercula  dolorosa  (Virchow)  are  small,  painful,  subcutaneous 
nodes  on  the  trunk  or  extremities,  the  anatomy  of  which  is  not  well 
understood.  The  neuroma  plexiforme  consists  of  twisted  cords  with 
nodes,  is  congenital  and  occurs  largely  in  the  distribution  of  the  fifth 


1146  DISEASES  OF  THE  NERVOUS  SYSTEM 

nerve.  The /a^^e  wewrowa  is  usually  fibrous ;  glioma  is  rare ;  sarcoma 
or  carcinoma  may  by  contiguity  invade  adjacent  trunks;  neuromata 
have  been  found  in  the  cerebral  nerves  in  syphilis,  and  in  the  peripheral 
nerves  in  leprosy.  The  nerve  trunks  suffer  more  in  the  false  than  in 
the  true  form.  Neuromata  in  amputation  stumps  are  of  frequent 
occurrence. 

There  may  be  no  symptoms;  local  tenderness  and  local  or  projected 
pain  are  frequent.  Reflex  muscular  spasm  is  common  from  nerve 
irritation.  Mentality,  sensation  or  motility  may  be  affected.  Pig- 
mentation has  occurred.  Diagnosis  is  certain  only  when  the  growths 
are  felt.  Treatment  is  symptomatic  for  the  exhausting  pain,  or  radical 
in  localized  growths.     Recurrence  is  not  infrequent. 

4.  Diseases  of  Cranial  Nerves. 

Olfactory  Nerve. — The  end  nerves  of  smell  are  located  on  the  two 
upper  turbinate  bodies  and  the  upper  septum;  thence  they  run  to  the 
olfactory  bulbs,  which  are  really  part  of  the  brain.  The  central 
connections  are  not  well  understood.  The  centre  is  thought  to  be  in 
the  uncinate  gyrus  and  the  hippocampus,  with  relations  to  the  optic 
thalamus,  opposite  internal  capsule  and  cerebral  cortex.  The  anterior 
nares  perceive  odors,  the  posterior,  flavors. 

Anosmia  is  loss  of  smell.  Tests  are  made  not  with  pungent  sub- 
stances, as  ammonia,  which  irritates  the  fifth  nerve,  but  with  musk, 
asafoetida,  cologne  water  and  the  essential  oils,  (a)  Disease  in  the 
nasal  mucosa  is  the  most  frequent  cause;  it  may  result  from  paralysis 
of  the  fifth  nerve,  arrest  of  secretion,  or  atrophy  in  old  age.  (b) 
Disease  of  the  bulb  and  tract  may  result  from  congenital  absence  of  the 
bulb,  basal  fracture,  or  meningitis  in  the  ant.  fossa,  disease  of  the  middle 
cerebral  artery,  tabes  (possibly  centric  atrophy),  hydrocephalus,  and 
foci  in  the  opposite  internal  capsule,  (c)  Central  disease  may  be 
located  in  the  hippocampus  and  uncinate  convolution,  as  softening. 
The  prognosis  is  usually  unfavorable  and  treatment  is  ineffectual. 
Hyperosmia,  or  oversensitiveness  of  smell,  occurs  in  insane  and  neu- 
rotic subjects;  it  may  be  cultivated,  so  that  individuals  are  recognized 
by  their  odor.  Parosmia,  or  perverted  sensation,  is  rare,  and  arises 
from  irritation  of  the  nerves  or  centres.  Hallucinations  of  smell  may 
occur.  Imaginary  odors,  as  of  burning  flesh,  may  constitute  the 
epileptic  aura. 

Optic  Nerve. — (A).  The  'Retina.— Retinitis  occurs  in  general 
diseases,  as  nephritis  (in  15  to  25  per  cent.),  especially  in  interstitial 
forms,  and  late  in  the  disease  rather  than  early.  The  degenerative 
form  is  most  common,  the  next  is  the  hemorrhagic  form,  with  "flame 
like"  hemorrhages  along  the  vessels,  and  finally  the  inflammatory  type, 
with  swelling  of  the  retina,  serum  exudation,  cloudiness  and  disk 
blurring,  which  may  be  as  marked  as  that  of  brain  disease;  the  white 
foci  which  are  seen  are  due  to  exudation,  fatty  change  or  sclerosis. 


PLATE  XIX. 


VISUAL  ^\^ 


^  1^1  S  UAL  ^^^ 


Visual  Paths.      (After  Vialet.) 

OP  N  optic  nerve.  OP.C,  optic  chiasm.  OP.T.,  optic  tract.  OP.R.,  optic  radiation.  V.S.,  visual 
speech  centre  A  lesion  at  (1)  causes  total  blindness  in  that  eye;  lesion  at  (2),  bitemporal  hemi- 
anopsia; at  (3),  unilateral  nasal,  and  lesions  at  (3)  and  (3A),  bilateral  nasal  hemianopsia;  at  (4) 
hemianopsia  of  both  eyes  and  the  hemianopsic  pupillary  reaction;  at  (r->)  or  (6),  heminnopsia  ot  both 
eyes  (pupillary  reflexes  being  normal);  at  (7),  amblyopi.a,  especially  of  the  opposite  eye;  at  (8),  word- 
blindne.^is. 


DISEASES  OF   CRANIAL  NERVES  1147 

Similar  findings  may  occur  in  syphilis,  anaemia  (Quincke),  malaria, 
leukaemia  (q.v.)  purpura,  plumbism,  and  diabetes  (see  Plates  V  and 
VI).    There  are  apparently  primary  cases. 

(B).  Optic  Nerve. — Optic  neuritis  (papillitis,  choked  disk)  has 
been  fully  described  and  differentiated  (see  Brain  Tumor  and  Plates 
V  and  VI).  Tumors  or  inflammation  in  or  back  of  the  orbit  may 
be  causal.  Errors  in  refraction  must  be  excluded.  In  the  primary 
form  there  is  no  initial  inflammation.  The  edges  of  the  disk  are  dis- 
tinct, its  arteries  nearly  normal  and  its  color  grayish;  it  may  develop 
hereditarily  in  males  at  puberty;  it  occurs  in  tabes,  paretic  dementia, 
multiple  sclerosis,  syphilis  (in  connection  with  all  of  which  it  has  been 
discussed),  and  less  often  from  exposure, excesses,  diabetes,  alcoholism, 
plumbism,  the  specific  fevers,  amaurotic  family  idiocy  and  familial 
cerebellar  ataxia.  The  form  secondary  to  inflammation  commonlyfollows 
choked  disk  and  has  the  same  significance;  the  disk  has  an  irregular 
contour,  small  arteries,  and  is  translucent.  The  symptoms  are 
diminution  in  acuity  of  vision,  field  of  vision,  color  perception,  and 
the  pupillary  reaction. 

(C).  Chiasm. — Each  half  of  the  retina  contains  fibers  from  the 
corresponding  occipital  lobe  (see  Plate  XIX),  that  is,  each  right 
half  receives  fibers  from  the  right,  and  each  left  half  from  the  left, 
occipital  lobe.  The  point  of  sharpest  vision,  the  macula,  receives  over- 
lapping fibers  from  both  sides  of  the  brain.  The  outer  (temporal) 
portion  of  the  field  of  vision  is  more  limited  than  the  inner  (nasal) 
portion,  because  the  nose  cuts  off  light,  and  consequently  it  receives 
fewer  nerve  fibers.  The  larger  number  of  fibers  from  each  eye,  i.  e., 
those  from  the  nasal  retinal  half,  decussate  at  the  chiasm  and  lie  in  its 
centre.  Those  from  the  temporal  half  are  direct  and  lie  at  the  side  of 
the  chiasm.  While  division  or  disease  of  one  optic  nerve  causes  blind- 
ness in  the  corresponding  eye,  lesions  affecting  the  centre  of  the  chiasm 
(decussating  fibers  to  the  nasal  half  of  each  retina)  cause  half  blindness 
in  the  opposite  (temporal)  visual  fields,  bitemporal  hemianopsia,  since 
oblique  rays  passing  the  pupil  fall  on  the  opposite  half  of  the  retina. 
The  macula  receives  fibers  from  both  sides  of  the  brain  and  therefore 
escapes  involvement.  Temporal  hemianopsia  may  result  from  tumors 
of  the  pituitary  gland,  pressure  from  the  infundibulum  of  the  third 
ventricle,  gummata  and  hemorrhage.  The  "oscillating"  or  varying 
bitemporal  hemianopsia  is  often  indicative  of  syphilis.  The  diagram 
illustrates  effects  of  lesions  of  the  lateral  part  of  the  chiasm  (3),  lesions 
affecting  both  sides  of  the  chiasm  (3  and  3A)  as  calcarious  or  aneurys- 
matic  carotids;  tabes  or  tumors  are  most  rare;  hinasal  hemianopsia 
is  therefore  most  exceptional;  a  large  lesion  might  produce  temporal 
hemianopsia  in  one  eye  and  total  blindness  in  the  other;  still  more 
extensive  disease  might  produce  total  blindness;  these  changes  may 
be  successive. 

(D).  Optic  Tract. — Just  back  of  the  chiasm  the  temporal  fibers 
of  the  right  and  the  nasal  fibers  of  the  left  side  form  the  right  optic 
tract,  i.  e.,  the  right  tract  contains  all  fibers  from  the  right  half  of  each 


1148  DISEASES  OF  THE  XERVOUS  SYSTEM 

retina.  The  tract  runs  over  the  crus  cerebri,  where  a  lesion  very  often 
causes  hemiplegia  on  the  same  side  as  the  blind  field.  The  fibers  enter 
the  geniculate  bodies  (in  which  80  per  cent,  of  the  optic  fibers  end), 
opt.  thalamus  and  ant.  quadrigeminate  body,  from  which  gray  ganglia 
the  fibers  pass  by  way  of  the  posterior  limb  of  the  internal  capsule  and, 
by  radiating  fibers  (optic  radiation),  to  the  visual  centre  in  the  posterior 
internal  part  of  the  occipital  lobe,  the  cuneus.  A  lesion  (at  5,  in 
diagram)  in  the  optic  tract  anywhere  between  the  chiasm  and  cuneus 
produces /a^eraZ  or  Jiomonymous  hemianopsia;  for  instance,  if  it  occurs 
in  the  right  optic  tract  it  produces  loss  of  function  in  the  temporal  half 
of  the  right  and  nasal  half  of  the  left  retina,  so  that  the  left  half  of  each 
field  of  vision  is  lacking.  Hemianopsia  may  be  partial  and  may  involve 
only  a  quadrant,  or  only  a  quadrant  may  remain  after  partial  recovery. 
The  unaffected  fields  may  sufi^er  some  reduction.  Heteronymous 
hemianopsia  designates  blindness  of  the  right  half  of  one  field  and  the 
left  half  of  the  other,  or  the  converse.  Disease  in  the  gray  ganglia  or 
internal  capsule  may  produce  contralateral  hemiplegia;  indeed  in  50 
per  cent,  of  cases  of  hemianopsia  this  association  is  observed,  and  less 
frequently  hemiansesthesia.  Transient  hemianopsia  is  sometimes  seen 
in  migraine.  The  optic  tract  is  injured  in  tumors,  multiple  sclerosis 
trauma,  hemorrhage  or  softening. 

(E).  Optic  Centre  (see  Cerebral  Localization). — A  lesion  in 
the  cuneus  produces  (a)  homonymous  hemianopsia.  Sometimes  only 
an  upper  quadrant  is  Wind  (disease  in  the  upper  part  of  the  cuneus)  or 
the  lower  quadrant  is  bhnd  (disease  in  its  lower  part) .  Purely  cortical 
hemianopsia  is  impossible,  and  Monakow  held  that  the  optic  radiation 
must  be  involved;  (b)  hemic hromatopsia,  or  homonymous  color  blind- 
ness or  confusion,  in  which  all  colors  seem  gray,  is  propably  due  to 
lesion  of  the  anterior  superficial  cuneal  cortex.  Other  results  are  (c) 
mind  blindness,  or  loss  of  visual  memory;  {d)  alexia  or  word  blindness; 
(e)  optic  aphasia;  and  (/)  crossed  amblyopia,  concentric  blurring  or  limi- 
tation of  the  visual  fields  for  form  and  color;  this  is  usually  referred, 
however,  to  disease  of  the  gyrus  angularis,  in  which  there  is  thought  to 
be  a  higher  centre  in  which  the  half  fields  are  combined  and  the  whole 
opposite  field  and  part  of  the  field  of  the  same  side  are  represented. 

Diagnosis. — The  eyes  should  be  tested  separately.  Disease  of 
an  optic  nerve  causes  loss  of  sight  and  pupillary  reaction  in  the  corre- 
sponding eye.  Central  scotoma  (blindness  in  the  centre  of  the  visual 
field)  indicates  inflammation  or  hemorrhage  in  the  central  (axial) 
fibers  of  the  nerve,  usually  back  of  the  orbit;  it  is  common  in  poisoning 
from  tobacco  and  alcohol.  Peripheral  limitation  of  the  visual  fields 
indicates  damage  to  fibers  coursing  in  the  periphery  of  the  optic  nerve 
and  some  damage  to  all  the  nerve  fibers.  Sectorial  blindness  indicates 
a  pronounced  but  circumscribed  affection  of  the  nerve.  Bitemporal 
hemianopsia  always  results  from  chiasm  disease;  unilateral  temporal 
hemianopsia  in  one  eye  with  complete  blindness  in  the  other  has  the 
same  significance,  but  also  implies  that  the  process  has  extended 
laterally,  possibly  even  to  the  optic  tract.    Lateral  homonymous  hemian- 


DISEASES  OF   CRANIAL  XERVES  1149 

opsia  indicates  disease  of  the  optic  tract  between  the  chiasm  and  cuneus. 
If  the  geniculate  (or  quadrigeminate)  bodies  are  the  seat  of  the  lesion, 
Wernicke's  liemianopsic  pupillary  reaction  is  obtained,  because  the 
pupil  reflex,  while  not  at  present  perfectly  understood,  implies  that  the 
retina,  the  optic  nerve,  the  centre  and  fibers  of  the  tliird  nerve  and  the 
iris  are  intact.  A  small  beam  of  light  in  a  dark  room  should  be  thrown 
on  the  hemianopsic  half  of  the  retina,  and  the  patient  should  look  at  a 
distance  to  eliminate  accommodation.  If  the  pupil  does  not  react  to 
light  on  the  blind  half,  Wernicke's  reaction  indicates  that  the  disease 
focus  lies  at  or  somewhere  to  one  side  of  the  geniculate  (or  quadrigem- 
inate) bodies.  If  the  lesion  lies  between  these  gray  ganglia  and  the 
cortex,  the  reaction  of  Wernicke  is  absent.  Transient  hemianopsia  is 
common  in  vascular  lesions ;  if  it  lasts  for  weeks  it  will  probably  remain. 
In  Sequin's  case  it  was  present  for  twenty-three  years.  It  may  occur  in 
migraine  and  very  rarely  in  hysteria.  Its  association  with  the  crus, 
internal  capsule  or  cortex  symptoms  which  have  been  already  con- 
sidered is  of  localizing  importance.  Amblyopia  and  concentric  limitation 
in  the  fields,  marked  in  one  eye  and  less  in  the  other,  may  result  from 
(a)  optic  atrophy,  with  the  absent  pupillary  reaction,  and  seen  with 
the  ophthalmoscope;  (6)  disease  of  one  hemisphere,  the  ophthalmo- 
scopic finding  and  pupillary  reflex  being  normal,  (or  (c)  possibly 
functional  disease). 

Functional  and  toxic  blindness  may  result,  (a)  Hysterical  blindness 
is  transitory,  and  is  rarely  complete  (it  is  clear  that  the  eye  functionates 
normally  though  the  visual  centre  neglects  the  impressions) ;  it  is  often 
associated  with  loss  or  inversion  of  the  color  perception  and  often  with 
hemianeesthesia.  (b)  In  amblyopia  from  tobacco,  vision  is  gradually 
impaired  in  both  eyes,  largely  as  central  scotoma  with  invariable  loss  of 
perception  for  red  and  green  colors ;  the  fundus  is  usually  normal  but 
sometimes  congested;  recovery  is  usual,  but  atrophy  may  result,  (c) 
Toxic  amaurosis,  usually  transitory,  may  occur  from  uraemia,  poisoning 
by  lead,  alcohol,  or  quinine,  syphilis,  acute  anaemia,  and  irritation  of 
the  fifth  nerve. 

Ocular  Paralysis;  Third,  Fourth  and  Sixth  Nerves. — General  Etiol- 
ogy.— (a)  Trauma  to  the  eye,  orbit  or  base  may  cause  ocular  paralysis; 
it  is  characterized  by  a  slow  course  and  often  imperfect  recovery.  (6) 
Coinpression  by  tumors  in  the  orbit  which  often  produce  exophthalmos; 
tumors  at  the  base,  aneurysm,  and  rarely  hemorrhage  into  the  nerve 
sheath  may  produce  it.  (c)  Neuritis  produced  by  the  above  factors, 
orbital  cellulitis,  meningitis,  syphilis,  cavernous  thrombosis,  alco- 
holism, and  rheumatism,  which  is  made  to  cover  many  obscure  cases, 
may  be  etiological  factors.  Neuritis  may  also  result  from  acute  infec- 
tions, as  diphtheria;  exophthalmic  goitre,  plumbism  and  diabetes  are 
rarer  causes,  {d)  Nuclear  disease  is  usually  due  to  chronic  wasting 
disease,  as  in  tabes,  multiple  sclerosis  or  bulbar  palsy,  but  it  is  some- 
times acute  from  polio-encephalitis  or  vascular  lesions,  (e)  Supra- 
nuclear disease  (v.  i.  Conjugate  Deviation)  may  be  a  cause.  (/)  In 
rare  cases  there  is  a  myopathic  form,  as  in  muscular  dystrophies. 


1150  DISEASES  OF  THE  XERVOUS  SYSTEM 

Anatomy  and  Physiology  of  the  Motor  Nerves  of  the  Eye.— The  nerve 
supply  is  by  the  sympathetic  (which  through  the  cihary  ganghon  dilates 
the  pupil)  and  by  the  third,  fourth  and  sixth  cranial  pairs,  which  arise 
from  the  middle  ventricle.  Sylvian  aqueduct  and  fourth  ventricle,  and  are 
arranged  as  follows  from  before  backward:  (a)  the  third  nerve  nucleus 
with  first  the  ciliary  and  behind  it  the  pupillary  centre,  then  its  muscles 
in  this  order:  the  internal  rectus,  levator  palpeb.  superior,  inferior 
rectus  and  inferior  oblique;  (6)  fourth  nerve  nucleus  for  the  superior 
oblique,  lying  close  to  the  third  nucleus,  and  (c)  nucleus  of  the  sixth 
nerve  for  the  ext.  rectus.  Their  connection  with  the  motor  cortex 
(and  possibly  with  the  occipital  and  parietal  lobes)  is  through  the 
internal  capsule  and  corona  radiata.  The  third  nucleus  is  connected 
with  the  seventh;  winking  and  movements  of  the  eyelid  are  thus 
associated  with  the  pupil  reaction  and  accommodation.  The  action  of 
the  various  muscles  is  indicated  by  their  names  but  convergence  is 
supplemented  by  the  sup.  and  inf.  recti  and  the  two  oblique  muscles. 
The  inf.  oblique  turns  the  eye  upward,  the  sup.  oblique  downward. 
The  upper  lid  is  raised  by  the  levator  palp.  sup.  (acting  usually  with  the 
sup.  rectus)  and  by  Miiller's  muscle. 

Paralysis  of  the  Third  Nerve. — This  nerve  emerges  from  the 
crus  and  follows  the  cavernous  sinus,  and  therefore  may  be  involved  in 
disease  of  these  structures.  A  complete  paralysis  involves  all  muscles 
save  the  external  rectus  and  sup.  oblique,  and  results  in  drooping  of  the 
lid  (ptosis),  which  the  patient  attempts  to  overcome  by  overaction  of 
the  frontalis.  The  eye  can  be  moved  only  outward  and  a  little  down 
and  inward.  Accommodation  is  lost,  the  pupil  is  wide  from  the  un- 
opposed action  of  the  sympathetic  nerve  and  does  not  react  to  light. 
There  is  double  vision  from  divergent  strahismus,  due  to  action  of  the 
unrestrained  ext.  rectus  muscle.  Paralysis  is  often  partial,  for  the 
levator  palp.  sup.  may  escape  involvement  or  be  affected  alone  or  with 
its  associate  (the  sup.  rectus),  especially  in  bilateral  nuclear  disease. 
Ptosis  may  be  (o)  part  of  an  ordinary  oculomotor  palsy;  (b)  part  of 
a  chronic  ophthalmoplegia  (v.  i.);  (c)  reflex  in  rare  cases  of  trigeminal 
irritation  as  from  disease  of  the  teeth;  (d)  myopathic  as  in  muscular 
dystrophy;  (e)  a  result  of  sympathetic  paralysis,  false  or  pseudo- 
ptosis (with  a  red,  hot,  oedematous  skin,  slight  recession  of  the  eyeball, 
and  contracted  pupil);  (/)  an  incurable  congenital  form,  usually 
partial  and  bilateral;  (g)  a  transient  form,  observed  in  the  morning  in 
women,  in  which  there  is  usually  a  good  prognosis;  (h)  an  hysterical 
form,  usually  bilateral,  in  various  associations  with  the  sup.  rectus, 
inf.  or  int.  rectus,  the  eyebrow  being  frequently  lower  on  the  side  of 
ptosis. 

Internal  oculomotor  palsy  includes  cycloplegia  and  iridoplegia.  (a) 
Cycloplegia  (paralysis  of  the  ciliary  muscle)  results  in  loss  of  accommo- 
dation. Near  vision  is  poor;  distant  vision  is  good;  extreme  myopia 
or  presbyopia  make  its  detection  difficult.  Isolated  cycloplegia  in  one 
eye  may  indicate  disease  of  the  lenticular  ganglion,  in  both  eyes  it  is 
nuclear,  as  in  diphtheria  or  tabes,     (b)  Iridoplegia  may  assume  three 


DISEASES  OF  CR AXIAL  XERVES  1151 

forms  (Gowers).  The  first  is  loss  of  associated  action,  accommodation 
iridoplegia,  in  which  there  is  no  pupillary  narrowing  in  the  act  of 
accommodation.  It  is  due  to  the  same  causes  as  cycloplegia  and  is 
usually  but  not  always  associated  with  it.  The  second  is  loss  of  the 
light  reflex,  reflex  iridoplegia,  the  Argyll-Robertson  pupil,  which  is 
seen  especially  in  tabes  and  paretic  dementia  (very  seldom  in  softening, 
tumors,  senile  atrophy,  hydrocephalus  or  congenitally).  The  reflex 
occurs  through  the  optic  nerve,  optic  tracts,  corp.  quadrigemina  or 
Corp.  geniculata,  anterior  part  of  the  oculomotor  nucleus,  probably 
the  second  branch  of  origin  of  the  third  nerve,  its  trunk,  the  ciliary 
ganglion,  and  its  nerves.  The  pupils  are  often  equally  affected  and  small 
(spinal  myosis)  but  may  be  unequal  (aniscoria,  which  is  also  observed  in 
some  normal  persons).  If  the  pupils  are  not  small,  cutaneous  iridoplegia 
is  not  present.  The  third  form  is  loss  of  the  skin  reflex,  the  cutaneous 
iridoplegia  of  Erb,  in  which  the  normal  dilatation  of  the  pupil  upon 
pinching,  sticking  or  faradizing  the  skin  of  the  neck  is  lost.  It  indicates, 
in  general  terms,  disease  in  the  cervical  sympathetic  nerve,  in  the  fibers 
between  it  and  the  cervical  cord,  diseases  of  the  cord,  especially  those 
affecting  sensation,  or  of  the  centre,  probably  situated  in  the  corp.  quad- 
rigemina just  outside  the  light  reflex  centre  in  the  trunks  of  the  first 
and  third  nerves.  The  seat  of  lesion  is  probably  nuclear,  unless  special 
localizing  symptoms  indicate  some  other  localization.  Specifically  it  is 
characteristic  of  tabes,  paretic  dementia  or  syphilis. 

Recurrent  or  periodic  palsy,  to  which  Gubler  (1860)  and  Mobius 
particularly  drew  attention,  is  a  rare  form,  involving  chiefly  most  (or 
possibly  only  one  branch)  of  the  third  nerve,  and  rarely  the  sixth  nerve. 
It  occurs  chiefly  in  women.  At  intervals  of  months  to  years,  possibly 
throughout  life,  a  recurring  paralysis  develops,  lasts  a  few  days  (two 
to  fourteen)  or  weeks  and  then  disappears.  Forms  which  begin  with 
headache,  pain  and  vomiting  were  called  ophthalmoplegic  migraine  by 
Charcot.  Its  nature  is  unknown.  It  is  probably  peripheral  in  form 
(Mauthner),  although  Mobius  thinks  it  is  nuclear;  von  jNIonakow 
considers  that  its  usual  cause  is  organic,  as  from  tumor,  meningitis  or 
tubercle;  the  lesion  affects  the  eye  nerves  (or  centres)  and  also  the 
descending  branch  of  the  fifth  nerve;  some  few  cases  are  seemingly 
hysterical. 

Paralysis  of  the  Fourth  (Trochlear)  Nerve. — The  superior 
oblique  muscle  moves  the  eye  downward  and  somewhat  inward.  Its 
paralysis  is  hard  to  recognize,  but  it  is  of  little  clinical  importance.  In 
attempts  to  converge  downward  the  normal  inward  rotation  of  the 
eyeball  is  lacking. 

Paralysis  of  the  Sixth  Nerve. — The  eye  cannot  be  moved  out- 
ward, and  is  rotated  inward  by  the  unopposed  internal  rectus,  marked 
diplopia  resulting.  This  nerve  is  frequently  involved,  because  of  its  long 
and  exposed  course.  The  nerves  of  the  eye  are  involved  in  the  following 
order  of  frequency:  1,  ext.  rectus;  2,  sup.  oblique;  3,  inf.  rectus;  4, 
sup.  rectus;  5,  int.  rectus;  6,  inf.  oblique  (von  Graefe). 

Combined    Eye    Paralysis. — Convergence    and    accommodation 


1152  ,  DISEASES  OF  THE  NERVOUS  SYSTEM 

are  associated  functionally  and  their  centres  lie  adjacent,  whence  they 
are  often  lost  together.  The  internal  recti  may  fail  to  contract  together 
but  may  move  separately  in  lateral  eye  movements.  Conjugate  devi- 
ation vasuj  occur  (see  Brain  Hemorrhage  and  Pons  Localization); 
if  a  lesion  occur  above  the  sixth  nucleus,  the  eyes  cannot  be  directed 
toward  the  side  of  lesion,  and  are,  therefore,  directed  toward 
the  paralyzed  side;  if  the  lesion  is  at  the  sixth  nucleus,  the 
sixth  nerve  on  that  side  is  paralyzed,  often  also  the  seventh,  and  the 
opposite  third  nerve  is  paralyzed,  not  from  lesion  in  the  third  nucleus 
but  from  the  fact  that  each  third  nucleus  receives  afferent  impulses 
from  the  contralateral  sixth  nucleus  for  associated  eye  movements. 

Symptoms. — ^The  general  symptoms  of  paralysis  of  the  eye  Tnuscles 
are  five  (Gowers): 

1.  Limitation  of  movement  in  the  paralyzed  muscle,  followed  by 
secondary  contraction  of  the  unresisted  opponent.  The  habitual 
position  of  the  head  corresponds  in  every  way  to  the  physiological 
action  of  the  paralyzed  muscle  (Landholt). 

2.  Strabismus  (squint),  causing  lack  of  parallelism  in  the  visual 
axes,  which  are  divergent  when  the  int.  rectus  and  convergent  when  the 
ext.  rectus  is  affected;   this  constitutes  the  primary  deviation. 

3.  Secondary  deviation  is  the  extra  movement  of  the  sound  eye  in 
its  efforts  to  see,  due  to  its  increased  innervation,  detected  by  testing 
with  the  diseased  eye  closed,  or  by  testing  with  ground  glass  over  the 
sound  one. 

4.  Erroneous  projection  in  the  paralyzed  eye.  Distance  is  normally 
judged  by  the  position  of  the  eyeballs  and  muscles,  and  therefore  when 
secondary  deviation  from  excessive  innervation  of  the  sound  muscles 
occurs,  it  gives  the  mind  an  impression  of  distance  greater  than  is 
actually  the  case. 

5.  Diplopia  (double  vision)  results  from  failure  of  the  visual  axes 
to  correspond.  The  sound  eye  sees  the  true  image,  while  the  paralyzed 
eye  sees  the  false  one,  which  is  less  clear,  since  the  image  falls  on  a  less 
sensitive  retinal  area.  When  the  images  are  either  near  together  or  else 
widely  separated,  the  false  one  may  be  "neglected."  Erroneous  pro- 
jection and  diplopia  always  produce  vertigo  at  first.  If  the  false  image 
is  on  the  same  side  of  the  true  image  as  the  eye  by  which  it  is  seen,  the 
diplopia  is  simple  or  homonymous;  if  on  the  other  side,  it  is  crossed  or 
heteronymous.  The  eyes  are  tested  by  holding  red  glass  before  one  eye 
and  testing  vision  with  a  strip  of  white  paper.  If  the  red  image  and 
covered  eye  are  on  the  same  side  the  diplopia  is  simple ;  if  on  opposite 
sides,  it  is  crossed.  When  the  eyes  converge  it  is  simple,  when  they 
diverge  it  is  crossed;  i.e.,  "when  the  prolonged  visual  axes  cross,  the 
diplopia  is  not  crossed."  Holding  the  test  object  stationary  and  the 
head  being  turned  in  one  way  or  another,  in  some  directions  the  images 
converge  or  perhaps  blend,  while  in  the  opposite  direction  they  separate. 
"The  affected  eye  is  that  one  in  the  direction  of  whose  image  the  diplo- 
pia increases;  the  paralyzed  muscle  is  the  one  which  would  give  to 
the  eye  the  direction  of  the  false  image"   (Landholt).     Monocular 


DISEASES   OF   CR AXIAL   XERVES  1153 

diplopia  is  almost  invariably  hysterical  (unless  there  is  disease  of  the 
eye  media  or  error  in  curvature). 

Treatment. — Treatment  is  often  unsatisfactory  from  the  etiologi- 
cal standpoint.  Surgical  interference  is  sometimes  indicated.  Syphi- 
htic  forms  (q.  v.)  may  respond  to  specific  treatment,  but  often  recur  or 
become  permanent.  In  subacute  or  acute  forms,  counterirritation  back 
of  the  ear  by  blisters,  leeches  or  hot  fomentations  is  indicated.  Some 
find  mercury  useful  in  peripheral  forms.  Galvanism  is  the  best  form  of 
electrotherapy,  but  may  be  painful  and  is  seldom  beneficial.  Prisms 
and  tenotomy  are  sometimes  helpful. 

Progressive  Nuclear  Ophthalmoplegia  (Nuclear  Palsy). — This 
disease  was  first  described  clinically  by  von  Graefe  (1856)  and  later 
pathologically  by  Hutchinson  and  Gowers.  The  etiology  is  not  clear. 
Wernicke  and  Siemerling  found  syphilis  causal  in  17  per  cent.,  which 
estimate  is  too  low  according  to  Hutchinson.  Lead,  alcohol,  and 
toxaemia  as  from  diabetes,  grippe,  or  diphtheria,  are  possible  causes. 
A  few  cases  are  hereditary  or  congenital.  Most  cases  develop  in  males 
under  thirty  years  of  age.  The  pathology  usually  consists  of  degener- 
ative nuclear  atrophy  resembling  that  of  bulbar  paralysis;  sometimes 
slow  compression  or  meningitis  is  found  or  much  more  rarely  no 
anatomical  alteration  is  detected;  this  is  the  so-called  functional  form. 

Symptoms. — The  symptoms  are  those  of  a  slowly  progressive  par- 
alysis of  the  eye  muscles;  ophthalmoplegia  is  called  external  when  it 
involves  the  extrinsic  muscles,  internal  when  it  involves  the  pupil,  or 
total  when  both  are  concerned.  The  eye  muscles  are  successively 
affected,  but  in  no  given  or  invariable  order,  until  many  or  all  of  them 
are  implicated.  The  expression,  the  fades  of  Hutchinson,  is  peculiar, 
being  staring,  from  immobility  of  the  eyeballs,  or  sleepy  from  the  partial 
bilateral  ptosis.  Diplopia  is  quite  uncommon,  or  at  the  most  only 
an  early  symptom,  because  of  the  chronicity  of  the  process.  Associated 
muscles  are  often  affected  by  groups,  because  of  their  successive 
nuclear  involvement  (v.  s.  Anatomy)  ;  as  the  pupil  and  convergence,  one 
internal  and  the  opposite  external  rectus,  the  two  internal  recti,  and  the 
sup.  rectus  and  the  levator.  Chronic  ophthalmoplegia  may  be  associ- 
ated with  the  quite  analogous  bulbar  paralysis  or  progressive  spinal 
muscular  atrophy;  with  optic  atrophy  or  with  double  facial  paralysis 
(the  rare  and  obscure  infantile  or  congenital  oculofacial  paralysis, 
without  pupillary  involvement,  of  which  Mobius  has  collected  44 
cases) ;  it  may  be  a  part  or  a  precursor  of  tabes,  paralytic  dementia,  or 
multiple  sclerosis. 

Diagnosis. — -Nuclear  involvement  is  probable  when  there  is  (a) 
partial  and  bilateral  ptosis;  (6)  no  involvement  of  the  pupil;  or  (c) 
involvement  of  one  or  more  conjugate  groups.  The  lesion  may  be 
supranuclear,  when  the  head  and  limbs  are  involved,  exceptionally 
when  there  is  isolated  convergence  paralysis  or  paralysis  of  up-and- 
down  movements  with  ptosis.  Sudden  apoplectiform  nuclear  palsy 
from  basilar  thrombosis  is  usually  asymmetrical,   acute   and  often 

73 


1154  DISEASES  OF  THE  XERVOUS  SYSTEM 

associated  with  hemiplegia.  Wernicke's  acute  superior  poliencephal- 
itis  is  likewise  distinguished  by  its  acuity,  and  toxaemic  symptoms  as 
delirium.  Total  or  partial  ophthalmoplegia  may  result  from  syphilitic 
meningitis,  polyneuritis,  tumors  (corp.  quadrigem.)  or  orbital  disease, 
but  they  are  generally  distinguished  by  their  relatively  acute  course 
and  concomitant  symptoms. 

Prognosis. — ^The  disease  is  very  chronic,  possibly  lasting  twenty  to 
forty  years  and  is  usually  progressive.  Arrest  is  possible,  but  can  never 
be  predicted.  The  disease  itself  causes  little  risk  to  life,  but  its  as- 
sociates are  dangerous,  as  tabes  or  psychoses,  which  develop  in  18  per 
cent. 

Treatment. — Treatment  is  generally  ineffectual.  Iodides  and  mer- 
cury are  useless  in  nuclear  disease,  but  may  be  given  if  the  localization 
is  not  definitely  known.  Strychnia  and  galvanism  usually  produce  little 
result. 

Sympathetic  Paralysis. — This  disease  was  first  described  by  Horner; 
it  produces  myosis,  which  is  due  to  paralysis  of  the  dilator  iridis, 
and  slight  ptosis,  due  to  paresis  of  Miiller's  muscle.  The  ocular 
tension  is  decreased,  the  cheek  is  wasted,  and  the  skin  is  reddened  and 
of  higher  temperature  than  normal.  Irritation  of  the  sympathetic  is 
characterized  by  wide  pupils,  widening  of  the  interpalpebral  space 
and  by  exophthalmos. 

Ocular  muscular  spasms  occur  in  conjugate  deviation,  irritation  of 
their  nerve  trunks  when  compressed  by  tumor,  and  rarely  in  chorea, 
facial  tic,  and  spasmodic  torticollis.  In  hysteria  the  eyes  may  be  rolled 
upward  and  to  one  side,  concealing  the  iris,  or  they  are  often  fixed  in 
convergence;  they  never  diverge;  there  may  appear  to  be  ptosis,  which 
is  really  spasm  of  the  orbicularis.  Convergent  spasm  may  also  occur  in 
hypermetropia,  and  divergent  spasm  in  myopia.  Isolated  spasm  of  the 
levator  palpebrse  may  occur  in  irritation  of  the  cervical  sympathetic 
nerve,  in  advanced  years,  in  Graves'  disease,  and  in  irritation  of  the 
fifth  nerve.  Secondary  deviation  {v.  s.)  is  spasmodic,  as  is  also  nystag- 
mus, which  latter  consists  of  rapid,  rhythmic,  clonic,  involuntary 
oscillations,  due  to  muscular  spasm  with  alternating  contraction  of  the 
opposing  muscles.  It  is  continuous,  as  distinguished  from  the  "tremor 
of  weakness"  which  occurs  in  paretic  muscles  on  movement.  It  is 
usually  horizontal,  less  often  rotatory  and  but  rarely  vertical.  Its 
physiology  is  not  understood,  but  it  is  probably  centric.  The  causes 
are  (a)  disease  of  the  eye,  as  opacities  and  choroiditis;  (6)  it  occurs 
very  frequently  in  albinos,  and  (c)  in  miners,  from  working  with  the 
head  down  and  eyes  strained  to  one  side,  {d)  It  also  occurs  in  numer- 
ous, usually  degenerative  nervous  diseases;  as  a  cardinal  sign  in 
multiple  sclerosis  and  Friedreich's  ataxia,  as  a  common  sign  in  tumor 
of  the  cerebellum,  corp.  quadrigem.  and  opt.  thalamus,  occasionally 
in  meningeal  inflammation  or  hemorrhage,  sinus  thrombosis,  brain 
hemorrhage  or  softening,  and  very  rarely  in  hysteria. 


DISEASES  OF  CR AXIAL  XERVES  1155 

Fifth  Nerve  (Trigeminus;  Trifacial  Nerve). — The  nerve  originates 
from  its  motor  nucleus  in  the  pons,  from  fibers  (wliich  are  probably 
motor)  descending  from  beneath  the  corpora  quadrigemina,  and  from 
sensory  fibers  ascending  from  the  medulla.  It  is  connected  with  the 
motor  cortex  and  with  the  cerebellum.  The  motor  and  sensory  fibers 
leave  the  pons  separately  and  join  only  after  the  sensory  trunk  has 
passed  through  the  Gasserian  ganglion.  The  Gasserian  ganglion  has 
three  branches;  (1)  which  passes  to  the  orbit  by  the  sphenoidal  fissure, 
supplying  the  skin  of  the  forehead,  anterior  scalp,  upper  lid,  bridge,  and 
top  of  the  nose;  it  is  connected  with  the  cervical  sympathetic  nerve; 
(2)  which  passes  by  the  foramen  ovale  to  the  sphenomaxillary  fossa  to 
supply  the  upper  and  lower  lid,  cheek,  fore  part  of  the  temples,  side  of 
the  nose,  upper  teeth,  gums,  pharynx,  tonsils,  soft  palate,  uvula  and 
roof  of  the  mouth;  it  has  connections  with  the  facial  nerve  by  the 
Vidian,  and  with  the  sympathetic  nerve;  (3)  which  passes  by  the  fora- 
men rotundum  and  sphenomaxillary  fossa  to  the  rest  of  the  temples, 
anterior  and  upper  part  of  the  ear,  auditory  meatus,  lower  cheek  near 
the  mouth,  lower  lip,  lower  teeth,  gums,  chin,  tongue,  mucosa  of  the 
mouth,  salivarv  glands,  and  as  a  motor  nerve  to  the  muscles  of  the 
lower  jaw,  temporals,  masseters,  pterygoids,  mylohyoids,  and  post, 
belly  of  the  digastric  muscle.  The  lingual  branch  gives  off  the  chorda 
tympani  which  joins  the  facial  nerve.  From  the  otic  ganglion  arises  the 
small  superficial  petrosal  nerve  which  connects  with  the  facial  nerve  and 
ends  in  the  tympanic  branches  of  the  glossopharyngeal  nerve. 

Causes  of  Paralysis. ^(a)  Lesions  of  the  cortex  may  produce  it  in 
very  rare  cases.  (6)  Focal  disease  in  the  pons,  especially  of  the  nerve- 
root  fibers,  as  hemorrhage,  and  tumors  may  cause  it  and  much  less 
often  degenerative  lesions  as  tabes  or  bulbar  paralysis,  (c)  It  may 
result  from  diseases  of  the  base,  as  syphilis,  meningitis,  tumors,  caries 
or  aneurysms,  (d)  Affections  involving  any  of  the  three  branches,  as  of 
the  first  branch  by  cavernous  thrombosis,  pituitary  tumor,  aneurysm 
or  orbital  disease,  or  of  the  second  and  third  branches  by  lesions  in  the 
sphenomaxillary  fossa  may  cause  paralysis,  {e)  Trauma,  puncture  or 
bullet  wounds,  but  rarely  fractures,  and  (/)  infrequently  neuritis,  un- 
less it  is  secondary,  are  causal. 

Symptoms. — 1.  Sensory  Portion. — Anaesthesia,  which  is  gener- 
ally unilateral,  is  found  in  one  or  all  branches,  and  tactile  sensation  is 
more  involved  than  the  sense  of  pain.  It  is  often  preceded  by  tender- 
ness along  the  nerves,  irritation  or  neuralgia.  In  complete  cases,  the 
skin  and  mucosa  of  the  mouth,  nose  and  conjunctiva  are  ansesthetic. 
The  tongue  is  furred  on  its  anesthetic  half,  because  the  food  is  not 
chewed  on  that  side.  The  conjunctival  reflex  is  abolished.  The 
secretions  are  increased  by  irritation  or  decreased  by  paralysis.  Smell 
is  blunted,  and  taste  (v.  ?'.)  is  lost.  Sometimes  there  is  redness,  cyanosis 
or  swelling  of  the  face,  or  the  teeth  may  be  loosened.  Two  trophic 
manifestations  are  especially  important.  The  first  is  neuroparalytic 
ophthalmia,  which  may  run  beyond  simple  inflammation  of  the  eye  into 
ulceration  or  complete  loss  of  the  bulb;    it  is  due  not  simply  to  con- 


1156  DISEASES  OF  THE  XERVOUS  SYSTEM 

junctival  ansestliesia,  which  may  lead  to  mflammation  because  of  for- 
eign particles  remaining  unnoticed  in  the  eye,  but  is  rather  due  to 
irritation  of  the  fifth  nerve,  especially  of  the  Gasserian  ganglion  or 
nerve  trunks  anterior  to  it.  (It  has  not  occurred,  however,  in  many 
cases  in  which  the  ganglion  has  been  surgically  removed.)  It  is  rare  in 
lesions  of  the  pons.  The  second  is  herpes  zoster,  which  is  most  common 
in  disease  of  the  first  branch,  results  from  irritation  of  the  Gasserian 
ganglion  or  the  nerves  just  anterior  to  it,  is  often  preceded  by  pain  and 
hyperesthesia,  and  sometimes  leads  to  iritis  or  ophthalmitis.  The 
relation  of  trigeminal  disease  to  hemifacial  atrophy  will  be  considered 
below,  under  the  latter  head. 

2.  Motor  Portion. — Placing  the  fingers  on  the  temporal  and 
masseter  muscles,  when  the  patient  attempts  to  close  the  teeth,  reveals 
their  failure  to  contract.  Paralysis  of  the  ext.  pterygoid  is  shown  (a) 
by  failure  to  move  the  jaw  toward  the  sound  side  and  (6)  by  deviation 
toward  the  paralyzed  side,  when  the  jaw  is  depressed.  The  muscles 
waste,  but  they  are  rather  too  deep  to  distinctly  elicit  the  reaction  of 
degeneration.  The  mylohyoid  and  digastric  muscles  cannot  be  sepa- 
rately tested  and  the  role  of  the  tensor  tympani  and  tensor  palati 
in  trigeminal  paralysis  is  still  in  dispute. 

3.  Gustatory  Portion. — The  sense  of  taste  covers  only  bitter, 
sweet,  sour,  salty  and  metallic  substances,  while  flavors  are  recognized  by 
the  olfactory  nerve.  The  tip  and  edges  of  the  tongue  detect  saltiness  or 
sourness;  the  base  of  the  tongue,  bitterness  and  sweetness.  It  is  often 
stated  that  the  fifth  nerve  supplies  the  anterior  two-thirds  of  the  tongue 
and  the  glossopharyngeal  nerve  the  posterior  third  and  the  palate; 
but  disease  of  the  glossopharyngeal  nerve  alone  does  not  destroy  the 
sense  of  taste.  In  a  study  of  26  cases  of  extirpation  of  the  Gasserian 
ganglion.  Gushing  decides  that  taste  is  only  temporarily  lost  and  that  it 
does  not  travel  by  the  fifth  nerve.  Disease  of  the  hngual  nerve  (from 
the  fifth),  after  the  chorda  tympani  joins  it,  produces  loss  of  taste 
(ageiLsia);  disease  of  the  lingual  above  the  juncture  or  disease  of  the 
central  part  of  the  fifth  in  the  pons  does  not  result  in  loss  of  taste.  It  is 
thought  that  the  gustatory  fibers  of  the  fifth  run  with  the  chorda  to  the 
seventh  nerve  which  they  leave  by  the  petrosal  nerve  to  again  reach  the 
fifth  through  Meckel's  ganglion.  It  is  interesting  to  note  that  anses- 
thesia  of  the  tongue  may  result  from  facial  neuritis  and  disease  of  the 
middle  ear. 

Diagnosis. — The  diagnosis  is  usually  easy  when  there  are  symptoms 
in  the  motor  or  sensory  nerves.  Organic  irritation  characterized  by 
pain  alone  may  be  diflScult  or  impossible  to  differentiate  from  trifacial 
neuralgia,  although  Gowers  holds  that  there  is  less  radiation  and  more 
hypersesthesia  in  organic  irritation.  The  localization  must  be  deter- 
nained.  When  all  branches  are  anaesthetic,  the  disease  probably  lies  at 
the  base  of  the  brain  or  in  the  Gasserian  ganglion.  In  disease  of  the 
middle  part  of  the  pons,  the  first  division  alone  may  be  affected;  in 
disease  at  its  side  all  divisions  are  involved,  often  with  implication  of 


DISEASES  OF   CRANIAL  NERVES  1157 

the  third  and  sixth,  or  less  often  of  the  seventh  and  eighth  nerves. 
Cortical  lesions  are  extremely  uncommon. 

Treatment.^— Counterirritation  over  the  occiput  or  mastoid  is  in- 
dicated by  an  inflammatory  causation,  but  no  irritatant  should  be 
applied  over  the  anaesthetic  areas  themselves,  lest  ulceration  occur. 
Galvanization  is  said  to  be  beneficial.  Gelsemium,  cocaine  and  mor- 
phine must  at  times  be  used  because  of  severe  pain,  but  the  acquisition 
of  drug  habits  must  always  be  borne  in  mind.  The  eye  should  always 
be  watched,  and  boric  acid  and  castor  oil  be  dropped  in  several  times 
daily.     Antisyphilitic  remedies  should  be  tried  in  every  doubtful  case. 

Masticatory  Spasm. — The  masticatory  spasm  of  Romberg  is  not 
common.  In  the  tonic  type  (trismus)  the  spasm  is  usually  bilateral, 
and  the  tense  muscles  are  hard  and  may  be  tender.  The  cause  may  be 
tetanus,  hysteria,  epilepsy,  tetany,  tumor  in  the  pons,  cortical  hemor- 
rhage, or  it  may  be  reflex  from  trigeminal  irritation  as  from  dental 
caries.  The  clonic  type  is  rare  and  may  be  serial  or  intermittent; 
chattering  of  the  teeth  is  an  example.  It  may  occur  in  chorea,  epilepsy 
or  hysteria.  Grinding  of  the  teeth  occurs  in  paretic  dementia,  menin- 
gitis or  typhoidal  states.  In  diagnosis,  tumor,  inflammatory  irri- 
tation and  disease  of  the  temporomaxillary  joint  must  be  considered. 
Treatment  consists  of  tonics  in  nervous  subjects,  galvanization,  blisters 
in  hysteria,  and  the  local  use  of  morphine  and  cocaine. 

Progressive  Hemifacial  Atrophy. — This  affection,  first  described 
by  Parry  (1825),  is  rare,  only  135  cases  having  been  reported  up  to 
1900.  Its  pathogenesis  is  not  clearly  understood,  but  it  is  classified 
under  disease  of  the  fifth  nerve  because  the  only  autopsy  on  record,  by 
Mendel,  showed  neuritis  of  the  ascending  root  of  the  fifth  nerve.  Mo- 
bius  holds  that  acute  infections,  as  measles  or  scarlatina,  are  causal, 
because  some  virus  enters  through  the  skin  or  tonsils  and  results  in 
atrophy.  The  essential  change  is  a  hemifacial  atrophy,  which  develops 
most  often  in  persons  between  ten  and  fifteen  years  of  age,  in  girls  (66 
per  cent.),  and  in  about  60  per  cent,  of  eases  affects  the  left  half  of  the 
face.  In  perhaps  a  half-dozen  cases  the  atrophy  was  bilateral.  There 
may  be  premonitory  pains,  hyper-  or  parsesthesias,  but  the  cardinal  sign 
is  atrophy  of  the  skin,  which  may  show  initial  infiltration.  The  skin  is 
decolorized  and  shrunken,  its  fat  disappears,  and  later  in  the  disease  the 
muscles  waste  and  the  rough  skin  lies  directly  on  the  bone.  The  hair  on 
the  affected  side  loses  its  pigment  and  may  fall  out,  the  eyebrows  and 
beard  especially,  sweat  secretion  is  lessened  or  absent,  and  the  mouth, 
if  involved,  is  drawn  toward  the  side  of  lesion.  The  bones  on  the 
affected  side  waste,  especially  in  young  subjects,  most  notably  the 
maxillae,  but  even  the  smaller  bones  and  nasal  cartilages  are  involved. 
On  the  wasted  side  there  may  be  no  vasomotor  reaction;  sensation  is 
usually  normal,  although  pain  or  para^sthesia  may  be  noted  in  the  dis- 
tribution of  the  trifacial  nerve.  The  tongue,  tonsils  and  palate  are 
rarely  involved.    The  course  is  very  chronic  and  practically  always  pro- 


1158  DISEASES  OF  THE  NERVOUS  SYSTEM 

gressive,  although  remission  is  possible.  The  outlook  is  hopeless  and 
there  is  no  treatment  other  than  administration  of  thyroid  extract  and 
the  injection  of  paraffin  by  the  Gersuny  method,  to  lessen  the  facial 
deformity. 

Hemifacial  hypertrophy,  of  which  13  cases  only  are  on  record,  affects- 
largely  the  cheek;  Werner  collected  9  congenital  cases.  Irritative 
neuritis  is  its  suspected  cause. 

Seventh  or  Facial  Nerve. — The  face  is  represented  in  the  lower 
Rolandic  cortex,  wdience  the  fibers  run  through  the  corona,  internal 
capsule,  crus  and  pons  (q.  v.),  where  they  decussate  and  enter  the 
nucleus  of  the  opposite  side.  The  nucleus  lies  in  the  floor  of  the  fourth 
ventricle  inside  of  the  ascending  branch  of  the  fifth  nerve  and  receives 
fibers  from  the  third  nucleus  above  for  the  orbicularis  of  the  eye  (where- 
by ocular  movements,  winking  and  accommodation  are  coordinated) 
and  fibers  from  the  hypoglossus  below  for  the  orbicularis  oris  (whereby 
correlation  of  lingual  and  labial  movements  is  effected).  It  curves 
around  the  sixth  nucleus,  emerging  near  the  juncture  of  the  pons  and 
medulla,  and  enters  the  auditory  meatus  with  the  eighth  nerve,  bends 
sharply,  and  presents  a  ganglionic  swelling  which  receives  the  large 
superficial  petrosal  from  the  Vidian  nerve,  containing  fibers  of  taste 
from  the  fifth  nerve.  These  latter  again  leave  the  facial  nerve  by  the 
chorda  tympani.  In  the  Fallopian  canal  the  facial  nerve  gives  off 
branches  as  follows :  (a)  a  motor  branch  to  the  tympanic  plexus;  (6) 
a  motor  twig  to  the  stapedius  muscle;  (c)  the  chorda  tympani  nerve  with 
secretory  branches  to  the  salivary  glands.  Passing  through  the  stylo- 
mastoid foramen,  it  supplies  (i)  a  few  sensory  branches  to  the  external 
ear;  (ii)  motor  fibers  to  the  external  auricular  muscles;  (iii)  motor 
fibers  to  the  posterior  part  of  the  occipitofrontalis,  and  in  the  parotid 
gland,  (iv)  breaks  up  into  branches  which  supply  all  the  muscles  of  the 
face,  the  platysma,  stylohyoid  and  post,  belly  of  the  digastric. 

Peripheral  facial  paralysis  (mimetic  facial  paralysis,  prosoplegia. 
Bell's  paralysis,  Bell,  1830)  is  the  most  frequent  peripheral  palsy. 

Etiology. — 1.  Neuritis  is  the  most  common  cause.  Exposure  to 
cold  ("refrigeration,"  "rheumatism")  produces  73  per  cent,  of  cases 
especially  in  men  between  the  twentieth  and  fortieth  years,  and  pro- 
duces a  perineuritis  w^hich  compresses  the  nerve  trunk.  Angina,  gout, 
diabetes,  diphtheria,  typhoid,  erysipelas,  mumps,  sepsis  and  other 
infections  are  occasional  causes. 

2,  Disease  of  the  petrous  portion  of  the  temporal  hone  (6  to  9  per 
cent.),  especially  caries  and  otitis  media  in  childhood,  may  cause  paraly- 
sis. The  danger  is  usually  proportionate  to  the  extent  of  the  bone 
disease,  but  infective  matter  may  reach  the  nerve  by  way  of  the  vessels. 
Eighty-three  per  cent,  of  cases  of  disease  of  the  labyrinth  cause  facial 
paralysis. 

3.  Trauma  causes  6  per  cent,  of  cases,  as  paralysis  which  results  from 
basal  fracture  by  tearing,  hemorrhage,  inflammation  or  undue  for- 
mation of  callus;  much  more  rarely  from  meningeal  or  cerebellar 
hemorrhage  at  birth;    from  the  use  of  obstetrical  forceps,  and  from 


DISEASES  OF  CRANIAL  NERVES  1159 

trauma  to  the  jaw  or  surgical  operations  on  the  parotid  gland.    Facial 
paralysis  may  occur  in  "head  tetanus"  (E.  Rose). 

4.  If  it  results  from  lesions  at  the  base,  it  may  be  due  to  syphilis  (3 
per  cent.),  which  should  always  be  considered  when  the  cause  is  intra- 
cranial; it  is  however,  less  common  than  the  usual  descriptions  would 
indicate;  syphilis  rarely  causes  a  peripheral  facial  paralysis.  Aneu- 
rysm, tumor,  meningitis  and  hemorrhage  are  next  in  frequency  and 
nearly  always  involve  simultaneously  the  closely  contiguous  eighth 
nerve. 

5.  In  the  pons,  the  root  fibers  or  nucleus  may  be  affected,  usually 
with  the  sixth  nerve  of  the  same,  or  the  arm  and  leg  of  the  opposite  side. 
Degenerative  affections,  as  tabes,  bulbar  paralysis,  multiple  sclerosis, 
and  progressive  muscular  atrophy  or  acute  poliencephalitis  rarely  invade 
the  seventh  nucleus. 

6.  Other  rarer  factors  are  primary  hemorrhage  into  the  Fallopian 
canal,  disease  of  the  parotid  or  lymphatic  glands,  and  leuksemic  in- 
filtration. It  is  suggested  by  Neumann  that  disease  of  the  lymph 
vessels  at  the  point  of  exit  of  the  facial  nerve  may  produce  paralysis. 

Pathology. — Few  autopsies  have  been  made  on  simple  cases.  The 
nerve  has  been  found  severed,  its  sheath  and  cylinders  destroyed,  the 
nuclei  in  Schwann's  sheath  increased,  the  connective  tissue  increased 
and  the  muscles  the  seat  of  fatty  change.  It  is  thought  that  the  essen- 
tial and  usual  change  is  a  perineuritis  and  that  the  exudation  in  the 
sheath  compresses  the  nerve  fibers,  which  then  undergo  parenchy- 
matous degeneration.  In  some  cases  degeneration  only  has  been  seen, 
and  it  is  probable  that  slight  swelling  interferes  with  conduction.  Facial 
neuritis  differs  from  multiple  neuritis  in  that  alcoholism  is  a  subordinate 
factor  and  the  chief  change  is  not  in  its  peripheral  twigs  but  in  the  trunk, 
usually  within  the  Fallopian  canal. 

Symptoms. —  The  symptoms  sometimes  begin  with  prodromes  as 
vertigo,  headache,  tinnitus,  pain  or  more  often  twitchings  in  the  face, 
even  fever  or  albuminuria,  or  sometimes  without  prodromes,  in  which 
cases  one  half  of  the  face  is  rather  suddenly  paralyzed  and  becomes 
"completely  immobile  and  torieless"  within  two  days.  The  forehead  is 
smooth,  the  lids  cannot  close  (lagophthalmos),  the  tears  run  over  the 
cheek,  and  when  a  strong  effort  is  made  to  close  the  eyes,  the  eye  on 
the  affected  side  is  turned  upward  by  the  inf.  oblique  muscle  (Bell's 
sign).  The  orbicularis  at  times  escapes  involvement,  since  it  receives 
some  fibers  from  the  third  nerve.  Smell  is  impaired  because  of  absence 
of  tears,  the  nasal  aperture  is  smaller  and  cannot  be  dilated,  sniffing  on 
the  affected  side  is  impossible,  and  the  nasolabial  furrow  is  lost.  The 
mouth  is  lower  from  paralysis  of  the  levator  anguli  oris,  it  cannot  be 
closed,  and  the  saliva  runs  out,  although  its  total  secretion  is  often 
lessened  (v.i.).  Labial  enunciation  is  imperfect,  puckering  the  lips,  as 
though  for  whistling,  is  impossible,  and  expectoration  is  impaired.  The 
loss  of  wrinkles  and  expression  on  the  affected  side  is  more  marked  in 
adult  and  aged  than  in  young  subjects,  especially  about  the  eye,  since 
years  lessen  the  elasticity  of  the  skin  and  the  subcutaneous  fat.     Chew- 


1160 


DISEASES  OF  THE  NERVOUS  SYSTEM 


ing  is  impaired  by  weakness  of  the  buccinator,  and  food  accumulates 
between  the  teeth  and  the  cheek.  The  unused  half  of  the  tongue  be- 
comes furred.  The  tongue  does  not  (but  may  seem  to)  deviate  on 
protrusion  on  account  of  asymmetry  of  the  mouth.  The  tongue  is  some- 
times slightly  depressed  from  weakness  of  the  stylohyoid  and  digastric 
muscles.  The  platysma  paralysis  is  elicited  by  asking  the  patient  to 
depress  the  lower  lip.  The  palate  is  sometimes  described  as  sagging, 
the  speech  as  nasal,  the  uvula  as  deviating  towards  the  sound  side,  but 
the  uvula  and  palate  are  often  asymmetrical  in  health  and  there  is  a 
growing  tendency  to  regard  the  spinal  accessory  as  the  motor  nerve 
for  these  structures  (Gowers,  Jackson). 

Taste  is  lost  in  disease  of  the  nerve  between  the  geniculate  ganglion 
and  the  offset  of  the  chorda;  it  is  lost  in  half  the  cases  of  "exposure" 
neuritis;  it  is  not  impaired  in  disease  of  the  pons  or  in  disease  outside 


Fig.  78. 
root  facialis 

ROOT  ACOUSTICUS 

LATE  GANGLION 


DIAC-ASTRIC  NERVE 
STYLOHYOID 


>°S  TO  FACE 
^"D  PLATYSMA. 

Relations  of  the  fifth  and  seventh  nerves  and  branches  of  the  seventh. 

the  skull  (see  Diagram).  The  chorda  supplies  the  anterior  two-thirds 
of  the  tongue  and  the  glossopharyngeal  the  posterior  third.  Perverted 
taste  (parageusia)  results  from  irritation  of  Jacobson's  nerve  or  the 
tympanic  plexus.  Hearing  may  be  impaired.  Deafness  and  tinnitus 
result  mostly  from  coincident  disease  of  the  ear.  When  the  stapedius 
is  paralyzed,  the  unopposed  tensor  tympani  (which  arises  from  the 
fifth  nerve)  overacts  and  results  in  aural  oversensitiveness  especially 
to  low  notes  (Lucae),  which  is  termed  hyperakusis  or  oxyokoia. 

All  facial  reflexes  are  abolished.  Wasting  may  be  noticed  in  thin 
subjects,  and  the  reaction  of  degeneration  appears  in  a  week  or  two  in 
severe  cases.  In  cases  of  moderate  severity,  the  excitability  may  be 
first  increased  and  then  gradually  decreased  in  seven  to  ten  days.  Sen- 
sation is  usually  normal,  since  the  facial  is  an  almost  wholly  motor 
nerve;  pain,  even  ansesthesia  in  the  ear  and  tenderness  over  the  nerve 


DISEASES   OF  CRANIAL  NERVES  1161 

trunk,  are  sometimes  observed;  they  are  caused  either  by  involvement 
of  the  fifth  nerve,  or  possibly  because  the  facial  nerve  carries  some 
sensory  filaments.  Accidental  sympathetic  symptoms,  as  oedema  or 
sweating,  have  been  observed.  Herpes  is  rare  and  indicates  trifacial 
involvement.  The  saliva  is  decreased  (the  fibers  for  its  secretion  run 
with  the  chorda)  and  secretion  of  tears  is  lessened  (the  fibers  from  the 
facial  nerve  run  to  the  fifth  by  the  large  petrosal  nerve). 

Diagnosis. — The  diagnosis  is  made  at  a  glance  in  fresh  cases,  while 
in  older  cases  secondary  spasm  (v.  i.)  on  the  paralyzed  side  may  at 
first  cause  confusion.  The  etiological  diagnosis  is  important,  as  is  also 
the  topographical. 

1.  Su'pranuclear  'paralysis,  paralysis  in  the  upper  neurone,  from  the 
cortex  to  the  nucleus,  is  differentiated  as  follows: 


Central  or  Supranuclear Peripheral     (Nuclear     and 

Palsy.  .  '  Infranuclear)  Palsy. 

Etiology;    vascular  disease,  tumor,  ab-         Neuritis,  ear  disease,  etc. 

scess. 

Distribution  of  paralysis:  partial,  lower  Complete:  orbicularis  and  occipito- 
facial involved  or  only  slight  or  tran-  frontalis  involved.  When  eyes  can- 
sient  weakness  of  orbicularis  palpebra-  not  be  closed,  probably  peripheral  or 
rum.  nuclear. 

Reflexes  persist  and  increased.  Lost.     Paralysis  flaccid. 

Taste,  auditory,  salivary  and  sensory         Often  present, 
symptoms  lacking. 

Pilocarpin  increases  salivary  flow.  Does  not  increase  it. 

Voluntary  motion  lost,  while  einotional         Both  lost, 
movement  very  often  persists. 

Degenerative  reaction  and  wasting  ab-         Present, 
sent. 

Cerebral  symptoms  present,  general  as  Absent, 
headache,  vertigo,  delirium,  in- 
creased reflexes  or  focal  as  cortical 
epilepsy,  hemiplegia,  usually  weak 
tongue,  alternating  paralysis  (see  crus 
and  pons  localization). 

In  lesions  of  the  pons,  all  parts  of  the  facial  nerve  are  affected, 
wherein  it  differs  from  facial  nerve  disease  in  the  internal  capsule.  In 
nuclear  disease,  the  orbicularis  oris  is  less  involved,  or  escapes  affection, 
its  centre  being  in  the  hypoglossus  nucleus. 

2.  Localization  in  the  'peripheral  type  (see  Fig.  78)  may  be  (a)  in 
the  pons  (q.  v.).  General  disease  of  the  posterior  pons  also  affects 
the  sixth  nerve  about  whose  nucleus  the  seventh  nerve  curves,  (b) 
In  localization  at  the  base,  taste  is  not  involved  and  deafness  results 
from  coincident  disease  of  the  eighth  nerve,  (c)  It  may  be  in  the 
Fallopian  canal,  when  taste  is  impaired,  the  salivary  flow  decreased, 


1162  DISEASES  OF  THE  NERVOUS  SYSTEM 

and  hearing  often  abnormally  acute,  (d)  It  may  be  external  to  the 
skull  and  then  there  is  no  involvement  of  taste,  salivary  flow,  or  the 
stapedius. 

Double  facial  paralysis  is  rare  and  usually  indicates  disease  within 
the  skull.  It  may  occur  in  bulbar  paralysis,  in  disease  of  both  sides  of 
the  pons,  or  one  focus  in  its  centre,  in  double  otitis,  especially  syphilis, 
multiple  neuritis,  tetanus  (of  which  J.  H.  Lloyd  in  1905  collected  7 
cases),  or  in  a  form  observed  in  childhood  with  ocular  paralysis  {q.v.). 
Hysterical  facial  paralysis  is  extremely  infrequent;  a  case  is  reported 
in  which  organic  facial  paralysis  existed  on  one  side  and  an  hysterical 
paralysis  on  the  other. 

Course  and  Prognosis. — The  onset  is  rapid  and  the  disease  is  usually 
manifest  during  the  first  day.  Its  duration  varies  from  a  week  to  over 
a  year,  two  or  three  months  for  moderate,  and  six  to  eight  (eighteen) 
months  for  severe  cases.  Even  in  cases  which  have  seemingly  re- 
covered and  in  those  lasting  over  a  month,  some  slight  vestige  of 
paralysis  usually  remains.  The  prognosis  depends  (1)  on  the  cause;  it 
is  favorable  in  syphilis,  birth  trauma,  and  polyneuritis;  in  ear  disease 
it  is  better  if  the  drum  has  not  ruptured;  it  is  unfavorable  in  tumor 
or  nuclear  disease;  (2)  it  depends  on  the  electrical  reaction.  If  after 
ten  days,  the  irritability  is  not  reduced,  the  outlook  is  good  and  recovery 
may  be  expected  in  about  three  weeks;  if  after  fourteen  days  it  is 
lowered  but  not  lost,  recovery  occurs  within  two  months;  if  after 
fourteen  days  the  irritability  is  lost,  the  prognosis  is  doubtful  and  the 
course  is  likely  to  cover  months.  Recurrence  is  infrequent,  although 
five  attacks  are  recorded.  Contracture  (secondary  overaction)  usually 
occurs  in  four  to  six  months  and  progresses  for  eight  to  twelve  months, 
when  it  lessens,  and  disappears  in  mild  but  remains  to  some  extent 
in  severe  cases.  In  old  subjects  it  balances  up  the  facial  contour;  in 
young  subjects  it  produces  deformity.  It  is  thought  to  depend  on  an 
altered  functional  state  of  the  nucleus. 

Treatment. — (a)  The  cause  should  be  reached,  if  possible;  for 
example,  antisyphilitic  remedies  and  ear-drainage  have  cured  cases 
even  of  twenty-three  years'  duration.  (6)  Antirheumatic  drugs  are 
inefficacious,  and  the  salicylates  do  not  usually  shorten  the  course. 
A  mercurial  purge,  hot  fomentations,  which  must  be  carefully  main- 
tained for  two  or  three  days,  keeping  the  patient  indoors,  and  the 
application  (invariably)  of  a  blister  over  the  mastoid  and  one  over  the 
side  of  the  neck  are  beneficial,  (c)  Correction  of  deformity  is  always 
necessary.  The  eye  should  be  douched  with  boric  acid,  bandaged 
closed  during  sleep  and  the  lids  massaged,  the  cheek  and  mouth 
should  be  massaged  upward,  and  the  placing  of  a  hook  in  the  angle  of 
the  mouth  (sustained  by  tape  over  the  ear  or  by  adhesive  plaster) 
prevents  deformity  to  some  extent.  At  night  the  eye  should  be  closed 
by  a  light  compress,  (d)  Electricity  should  not  be  used  for  two  or 
three  weeks,  and  then  the  galvanic  current  should  be  given,  for  fifteen 
minutes  each  day,  in  strength  just  sufficient  to  produce  muscular 
contraction;  the  application  of  the  anode  over  the  muscles  is  the  least 


DISEASES  OF  CR AXIAL  XERVES  '  1163 

painful   method.     The   faradic    current   causes   pain,      (e)  For  co7i- 
tracture  Httle  can  be  done,  excepting  massage  and  steaming  the  face. 
(/)  In  irreparable  cases,  surgical  transplantation  of  the  facial  trunk 
to  the  spinal  accessory  nerve  has  been  successfully  performed.    (Spiller 
thinks   anastomosis   with  the  hypoglossus   produces   better  results.) 

Facial  and  Mimetic  Spasm  (Tic  Convulsif). 

Etiology. — The  causes  are  (a)  organic  disease  in  the  cortex,  pons 
or  nerve  trunk,  which  irritates  (perhaps  later  paralyzes)  the  centre, 
nucleus  or  paths.  Irritation  of  the  fifth  nerve  is  considered  causal. 
(6)  There  is  an  idiopathic  form,  which  occurs  in  persons  between  the 
fortieth  and  sixtieth  years,  most  often  in  women  with  neuropathic  or 
emotional  tendencies  (see  Habit  Spasm  under  Chorea).  There  is 
also  a  reflex  form  which  results  from  worms  or  uterine  disease. 

Symptoms. — The  spasm  begins  paroxysmally  on  one  side  and  is 
more  often  clonic  than  tonic.  The  clonic  form  affects  the  orbicularis 
palpebrarum  (blepharospasm)  and  zygomatici  most  frequently, 
although  the  frontalis,  chin  depressors  or  all  the  facial  muscles  may  be 
concerned  in  severe  cases.  Pain  and  paresis  are  absent  save  in  pro- 
gressive organic  disease.  The  spasm  is  lessened  by  rest,  and  is  in- 
creased by  cold  or  emotion.  It  is  usualy  unilateral,  but  may  spread 
to  the  opposite  side  or  exceptionally  to  the  muscles  of  mastication,  or 
those  of  the  tongue,  pharynx,  larynx,  neck  or  arm.  The  tonic  form 
is  seen  in  photophobic  disease  of  the  eye,  in  paralysis  agitans,  tetanus, 
tetany  or  hysteria.  The  prognosis  is  unfavorable  after  the  first  few 
months,  and  the  disease  is  then  likely  to  last  for  years  or  for  the  rest  of 
the  patient's  life. 

Treatment. — Treatment  is  often  useless,  and  varies  with  the  cause 
of  the  affection.  Trigeminal  irritation  should  be  removed  if  possible. 
Arsenic  has  proved  beneficial  in  some  cases,  but  nervines  and  anti- 
spasmodics are  generally  useless.  Galvanization,  especially  if  tender 
points  are  found,  has  cured  a  few  cases  (Berger).  Wier  Mitchell  has 
recommended  freezing  of  the  cheek  with  ethyl  chloride.  Stretching  of 
the  facial  nerve  usually  affords  relief,  which  is  but  temporary,  although 
a  few  cures  are  on  record. 


The  Eighth  or  Auditory  Nerve. — The  eighth  nerve  in  the  old 
nomenclature  was  called  the  portio  mollis  of  the  seventh  pair,  the 
facial  nerve  being  the  portio  dura;  as  the  names  imply,  the  auditory 
is  softer  than  the  facial  nerve  and  therefore  less  resistant  to  pressure. 
It  is  purely  sensory  and  consists  of  two  distinct  roots,  the  cochlear  and 
vestibular.  At  the  point  where  their  roots  separate  is  found  a  group  of 
cells,  analogous  to  the  spinal  ganglia,  from  which  arises  Wrisberg's 
nerve,  an  accessory  structure  with  vasomotor  and  salivary  secreting 
fibers. 

The  cochlear  nerve  is  the  true  auditory  nerve  and  its  nuclei  are  found 
in  the  floor  of  the  fourth  ventricle.     It  is  connected  through  the  teg- 


1164  DISEASES  OF  THE  XERVOUS  SYSTEM 

mentum  of  the  crus  and  internal  capsule  with  the  contralateral  and  to 
a  less  degree  with  the  homolateral  temporosphenoidal  lobe.  It  is 
distributed  to  or  arises  from  the  cochlea  and  ganglionic  cells  of  the 
organ  of  Corti.  (a)  Cortical  disease  (see  Brain  Localization)  may  in 
rare  cases  cause  word  deafness,  as  may  (6)  disease  of  the  auditory 
tracts  by  lesions  of  the  lateral  lemniscus,  the  (post.)  corp.  quadrigemina, 
internal  capsule  or  less  often  of  the  pons.  Nuclear  disease  is  almost 
unknown.  Neuromata  are  rare,  but  occur  on  the  auditory  trunk 
oftener  than  on  any  other  cranial  nerve.  The  nerve  trunk  may  degen- 
erate in  tabes,  (c)  Lesions  at  the  base  may  follow  trauma  and  menin- 
geal inflammation,  hemorrhage,  or  syphilis,  (c^)  Most  auditory  nerve 
diseases  result  from  disease  of  the  internal  ear,  which  is  either  primary, 
or  secondary  to  disease  of  the  middle  ear;  these  affections  include 
acute  or  chronic  inflammation,  syphilis,  degeneration  or  hemorrhage 
in  the  labyrinth.  There  are  three  prominent  symptoms:  (a)  Nervous 
deafness  may  result.  Deaf-mutism  is  congenital  in  80  per  cent,  and  is 
acquired  in  early  life  in  20  per  cent,  of  cases.  Deafness  from  occlusion 
of  the  meatus  or  from  disease  of  the  middle  ear  is  excluded  by  Rinne  's 
test ;  a  vibrating  tuning-fork  or  watch,  if  held  over  the  meatus,  is  not 
heard  in  these  affections,  but  is  heard  when  its  base  is  placed  on  the 
mastoid  which  conducts  vibrations  to  the  internal  ear.  In  disease  of 
the  internal  ear,  bone-conduction  is  lacking.  Differentiation  between 
deafness  due  to  disease  of  the  internal  ear  and  that  due  to  bone  disease 
is  only  made  by  means  of  the  associated  symptoms.  The  treatment  of 
nervous  deafness  is  etiological.  Iodides  are  sometimes  beneficial,  as 
are  full  doses  of  pilocarpine.  Electricity  is  nearly  always  useless. 
(6)  Auditory  hypercBsthesia  may  result  from  central  or  peripheral 
disease.  In  genuine  hypersesthesia  (hyperacusis),  sounds  are  heard 
by  the  patient  which  other  individuals  may  not  hear;  this  occurs  in 
hysteria,  epilepsy,  migraine,  meningitis,  acute  mania  and  at  times 
after  use  of  caffeine,  alcohol  or  opium.  The  spurious  hyperacusis 
results  from  paralysis  of  the  stapedius.  In  dyssesthesia  (dysacusis) 
ordinary  sounds  cause  disproportionate  sensations  or  discomfort; 
this  is  common  in  headache  and  cerebral  disorders,  (c)  Tinnitus 
aurium  designates  subjective  distressing  and  intractable  sensations, 
as  ringing,  roaring  or  whistling  in  the  ears.  In  80  per  cent,  of  cases  it 
is  caused  by  disease  of  the  internal  ear.  It  may  also  occur  in  any 
disease  of  the  middle  ear,  when  there  is  cerumen  or  foreign  bodies  in 
the  external  meatus,  or  occlusion  of  the  Eustachian  tube,  when  the 
individual  is  subject  to  long  exposure  to  loud  sounds,  as  in  boiler 
factories,  and  in  the  neuroses  (hysteria,  neurasthenia,  migraine, 
epilepsy),  aneurysm,  anaemia,  gout  or  cinchonism.  Sounds  of  centric 
origin  are  usually  continuous  and  sometimes  elaborate.  Wax  or 
bilateral  labyrinthine  disease  may  also  cause  continuous  tinnitus, 
while  in  anaemia  or  aneurysm,  these  sensations  are  intermittent 
(Gowers).  Hearing  may  be  hyperacute,  deranged  or  lost.  Spasm  of 
the  palate  or  musculature  of  the  Eustachian  tube  may  produce  a  most 
annoying  snapping  sound,  which  is  at  times  audible  to  bystanders. 


DISEASES  OF  CRANIAL  XERVES  1165 

While  nothing  is  usually  heard  on  examination,  in  children  or  less 
often  in  adults  we  may  hear  a  systolic  brain  murmur  (seeBfiAiNTuMOR). 
Treatment  depends  on  the  cause.  Bromides  are  most  useful  when 
combined  wfth  a  few  drops  of  the  tr.  belladonna  or  cannabis  indica. 
Quinine  was  recommended  by  Charcot  and  Politzer  and  salicylates 
by  Gowers,  but  they  seldom  give  relief.  Full  doses  of  nitroglycerine 
relieve  certain  cases  and  counterirritation  over  the  mastoid  sometimes 
mitigates  tinnitus. 

The  vestibular  nerve  arises  from  the  medulla,  supplies  the  vestibule 
and  semicircular  canals,  subserves  sensation  of  space  and  equilibration, 
and  has  cerebral  and  cerebellar  connections. 


Meniere's  Disease,  Auditory  Vertigo,  Vertigo  ah  aure  loesa. — Paul 
Meniere  in  1861  described  a  condition  consisting  of  vertigo,  tinnitus, 
vomiting  and  sometimes  deafness,  developing  with  apoplectiform 
suddenness,  and  due  to  acute  labyrinthine  disease.  The  lesion  is 
usually  a  chronic,  slightly  irritative  disease  of  the  vestibular  nerve, 
which  supplies  the  organs  of  equilibration,  the  semicircular  canals. 
According  to  Gowers  80  per  cent,  occurs  in  persons  between  the 
thirtieth  and  sixtieth  year,  66  per  cent,  in  males,  and  90  per  cent,  of  all 
cases  of  vertigo  not  due  to  epilepsy  or  organic  brain  disease  are 
caused  by  lesions  of  the  labyrinth.  Frankl-Hochwart  thus  classifies 
Meniere's  complex,  which  may  be  elaborated  as  follows:  (a)  Apo- 
plectiform cases,  which  occur  in  healthy  ears,  of  which  few  more  than 
30  cases  are  recorded,  due  to  labyrinthine  hemorrhage,  or  to  trauma; 
leukaemia  and  arteriosclerosis  are  promoting  factors  and  it  is  thought 
that  acute  angioneurotic  transudation  of  lymph  may  occur  in  the 
canals,  (h)  Cases  developing  in  ears  already  acutely  or  chronically 
diseased;  the  internal  ear  is  the  usual  seat  of  disease,  but  the  external 
or  middle  ear  may  be  affected,  or  the  branches  of  the  eighth  nerve, 
perhaps  by  tumors,  syphilis,  tabes,  paretic  dementia,  gout,  cold, 
facial  paralysis  or  drugs,  such  as  quinine  and  the  salicylates,  (c) 
Cases  caused  by  external  influences  or  procedures,  as  pressure  on  the 
drum  by  violent  douching  of  the  ear;  (d)  pseudo-Menidre's  disease, 
which  occurs  in  the  neuroses,  as  epilepsy,  hysteria,  neurasthenia 
migraine,  or  sea-sickness. 

Symptoms. — The  symptoms  begin  gradually  or  with  a  sudden 
stroke,  and  are  paroxysmal;  the  attacks  may  be  separated  by  weeks 
or  months  or  perhaps  occur  daily,  (a)  The  vertigo  is  subjective  or 
objective,  perhaps  combined;  the  patient  cannot  stand;  he  is  likely 
to  fall  backward,  or,  if  standing  is  possible,  is  ataxic.  These  symp- 
toms indicate  lesion  in  the  vestihidar  nerve;  there  is  occasionally 
momentary  loss  of  consciousness;  some  slight  vertigo  may  persist 
between  paroxysms,  (b)  Nausea  and  vomiting  are  usual,  save  in  the 
lighter  forms,  and  are  often  attended  by  headache,  sometimes  collapse, 
pallor  and  clammy  skin,  and  rarely  by  death,  (c)  The  tinnitus  of  a 
roaring,  throbbing  character  and  id)  7iervous  deafness,  which  is  usually 


1166  DISEASES  OF  THE  XERVOUS  SYSTEM 

not  absolute,  indicate  disease  of  the  cochlear  nerve.  Nystagmus, 
double  vision  and  ataxia  are  occasional  symptoms,  and  result  from 
the  relations  between  the  labyrinth,  cerebellum  and  cerebrum.  The 
prognosis  is  always  uncertain.  Acute  or  progressive  disease  is  un- 
favorable. The  vertigo  may  cease  when  complete  destruction  of  the 
nerve  results  in  deafness.    Some  cases  recover. 

Diagnosis. — Aural  vertigo  constitutes  90  per  cent,  of  vertigo.  Differ- 
entiation is  as  follows :  (a)  Gastric  disease  may  cause  vomiting  or  vertigo 
{a  stomacho  loeso,  Trousseau)  but  does  not  produce  tinnitus  nor  deaf- 
ness. Gastric  vertigo  was  once  thought  to  cause  80  per  cent,  of  cases 
of  vertigo;  now,  but  5  per  cent.  (Gowers)  is  attributed  to  it.  Many 
of  these  cases  are  neurotic.  (6)  Epilepsy,  especially  petit  mal,  may 
produce  vertigo,  very  rarely  tinnitus  or  deafness,  and  much  oftener  loss 
of  consciousness,  (c)  Cardiac  disease,  as  aortic  regurgitation  or 
arteriosclerosis,  may  cause  vertigo  but  not  the  other  symptoms,  {d) 
Organic  brain  afJectio7is,  as  tumor,  have  other  distinctive  signs,  as 
headache,  or  focal  lesions.  Confusion  is  possible  with  arteriosclerotic 
vertigo,  and  especially  with  coincident  accidental  deafness.  (e) 
Ocular  vertigo  ceases  on  closing  the  eyes.  Gerher  (1887)  described  a 
form  which  is  endemic  in  France  and  Switzerland,  and  is  characterized 
by  vertigo,  great  depression,  paretic  weakness  of  the  neck  and  limbs, 
ptosis,  strabismus,  diplopia  and  retinal  hypereemia,  hemorrhage  or 
oedema.  A  similar  form  occurs  in  Japan.  Recovery  occurs  in  one  to 
four  months. 

Treatment. — Labyrinthine  disease  is  little  influenced  by  drugs, 
except  when  syphilis  and  gout  are  its  causes.  Quinine,  salicylates  and 
nitroglycerine  should  be  given  (see  Tinnitus).  Bromides  are  most 
useful  in  daily  doses  of  one  dram.  Galvanization  with  the  anode 
over  the  ear  and  cathode  to  the  neck  has  seemingly  helped  some  cases, 
as  has  bhstering  of  the  mastoid.  Disease  of  the  pharynx.  Eustachian 
tube,  and  accumulation  of  wax  must  be  recognized  and  treated. 
Removal  of  the  malleus  and  incus  with  mobilization  of  the  stapes 
relieves  a  few  cases. 


Ninth  or  Glossopharyngeal  Nerve. — This  nerve  is  almost  inseparably 
connected  in  its  course  and  functions  with  the  vagus  and  the  internal 
part  of  the  spinal  accessory  nerve;  their  nuclei  blend,  their  sensory 
and  motor  filaments  supply  the  digestive  tract  from  the  spinal  accessory 
nerve,  and  send  motor  branches  to  the  lungs,  larynx  and  heart.  Com- 
pared with  disease  of  the  first  eight  cranial  nerves,  affections  of  these 
visceral  nerves  are  infrequent.  Of  all  the  cranial  nerves,  the  ninth  is 
least  understood  and  is  almost  never  the  seat  of  isolated  disease.  The 
causes  of  its  disease  are  essentially  the  same  as  those  of  the  vagus  (v.  i.) ; 
its  nuclei  suffer  in  bulbar  palsy  and  its  roots  in  basal  disease. 

It  is  distributed  as  follows:  (a)  its  sensory  fibers  supply  the  back 
of  the  tongue,  pharynx,  soft  palate,  tonsil,  upper  pharynx,  Eustachian 
tube  and  tympanic  cavity.     It  is  probably  the  nerve  of  nausea.     (6) 


DISEASES   OF   CRANIAL   NERVES  1167 

Its  motor  fibers  supply  the  upper  pharynx  and  possibly  the  palate. 
(c)  Taste  fibers  are  usually  thought  to  be  distributed  to  the  posterior 
third  of  the  tongue  and  palate,  but  they  are  not  found  in  the  nerve 
root  and  are  considered  to  pass  through  the  fifth  nerve  to  the  brain. 
Increased  flow  of  saliva  and  loss  of  taste  on  the  root  of  the  tongue  may 
result  from  disease  of  the  middle  ear  due  to  relations  between  the  nerve 
of  Jacobson  (ninth)  and  the  branches  of  the  fifth  nerve.  The  nerve 
is  thouglit  to  regulate  and  inhibit  the  contractions  of  the  pharynx, 
which  become  frequent  (spasm)  in  disease  or  on  section  of  the  nerve. 


Tenth  Nerve  or  Vagus. — This  nerve  arises  in  the  medulla  above  the 
ninth,  below  the  eleventh,  and  outside  of  the  twelfth  nuclei.  With 
the  internal  part  of  the  accessory  nerve  it  has  an  enormously  diffuse 
and  important  visceral  distribution.  It  is  a  mixed  nerve,  the  motor 
fibers  originating  from  the  nuclei,  and  the  sensory  fibers  from  the 
jugular  and  plexiform  ganglia.  It  is  generally  maintained  that  the 
vagus  carries  the  sensory  and  the  accessory,  motor  fibers. 

Etiology. — Affections  of  the  vagus  result  from :  (a)  Nuclear  disease, 
as  degenerative  bulbar  palsy  or  acute  vascular  lesions,  which  usually 
also  involve  other  nuclei;  (6)  involvement  of  the  root  and  trunk  by 
meningitis,  syphilis,  caries,  trauma,  tumor,  aneurysm  of  the  arch  or 
its  branches,  carcinoma,  oesophageal  growths,  tuberculous  or  other 
adenopathies,  pleural  (right-sided  especially)  or  pericardial  effusions 
or  adhesions,  mediastinitis,  goitres,  operations  on  the  neck  (laryngeal 
paralysis  occurs  in  14  per  cent,  of  thyroid  extirpations)  or  rarely 
neuroma  and  neuritis  from  diphtheria  or  other  infections,  tabes,  or 
plumbism.  Cortical,  especially  functional,  causes  may  occasion  symp- 
toms. Irritative  and  paralytic  manifestations  occur  in  numerous 
combinations  and  will  be  treated  topographically. 

Pharyngeal  Branches. — The  pharyngeal  plexus  consists  of  bran- 
ches from  the  ninth  and  tenth  nerves.  In  paralysis,  sensation  and 
the  pharyngeal  reflex  are  lost,  while  bilateral  (rarely  unilateral)  disease 
causes  dysphagia.  The  stomach  tube  can  be  introduced  without 
sensation  or  spasm.  Pulpy  foods  are  better  swallowed  than  dry  foods 
or  fluids.  Food  is  likely  to  enter  the  larynx,  and  when  the  palate  is 
involved  there  is  regurgitation  into  the  nose,  and  nasal  speech  results. 
The  innervation  of  the  palate  is  not  definitely  known,  but  it  is  probably 
supplied  by  the  accessory  nerve.  Spasm  is  not  frequent,  is  always 
functional,  is  transient  or  recurrent,  does  not  allow  of  introduction  of 
the  stomach  tube,  and  includes  the  globus  hystericus,  oesophagismus, 
pharyngismus,  false  and  genuine  hydrophobia  and  the  pharyngeal 
crises  of  tabes.  The  oesophagus  is  rarely  affected  except  in  diseases  of 
the  centres  or  trunk. 

Laryngeal  Branches. — There  are  two  laryngeal  nerves,  the  supe- 
rior laryngeal  and  the  recurrent  laryngeal. 

The  superior  laryngeal  is  (a)  the  sensory  nerve  for  all  parts  above 
the  vocal  cords,  ih)  the  motor  nerve  for  but  one  larynx  muscle,  the 


1168 


DISEASES  OF  THE  XERVOUS  SYSTEM 


cricothyroid,  which  modulates  the  voice  by  regulating  tension  in  the 
cords,  and  (c)  it  is  the  motor  nerve  for  the  depressors  of  the  epiglottis, 
the  thyro-epiglottic  and  ary-epiglottic  muscles,  paralysis  of  which  causes 
the  epiglottis  to  stand  upright,  thereby  risking  entrance  of  food  into  the 
larynx  and  aspiration  pneumonia.  (Some  maintain  that  the  recurrent 
nerve  supplies  these  depressors.) 

Figures  illustrating  the  laryngeal  paralyses,  from  Church's  Nervous 
Diseases. 


Fig.  79. 


normal  phonation ;  2,  normal  deep  inspiration;  3,  normal  cadaveric  pos'tion;  A,  bilateral  ad- 
ductor palsy;  attempted  phonation;  B;  Left  adduction  palsj';  attempted  phonation;  C, 
bilateral  abductor  paralysis;  deep  inspiration;  D,  left  abductor  paralysis;  deep  inspiration; 
affected  cord  in  cadaveric  position;  E,  left  abductor  paralysis;  phonation;  affected  cord  in 
cadaveric  position;  right  cord  crossing  mediima  line;  F,  bilateral  thjTo-arytenoid  paralysis;  G, 
bilateral  thjTo-  arytenoid  paralysis  and  paralysis  of  arytenoideus,  giving  an  hour-glass  opening. 


DISEASES  OF  CRANIAL  NERVES  1169 

The  recurrent  laryngeal  curves  around  the  aortic  arch  on  the  left  and 
the  subclavian  artery  on  the  right  side;  (a)  it  is  the  sensory  nerve  to 
the  mucosa  of  the  larynx  below  the  cords  and  to  the  trachea  and  (6) 
is  the  motor  nerve  to  every  intrinsic  muscle  of  the  larynx  except  the 
cricothyroid.  The  larynx  muscles  are  physiologically  complicated, 
but  they  have  three  main  movements:  (a)  to  render  the  cords  tense 
(this  is  accomplished  by  the  cricothyroids  and  to  a  less  extent  by  the 
thyro-arytenoids) ;  (6)  to  adduct  the  cords,  which  is  done  chiefly  by 
the  lateral  crico-arytenoids  (also  by  the  thyro-arytenoids  and  arytenoids) ; 
(c)  to  abduct  the  cords,  which  is  done  by  the  post,  crico-arytenoid; 
it  is  especially  important  because  it  is  the  only  special  abductor;  it  is 
very  frequently  and  almost  invariably  first  involved  in  incomplete 
recurrent  paralysis  (Rosenbach  and  Semon),  even  though  the  ad- 
ductors are  affected  later  in  complete  paralysis. 

Treatment  depends  wholly  on  the  cause,  which  is  usually  peripheral. 
In  nuclear  types  there  is  no  therapy.  Suggestion,  or  its  equivalent, 
electrotherapy,  is  valuable  in  hysterical  forms.  The  faradic  current 
may  be  used,  with  the  positive  pole  to  the  forehead  and  the  negative 
to  the  larynx  externally  or  internally;  should  this  fail,  the  galvanic 
current  may  be  given.  Other  measures  include  laryngeal  gymnastics, 
in  which  the  patient  repeatedly  attempts  to  speak,  intralaryngeal 
insufflations  of  alum,  other  topical  applications,  the  administration  of 
strychnia  hypodermatically,  and  Ollivier's  procedure,  in  which  the 
thyroid  cartilage  is  compressed  between  the  index-finger  and  thumb 
during  inspiration  and  expiration,  while  the  subject  attempts  to 
phonate.  Tracheotomy  and  feeding  by  the  nasal  catheter  are  some- 
times indicated. 

Ancesthesia  of  the  larynx  is  rare  but  may  occur  uni-  or  bilaterally 
in  disease  of  the  sup.  laryngeal  nerve,  the  vagus  roots,  its  nucleus  or 
in  the  hemiansesthesia  of  hysteria  or  organic  brain  disease.  In  nuclear 
disease  it  is  partial;  in  affections  of  the  nucleus,  root  and  trunk 
the  reflexes  are  lost,  but  they  are  present  in  supranuclear  and  functional 
affections.  Hyperoesthesia  is  even  rarer,  being  observed  in  neurotics 
as  a  tickling,  tendency  to  cough  or  spasm;  neuralgia  and  crises  also 
occur. 

The  most  common  form  of  laryngeal  spasm  is  spasm  of  the  adductors 
(which  are  especially  concerned  in  reflexes  inimical  to  entrance  of  foreign 
bodies  into  the  larynx);  it  may  result  from  centric,  local  (laryngitis 
with  croup-like  cough  at  night)  or  reflex  irritation  from  distant  or 
neighboring  foci  as  elongated  uvula,  goitre  or  hypertrophy  of  the 
pharyngeal  tonsil.  It  includes  laryngismus  stridulus,  which  occurs  in 
children  under  three  years  of  age,  especially  in  boys,  and  was  previously 
referred  to  the  thymus  gland,  but  is  due  to  rickets  in  66  per  cent,  of 
cases  and  also  to  tetany,  and  reflexly  to  alimentary  disorders;  it  comes 
on  at  night  or  on  awakening  in  the  morning,  with  croup-like  cough, 
and  presents  all  the  symptoms  of  acute  sufl'ocation,  as  inspiratory 
and  expiratory  stridor,  pallor,  cyanosis,  wide  pupils,  protruding  eyes, 
low    diaphragm,    involuntary    evacuations,    centric    vasomotor    and 

74 


1170 


DISEASES  OF  THE  XERVOUS  SYSTEM 


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DISEASES  OF  CR AXIAL  XERVES  1171 

cardiac  disturbance  and  convulsions  either  generalized  or  of  the 
infantile  carpopedal  type.  The  attacks  last  from  a  few  seconds  to 
one-half  or  one  minute  and  are  sometimes  attributed  to  loss  of  temper 
when  they  follow  a  reproof.  In  the  adult,  laryngeal  spasm  occurs  in 
tabes,  hysteria,  tetany,  hydrophobia,  epilepsy  (the  initial  cry  of  which 
arises  from  spasm),  asthma  or  migraine.  The  attacks  are  recognized 
by  the  negative  laryngoscopic  findings,  paroxysmal  occurrence,  and 
the  stridor  being  manifest  in  both  inspiration  and  expiration.  Partial 
spasm  occurs  in  some  types  of  stuttering,  in  clergymen's  sore  throat, 
and  in  explosive,  unmodulated  speech. 

Nervous  cough  is  present  in  the  explosive  hysterical  type,  in  the 
metallic  ovarian  form  in  young  girls,  and  in  the  barking  variety  in 
young  masturbators. 

Treatment  of  spasm  includes  removal  of  the  cause,  relief  of  local 
irritation,  as  affections  of  the  ear  (which  has  branches  from  the  vagus) 
or  pharynx,  correction  of  hygiene,  administration  of  tonics,  as  cod- 
liver  oil  in  children,  and  such  immediate  measures  as  thrusting  a  finger 
into  the  throat,  dashing  water  in  the  face,  hydrotherapy,  and  for  the 
attack  chloral  and  bromides  by  enema,  local  application  of  cocaine, 
inhalation  of  chloroform  and  in  adults  nitrite  of  amyl  and  morphine. 

Pulmonary  Branches. ^The  vagus  and  the  sympathetic  nerve 
form  the  pulmonary  plexus.  Afferent  fibers  convey  sensory  impres- 
sion to  the  respiratory  centre;  these  include  accelerating  fibers  which- 
predominate,  and  inhibitory  fibers,  stimulation  of  which  (sup.  laryn- 
geal nerve)  arrests  breathing.  Afferent  impulses  are  also  carried  to 
the  vasomotor  centre.  Efferent  motor  impulses  are  conveyed  to  the 
bronchi.  Division  of  the  vagus  causes  rapid  congestion  of  the  lungs 
with  hemorrhage  (also  observed  in  acute  lesion  of  the  pons)  and 
slower  but  deeper  breathing;  stimulation  of  the  divided  end  of  the 
nerve  accelerates  breathing  even  to  its  tetanic  arrest.  Broncho- 
pneumonic  foci  are  as  yet  thought  to  be  trophic  but  should  be  con- 
sidered aspiration  pneumonia  from  paralysis  of  the  palate  and  larynx. 
The  pulmonary  twigs  are  probably  concerned  in  Cheyne-Stokes 
breathing,  bronchial  asthma  and  hiccough. 

Cardiac  Branches. — The  vagus  and  sympathetic  nerves  constitute 
the  cardiac  plexus,  (a)  Motor  fibers  from  the  spinal  accessory  nerve 
inhibit  and  coordinate  cardiac  action,  which  is  sometimes  under  the 
control  of  the  will;  the  heart  may  at  times  be  slowed  by  pressure  on 
the  neck;  marked  irritation  of  the  vagus  slows  the  heart  (bradycardia) 
or  even  arrests  its  action.  Division  may  cau.se  sudden  death,  though 
this  is  unusual  in  unilateral  lesions.  Paralysis  of  these  fibers  allows 
the  sympathetic  accelerator  fibers  to  dominate,  producing  arrhythmia 
and  tachycardia.  Digitalis  is  naturally  ineffective  in  paralysis  of  the 
vagus,  (h)  The  sensory  fibers  are  concerned  in  pain  and  palpitation 
(see  Cardiac  Neuroses),  (c)  These  are  probably  trophic  fibers,  as 
Eichhorst's  experiments  show  fatty  myocardial  degeneration  on  divi- 
sion of  the  vagi. 


1172  DISEASES  OF  THE  XERVOUS  SYSTEM 

Gastric  Branches. — (a)  Motor  branches  supply  part  of  the  stomach 
and  are  concerned  in  reflex  vomiting;  they  cause  nausea  and  are  con- 
cerned in  direct  or  centric  vomiting,  as  in  brain  lesions,  wherein  the 
vomiting  usually  occurs  without  nausea,  (b)  There  are  sensory 
branches;  the  vagus  is  seemingly  the  nerve  of  hunger  and  thirst,  and 
its  disease  often  but  not  always  causes  anorexia  and  loss  of  thirst. 
Centric  disease  causes  the  gastric  crises  of  tabes,  and  cortical  func- 
tional disease  produces  the  epigastric  aura  of  epilepsy  and  perhaps 
gastralgia  in  the  neuroses.  Vertigo  probably  causes  vomiting  through 
the  vagus.  Intestinal  and  splenic  symptoms  are  lacking  in  affections 
of  the  vagus,  although  the  nerve  somewhat  accelerates  peristalsis. 


Eleventh  or  Spinal  Accessory  Nerve  (externiil  portion). — The 
internal  and  minor  part  runs  with  the  vagus,  while  the  external  and 
major  segment  is  really  a  spinal  motor  nerve,  arising  from  the  lateral 
portion  and  ant.  horns  of  the  cord  between  the  sixth  cervical  segment 
and  the  medulla.  It  courses  upward  through  the  foramen  magnum 
into  the  cranium  and  leaves  it  with  some  of  the  true  cranial  nerves. 
It  is  the  chief  or  sole  supply  of  the  sternomastoid  muscles  and  the  upper 
part  of  the  trapezius,  the  lower  two  parts  of  which  are  supplied  by 
the  cervical  and  upper  dorsal  nerves.  Rarely  the  eleventh  supplies 
•the  whole  trapezius  muscle. 

Paralysis  is  rarely  caused  by  cortical  disease,  because  the  muscles 
have  bilateral  representation.  The  usual  causes  are  bulbar  paralysis, 
lesions  near  the  foramen  magnum,  meningitis  (then  usually  with 
involvement  of  the  inner  accessory  branches  and  the  twelfth  nerve), 
syphilis,  trauma,  disease  of  the  cord  (tabes,  syringomyelia,  progressive 
muscular  atrophy),  of  the  spine  (caries,  tumor),  or  disease  of  the  nerve 
trunks,  as  cold,  trauma  or  neuritis.  The  symptoms  are  paralysis 
of  (a)  the  sternomastoid,  in  which  there  is  impaired  rotation  of  the 
face  to  the  side  opposite  the  lesion;  in  old  cases  contracture  turns  the 
face  toward  the  paralyzed  side.  (6)  That  part  of  the  trapezius  from 
the  occiput  to  the  acromion  is  paralyzed,  showing  a  concave  instead  of 
a  straight  line,  which  is  best  seen  in  deep  inspiration  or  on  shrugging 
the  shoulders.  (Paralysis  of  the  second  portion  causes  imperfect 
elevation  of  the  arm,  some  drooping  and  winging  out  of  the  scapula, 
the  lower  part  of  which  is  drawn  toward  the  spine  by  the  rhomboids 
and  lev.  anguli  scapulae;  paralysis  of  the  third  portion  results  in  weak- 
ness in  the  adduction  of  the  scapula  to  the  spine.)  If  it  is  bilateral 
as  in  chronic  meningitis  of  childhood  or  progressive  muscular  atrophy, 
the  head  falls  forward  or  backward  as  the  sternomastoids  or  trapezii, 
respectively,  are  affected.  In  peripheral  disease  there  is  wasting  and 
the  reaction  of  degeneration.  In  centric  disease  the  electrical  reactions 
vary,  as  in  progressive  muscular  atrophy. 

Accessory  Spasm,  Spasmodic  Torticollis  or  Wr3meck. — Etiology. — 
It  occurs  in  women  in  66  per  cent,  of  cases  (Gowers),  although  Osier 
finds  it  largely  in  males,  between  30  and  50  years  of  age.     A  neurotic 


DISEASES  OF  CRAXIAL  XERVES  1173 

tendency,  bad  health,  trauma,  overexertion,  acute  infections,  alco- 
hoHsm,  plumbism,  cervical  caries,  brain  tumor,  and  diseases  of  the 
eye  and  ear  Ctorticollis  ab  oculo  Iseso,  ab  aure  Itesa)  are  among  its 
uncertain  causes. 

Symptoms.— The  symptoms  vary  as  the  affection  is  clonic  or  tonic, 
unilateral  or  bilateral,  and  also  with  the  number  of  muscles  involved. 
One  sternomastoid  is  generally  involved,  especially  in  tonic  spasm, 
in  which  the  occiput  is  turned  to  the  diseased  side,  the  face  to  the  oppo- 
site side  and  somewhat  upward,  and  the  ear  brought  nearer  the  clavicle. 
The  upper  part  of  the  trapezius  comes  next  in  frequency  of  involve- 
ment, and  is  affected  equally  by  clonic  and  tonic  spasm.  The  affected 
shoulder  is  raised  and  shghtly  rotated,  the  scapula  drawn  toward  the 
spine  and  the  head  backward.  The  spine  is  often  convex  toward  the 
diseased  side.  The  splenius  is  half  as  frequently  affected  (Gowers), 
the  head  being  drawn  backward,  the  face  a  little  to  the  affected  side 
and  upward.  Less  often  the  scalenus,  platysma,  rectus  and  obliquus 
capitis  are  affected.  The  muscles  in  tonic  spasm  are  hard,  prominent 
and  sometimes  hypertrophied.  Clonic  spasm  disappears  during 
sleep,  but  is  increased  by  fatigue  and  emotions;  it  may  also  invade  the 
face,  neck,  eyeballs,  vocal  cords  or  the  arm.  There  may  be  pain, 
fatigue  and  rarely  tender  spots  or  formication  from  compression  of  the 
brachial  plexus  by  the  scaleni.  Bilateral  clonic  or  tonic  spasm  of 
the  trapezius  draws  the  head  backward  (retrocolhc  spasm),  and 
always  involves  the  frontalis  muscle. 

Course  and  Prognosis. — The  onset  is  gradual,  the  disease  is  usually 
stationary  or  progressive  in  its  course,  rarely  recurrent;  recovery  is 
infrequent.     The  outlook  is  generally  grave  in  well  developed  types. 

Diagnosis. — (a)  In  congenital  or  fixed  wryneck  there  is  no  active 
spasm.  One  sternomastoid  (but  rarely  the  trapezius)  shows  atrophy, 
induration  and  cicatrization,  which  Stromeyer  considers  due  to  traction 
on  the  neck  with  injury  during  dehvery.  Seventy  per  cent,  of  cases 
occur  in  left  occipito-anterior  presentations.  The  disease  escapes 
notice  for  years,  because  of  the  shortness  of  the  child's  neck.  Wilks 
always  found  facial  asymmetry.  Golding-Bird  considers  the  affection 
a  contracture  from  a  central  lesion.  Tenotomy  cures  it.  (b)  Hyster- 
ical torticollis  occurs  in  subjects  under  thirty  years  of  age;  other  stigmata 
usually  develop.  Bompaire  and  Brissaud  describe  a  mental  torti- 
collis, which  is  clearly  a  cortical  or  psychical  phenomenon,  (c)  Tor- 
ticollis may  occur  in  children  from  dentition  to  puberty;  clonic  spasms, 
especially  in  the  deep  muscles,  lead  to  nodding,  salaam  movements, 
spasmus  nutans,  nictitatio  spastica.  The  eyes  may  show  nystagmus. 
The  affection  may  develop  from  reflex  dental  or  digestive  disorders, 
or  from  organic  cerebral  disease.  It  is  sometimes  habit  spasm, 
hysteria,  or  even  part  of  an  epilepsy  or  idiocy. 

Treatment. — ^Treatment  is  first  etiological.  Nervines,  sedatives 
and  electricity  seldom  produce  permanent  results.  Morphine  is 
a  dangerous  agent,  although  its  local  hypodermatic  use  has  led  to 
recovery.     Massage  and  deep  compression  are  occasionally  helpful. 


1174  DISEASES  OF  THE  NERVOUS  SYSTEM 

In  chronic  cases  resection  of  the  accessory  nerve  is  indicated.  If 
many  muscles  are  involved,  the  third  and  fourth  cervical  nerves  must 
also  be  resected.  Successful  results  are  reported  by  W.  W.  Keen  and 
Noble  Smith. 


Twelfth  or  H3rpoglossal  Nerve. — This  is  purely  a  motor  nerve. 
Paralysis  of  the  tongue  is  (a)  rarely  cortical;  supranuclear  glossoplegia 
from  lesions  between  its  centre  in  the  lower  part  of  the  ant.  ascending 
and  the  third  frontal  convolutions,  almost  always  occurs  with  hemi- 
plegia and  paralysis  of  the  lower  facial  fibers;  there  is  no  wasting  or 
reaction  of  degeneration.  The  root  of  the  tongue  is  higher  (hyoglossus 
paralysis)  and  on  protrusion  the  tongue  deviates  to  the  paralyzed  side, 
being  pushed  over  by  the  sound  genioglossus.  (b)  Nuclear  paralysis 
occurs  often  in  degenerative  disease  as  bulbar  paralysis,  sometimes  in 
tabes  or  paretic  dementia,  and  much  less  frequently  in  acute  inflam- 
mation or  softening  in  the  medulla.  Nuclear  lesions  are  almost 
invariably  bilateral  (since  the  nuclei  are  closely  contiguous),  and  show 
the  reaction  of  degeneration  and  wasting,  the  mucosa  being  wrinkled 
over  the  atrophic  half.  Wasting  may  be  more  marked  than  paralysis. 
Fibrillation  is  frequent,  as  in  paretic  dementia,  from  cortical  and  nuclear 
changes.  In  bilateral  glossoplegia  the  tongue  cannot  be  protruded, 
there  is  impairment  of  the  first  act  of  swallowing,  in  chewing  and 
articulation,  all  of  which  are  but  slightly  marked  in  unilateral  paralysis. 
(c)  Infranuclear  paralysis  results  from  lesions  near  the  surface  of 
the  medulla,  which  may  produce  unilateral  paralysis  of  the  tongue, 
palate  and  vocal  cord.  Contralateral  hemiplegia  may  occur.  The 
lesion  may  affect  one  or  both  nerves.  Syphilis,  trauma  or  tumors 
are  causal;  neuritis  is  infrequent  (there  being  recorded  only  40  cases 
of  peripheral,  isolated  hypoglossal  paralysis,  Panski,  1903).  Wasting, 
the  degenerative  reaction  and  fibrillation  are  present.  Treatment  is 
that  of  other  paralyses. 

Spasm  is  rare  either  in  the  tonic  or  clonic  form.  It  occurs  in  chorea, 
facial  spasm,  certain  types  of  stuttering,  epilepsy  (in  which  the  tongue, 
protruded  by  the  genioglossus,  is  bitten),  hysteria  (in  which  the  tongue 
is  rarely  bitten),  certain  psychoses,  meningitis,  neurotic  spasm  in 
speakers  (aphthongia)  or  musicians.  The  prognosis  varies  with  the 
cause  and  in  general  is  favorable. 


5.  Diseases  of  the  Spinal  Nerves. — The  spinal  nerves  differ  from 
the  cerebral  in  that  they  contain  sensory,  motor  and  vasomotor  fibers 
Disease  or  injury  therefore  suspends  motility  and  sensation,  causes 
vasomotor  paralysis,  trophic  changes  or  wasting,  glossy  skin,  the 
reaction  of  degeneration,  atrophy  and  contracture. 

Phrenic  Nerve. — -Paralysis. — (a)  Disease,  or  trauma  of  the  vertebrae, 
cord,  membranes  or  of  the  third,  fourth  and  fifth  cervical  nerves  of 


DISEASES  OF  SPINAL  NERVES  1175 

origin  may  cause  it.  In  disease  of  the  cord  other  paralysis  is  always 
present;  phrenic  paralysis  is  usually  bilateral.  (/>)  Its  trunk  is  well 
protected  but  may  be  injured  in  its  course  or  damaged  by  aneurysm, 
tumors,  or  pleurisy.  Neuritis  is  a  rare  cause,  although  it  is  sometimes 
involved  in  multiple  neuritis  or  degenerative  lesions  as  tabes  or  pro- 
gressive muscular  atrophy. 

Symptoms. — The  diaphragm  is  paralyzed  on  one  or  both  sides. 
The  abdomen  retracts  in  inspiration  and  bulges  in  expiration,  which  is 
the  converse  of  its  normal  movements.  Litten's  diaphragmatic  sign 
is  naturally  absent,  and  there  is  no  inspiratory  descent  of  the  liver  or 
spleen.  Blowing,  coughing  and  pressing  at  stool  are  impossible.  Costal 
breathing  is  exaggerated,  the  accessory  muscles  are  strongly  in  play, 
dyspnoea  and  cyanosis  are  present  especially  on  exertion,  and  coincident 
bronchitis  may  cause  most  alarming  symptoms,  allowing  stagnation 
of  mucus  and  basal  congestion.    The  nerve  may  be  tender  in  the  neck. 

Diagnosis  and  Treatment. — Costal  hysterical  breathing  may  at  first 
cause  confusion,  as  may  inflammation  and  degeneration  of  the  dia- 
phragm from  diaphragmatic  pleurisy.  The  outlook  is  always  grave. 
It  is  more  favorable  in  syphilis,  lead  or  diphtheritic  neuritis  than  in 
alcoholic  forms.  Treatment  is  that  of  the  cause,  but  is  usually  futile. 
Faradic  phrenic  stimulation  is  sometimes  beneficial,  as  in  apparently 
asphyxiated  new-born  infants. 

Phrenic  Spasm. — 1.  Clonic  spasm,  singultus,  or  hiccup  is  a  form 
in  which  the  diaphragm  spasmodically  contracts  with  a  sound  due  to 
sudden  closure  of  the  glottis,  sometimes  50  to  100  times  a  minute.  It 
is  probable  that  the  vagus  and  respiratory  centres  are  involved,  for 
dyspnoea,  dysphagia  or  dysarthria  may  occur.  Clonic  spasm  occurs 
(a)  in  inflammation,  either  thoracic  (pleurisy,  pericarditis)  or  abdom- 
inal (peritonitis,  appendicitis,  obstruction);  (b)  in  irritation;  oesopha- 
geal, mediastinal,  hepatic  or  gastric,  directly  or  reflexly;  (c)  in 
nervous  affections,  as  centric  disease  or  the  neuroses;  and  (d)  in 
toxaemia,  fevers  or  ursemia.  Treatment  is  that  of  the  cause.  Gastric 
lavage;  apomorphine;  circular  constriction  of  the  lower  chest  with 
the  head  bent  forward;  attempts  to  sneeze,  cough,  breathe  deeply  or 
press  down  with  the  glottis  closed;  faradization,  freezing,  blistering 
the  neck  and  epigastrium;  antispasmodics  and  depressomotors,  as 
asafoetida,  chloral,  or  bromides;  and  narcotics,  and  inhalations  of 
chloroform  or  amyl  nitrite  may  be  beneficial,  although  the  aft'ection  is 
often  intractable. 

2.  Tonic  phrenic  spasm  is  rarer.  The  causes  are  tetany,  epilepsy, 
tetanus,  rheumatism,  and  hysteria.  The  diagnosis  is  easy.  The  lower 
chest  and  upper  abdomen  are  distended  and  often  sensitive,  the  upper 
chest  moves  rapidh'  and  forcibly,  with  the  accessory  muscles  in  full 
play,  there  is  no  respiratory  excursion,  the  lungs  are  acutely  distended, 
the  abdominal  viscera  are  luxated  downward,  there  is  dyspnoea,  and 
cyanosis  and  death  may  result.  Treatment  consists  of  the  application 
of  heat,  blisters  and  the  faradic  current  to  the  lower  chest,  and  the 
use  of  chloroform  inhalations   and  morphia   internally.      Analogous 


1176  DISEASES  OF  THE  NERVOUS  SYSTEM 

spasm  may  occur  in  the  respiratory  muscles,  as  yawning,  sneezing, 
coughing,  laughing  and  weeping  spasms,  possibly  from  vagus  disease, 
or  from  the  neuroses,  psychoses,  multiple  sclerosis,  bulbar  paralysis 
or  disease  of  the  ear,  nose  or  stomach. 

The  Posterior  Thoracic  Nerve. — This  nerve  is  often  affected  in  its 
long  course,  from  trauma,  muscular  strains  in  overhead  work  (the 
nerve  originates  in  the  scalenus  medius)  and  from  carrying  loads  on 
the  shoulder — whence  its  occurrence  in  90  per  cent,  of  cases  in  men; 
it  is  also  involved  in  muscular  atrophies  with  other  muscles  and  in 
neuritis.  The  results  are  impaired  fixation  of  the  scapula,  movement 
of  the  arm,  and  inspiration.  The  scapula  wings  out  when  the  arm  is 
moved  forward,  and  stands  less  obliquely  than  normal,  its  outer  part 
moving  forward,  while  the  lower  angle  is  drawn  in  by  the  rhomboids 
and  trapezius.  The  sole  sensory  change  is  pain  in  the  neck  and 
shoulder.  The  course  is  at  best  tedious,  and  rest,  especially  of  the 
scaleni,  is  the  prime  indication. 

Suprascapular  Nerve. — It  originates  in  the  fourth,  fifth  and  sixth 
cervical  nerves,  and  is  affected  in  disease  of  the  plexus  or  alone  in 
trauma,  shoulder  dislocations,  or  falls  on  the  hands.  The  supra- 
spinatus  and  infraspinatus  are  paralyzed,  giving  some  weakness  in 
fixation  of  the  humerus,  as  uncertainty  in  writing,  turning  of  the  lower 
scapular  angle  up  and  in,  some  anaesthesia  over  the  scapula,  frequently 
shoulder  girdle  pain,  and  often  involving  the  Circumflex  Nerve, 
which  arises  from  the  fifth,  sixth  and  seventh  cervical  nerves  of  the 
posterior  cord  of  the  brachial  plexus.  Deltoid  paralysis  (dislocation, 
crutch  paralysis,  plexus  disease)  produces  inability  to  deviate  laterally 
the  arm,  changes  in  the  shape  of  the  shoulder,  which  becomes  angular, 
sometimes  adhesions  in  the  joint,  which  are  probably  trophic  from 
its  articular  branch,  and  anaesthesia  over  the  lower  part  of  the  deltoid. 
It  may  be  confused  with  primary  joint  disease,  in  which,  however,  the 
scapula  follows  the  arm  movements.  Paralysis  of  the  teres  minor  is 
unimportant. 

Musculo  spiral  Nerve. — Arising  from  all  the  roots  in  the  plexus 
except  the  first  dorsal,  and  curving  around  the  humerus,  it  is  the  most 
exposed  and  most  frequently  injured  nerve  in  the  arm  or  body;  injuries 
result  from  fracture,  callus,  blows,  muscular  exertion,  carrying  heavy 
weights,  tying  the  arms  to  the  side  or  behind  the  back,  sleeping  with 
the  arm  over  the  back  of  a  chair,  especially  in  alcoholics,  lifting  the 
arms  during  surgical  anaesthesia,  and  Esmarch's  constrictor;  less 
often  injury  results  from  injections  of  ether,  from  cold  or  from  lead 
palsy.  Musculospiral  (radial)  paralysis  involves  (a)  the  extensors 
of  the  upper  extremity,  i.  e.,  the  triceps,  so  that  the  elbow  cannot  be 
extended,  and  the  supinators ;  the  triceps  sometimes  escapes  affection ; 
the  supinator  longus  is  not  involved  in  lead  palsy  or  traumatism 
below  the  lower  third  of  the  humerus  and  in  centric  disease  it  escapes 
because  its  centre  is  with  the  flexors.     The  extensors  of  the  urist  are 


DISEASES  OF  SPIXAL  NERVES  1177 

involved,  producing  marked  atrophy  of  the  back  of  the  forearm  and 
the  characteristic  wrist  drop;  the  extensors  of  the  thwrib  and  fingers, 
are  affected,  and  become  semiflexed  and  can  only  be  extended  by  the 
interossei  (ulnar  nerve)  after  the  first  phalanges  are  passively  extended. 
Changes  in  the  synovial  sac  or  bones  of  the  dorsal  wrist  produce  the 
painless  carpal  tumor  of  Gubler,  from  involvement  of  branches  to 
the  wrist,  or  more  probably  from  the  mere  mechanical  action  of  flexion 
(see  Lead  Intoxication)  .  (6)  Sensory  disturbance,  which  is  slight  com- 
pared with  the  palsy,  may  rarely  cause  anaesthesia  over  the  deltoid 
and  over  the  back  of  the  forearm  or  more  often  over  the  radial  side  of 
the  dorsum  of  the  hand,  thumb,  index  and  half  of  the  middle  finger. 
Most  cases  recover  with  rest  and  immobilization.  Flexor  contracture 
can  be  avoided  by  careful  splinting. 

Median  Nerve. — The  median  nerve  originates  from  the  outer  and 
inner  cords  of  the  plexus  and  contains  fibers  from  all  its  cervical 
roots.  Isolated  paralysis  is  not  common.  It  results  from  trauma, 
fractures,  stabs,  carrying  weights  in  the  bend  of  the  elbow,  and  sleep- 
ing on  the  arm.  (a)  Motor  symptoms  are  conspicuous.  Both  prona- 
tors are  involved,  besides  all  the  flexors  of  the  forearm,  wrist  and 
fingers  except  the  flexor  carpi  ulnaris  and  the  ulnar  part  of  the  deep 
flexor  of  the  third  and  fourth  fingers.  In  the  hand,  the  palmaris 
longus,  the  abductor,  opponens  and  short  flexor  of  the  thumb  (resulting 
in  flattening  of  the  thenar  prominence  and  the  "ape  hand"  from  the 
index  finger  and  thumb  lying  parallel)  and  the  two  radial  lumbricales 
are  affected.  The  second  phalanges  cannot  be  flexed  on  the  first 
(save  in  the  two  ulnar  fingers);  flexion  of  the  first  phalanges  by  the 
interossei  is  possible;  metacarpophalangeal  subluxation  may  result 
from  the  unopposed  extensor  action  of  the  interossei  on  the  second 
and  third  phalanges.  The  paralyzed  muscles  may  waste  and  trophic 
manifestations  are  quite  common,  (b)  Sensory  symptoms  are  often 
slight.  Anaesthesia,  if  present,  is  greatest  in  the  palm,  front  of  the 
thumb,  the  first  two  fingers  and  half  of  the  third. 

Ulnar  Nerve. — Its  origin  is  the  last  cervical  and  first  dorsal  nerves; 
its  superficial  course  at  the  inner  condyle,  forearm  and  wrist,  expose 
it  to  injury,  as  by  dislocation  of  the  elbow,  cuts  and  pressure  on  the 
elbow  during  sleep  and  work.  Neuritis  occasionally  causes  paralysis. 
It  must  be  distinguished  from  spinal  disease,  which  ascends  from  the 
dorsal  to  the  cervical  region;  this  form  is  usually  bilateral,  and  is 
preceded  by  ulnar  anaesthesia  (Biernacki)  in  tabes  and  paretic  demen- 
tia. The  flexor  carpi  ulnaris  is  paralyzed  (the  hand  deviates  to  the 
radial  side  in  attempts  at  flexion),  and  also  the  ulnar  half  of  the  deep 
flexors  of  the  fingers,  the  muscles  of  the  little  finger,  palmaris  brevis, 
the  interossei,  the  third  and  fourth  lumbricals,  the  adductor  and 
inner  head  of  the  short  flexor  of  the  thumb  (the  thumb  being  rotated 
toward  the  palm).  The  first  phalanges  cannot  be  flexed  nor  the  others 
extended,  although  this  is  less  in  the  first  and  second  fingers,  in  which 


1178  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  lumbricals  are  supplied  by  the  median  nerve.  The  "claw  hand" 
results,  although  it  is  less  marked  than  in  spinal  muscular  atrophy; 
the  hypothenar  eminence,  palm  and  interosseous  spaces  become  thin. 
Sensory  loss  is  limited  to  the  back  and  front  of  the  ulnar  side  of  the 
hand,  the  dorsum  of  two  and  a  half  fingers,  and  the  front  of  one  and 
a  half  fingers  on  the  ulnar  side. 

Combined  Paralysis  of  the  Arm  Nerves. — ^This  affection,  described 
by  Erb  (1884),  is  very  common  and  is  due  to  affections  of  the  verte- 
brae, cord  or  the  nerve  roots,  to  tumors,  trauma  or  cicatrices  of  the 
neck,  and  wrenches  or  forcible  delivery  in  obstetrics.  Several  nerves 
are  involved,  as  the  musculospiral  and  ulnar  in  fracture  of  the  hu- 
merus, or  in  subcoracoid  luxation;  in  Erb's  case,  the  circumflex, 
suprascapular  and  musculocutaneous  nerves,  fifth  and  sixth  cervical 
roots,  with  some  branches  from  the  fourth  were  imbedded  in  a  cicatrix 
and  paralyses  of  the  deltoid,  teres  minor,  spinati,  biceps,  brachialis 
and  supinators,  with  few  sensory  signs  resulted.  Excision  of  the  scar^ 
resection  and  suture  of  the  nerve  resulted  in  recovery.  Erb  found  one 
spot  between  the  scaleni  where  all  these  nerves  could  be  stimulated 
and  where,  therefore,  they  could  be  simultaneously  affected.  Neuritis 
ascending  from  the  median  nerve  may  cause  ulnar  and  musculo- 
cutaneous or  other  paralysis.  Obstetrical  paralysis  usually  results  in 
recovery,  while  adult  forms  depending  on  their  etiology  are  often 
protracted  or  permanent.  Flaubert  (1827)  described  a  combined 
paralysis,  which  usually  bears  Klumpke's  (1885)  name,  in  which 
paralysis  of  the  first  dorsal  and  eighth  cervical  roots  (ulnar  and  median 
paralysis)  also  causes  sympathetic  symptoms,  as  narrowing  of  the 
pupil  and  the  interpalpebral  fissure. 

Brachial  Neuritis. — -This  affection  was  first  clearly  described  by 
Gowers  and  held  to  be  a  perineuritis  of  the  plexus  or  nerve  roots 
(radicular  neuritis),  occurring  largely  in  gouty  or  rheumatic  subjects 
over  fifty  years  of  age,  but  at  times  due  to  compression  or  trauma. 
The  author  saw  one  case  which  occurred  in  the  right  arm  of  a  busy 
surgeon.  A  cervical  rib  may  cause  compression  symptoms ;  Reisman 
(1904)  collected  46  cases  of  which  24  were  operated  on  with  good 
results.  It  is  marked  by  great  pain,  the  first,  most  severe  and  most 
enduring  symptom.  It  is  constant,  with  paroxysmal  exacerbations, 
is  increased  by  the  least  movement,  and  is  experienced  over  the  plexus, 
nerves,  or  referred  to  the  wrist  or  scapula.  Associated  with  it  are 
tenderness  over  the  trunks  or  plexus,  hypersesthesia  of  the  skin,  some 
muscular  wasting,  mostly  in  radicular  forms,  and  somewhat  less  often 
anaesthesia,  anaesthesia  dolorosa,  oedema,  glossy  skin  and  trophic 
alterations  in  the  joints.  Neuralgia,  angina  pectoris  and  aneurysm 
may  cause  diagnostic  difficulties.  Remak  holds  that  reported  recover- 
ies of  acute  poliomyelitis  in  children  (Kennedy's  temporary  paralysis) 
are  only  plexus  neuritis.  The  outlook  is  usually  favorable,  but  a  long 
course  of  from  a  month  to  more  than  a  year,  relapses  and  even  in- 


DISEASES  OF  SPIXAL  XERVES  1179 

complete  recovery  (some  wasting,  cramps,  rheumatic  pains  and  joint 
adhesions)  must  be  considered  in  framing  the  prognosis,  despite 
perhaps  early  and  careful  treatment  as  in  reduction  of  shoulder  dis- 
locations. Treatment  as  in  neuritis,  consists  of  rest  by  immobilization, 
injection  of  cocaine  in  severe  cases,  and  treatment  of  the  underlying 
trauma,  gout  or  rheumatism. 

Nerves  of  the  Trunk. — These  are  rarely  involved  except  in  lesions 
of  the  spine  or  cord.  The  neuritic  pain  in  Pott's  disease  or  cord  tumor, 
and  the  girdle  pain  of  tabes  are  of  great  localizing  value.  It  has  been 
shown  that  herpes  zoster  is  due  to  inflammation  in  the  spinal  root 
ganglia  (Campbell  and  Head). 

Nerves  of  the  Lower  Extremities. — ^These  nerves,  except  in  sciatica, 
are  less  frequently  affected  than  those  of  the  arm. 

The  Lumbar  Plexus. — The  lumbar  plexus  (the  first  three  and  a  half 
lumbar  roots)  may  suffer  in  abdominal  tumors,  glandular  enlargements, 
parturition,  psoas  abscess,  pelvic  inflammations,  spinal  meningitis, 
vertebral  disease  or  in  neuritis  ascendens.  The  symptoms  are  paralysis 
of  the  cremasters,  flexors  and  adductors  of  the  hip  and  extensors  of  the 
knee;  all  the  hip  flexors  are  involved  in  plexus  disease  only;  great 
pain  in  neuritic  forms  is  noted  in  the  ilio-inguinal,  iliohypogastric  and 
genitocrural  areas.  Anwsthesia  exists  over  the  lower  abdomen,  front 
and  sides  of  thigh  and  inner  side  of  leg  and  foot  and  adjacent  sides  of 
first  and  second  toes. 

Anterior  Crural  Nerve. — Lesions  in  the  abdomen  cause  paralysis  of 
the  iliacus  (not  the  psoas),  the  hip  flexors  and  knee  extensors,  with 
wasting,  loss  of  knee  jerk  and  anaesthesia  over  the  front  and  sides  of 
the  thigh  and  the  inner  side  of  the  leg  and  foot.  It  has  occurred  in 
1 . 7  per  cent,  of  labor  cases  and  may  result  from  stab  wounds  of  the 
thigh,  in  which  case  the  iliacus  escapes  involvement.  Neuritis  of  its 
external  cutaneous  branch  (multiple  neuritis,  alcoholism,  nicotinism 
or  gout)  may  cause  isolated  anaesthesia  over  the  lower  outer  half  of 
the  thigh,  paraesthesia  or  marked  hypersesthesia;  the  last  condition, 
known  as  meralgia,  was  described  by  Bernhardt  and  Roth  and  is 
usually  neuritis  but  may  be  due  to  pressure  from  varicose  veins.  It 
is  noted,  chiefly,  on  standing  or  w^alking.  In  1900  ]\Iusser  and  Sailer 
collected  99  cases  (74  per  cent,  in  men). 

Pressure  on  the  cord  at  the  fourth  lumbar  roots  produces  the  same 
result  as  a  partial  lesion  of  the  ant.  crural  nerve,  as  paralysis  of  knee 
extensors,  loss  of  knee-jerk  and  anaesthesia  of  anterior  part  of  thigh, 
but  foot  clonus  is  present.  Disease  of  the  anterior  horns  on  one  side 
may  exceptionally  occur  in  adults,  but  its  wider  prevalence  and  sensory 
exemption  are  usually  sufficiently  distinctive.  Caudal  lesions  are 
usually  bilateral. 

Obturator  Nerve. — This  nerve  is  rarely  alone  involved   save  during 


1180  DISEASES  OF  THE  NERVOUS  SYSTEM 

parturition.  Its  paralysis  affects  the  thigh  adductors,  so  that  the  knees 
cannot  be  crossed,  and  the  pectineus  and  ext.  obturator,  so  that  impair- 
ment of  outward  rotation  of  the  thigh  results.  Sensory  symptoms 
concern  the  hip  and  knee  joints,  which  sometimes  show  trophic  dis- 
turbance. The  pain  of  hip  disease  is  referred  to  the  knee  by  the 
obturator  nerve. 

Superior  Gluteal  Nerve. — This  arises  from  the  lumbosacral  cord, 
being  intermediate  between  the  lumbar  and  sacral  plexuses.  Its  rare 
isolated  involvement  results  in  loss  of  thigh  abduction  and  circum- 
duction (gluteus  medius  and  minimus). 

The  sacral  plexus  (half  of  the  fourth,  the  fifth  lumbar  and  the  first 
four  sacral  nerves)  supplies  motion  to  the  extensors  and  rotators  of 
the  hip,  flexors  of  the  knee  and  all  the  foot  muscles,  and  sensation 
to  the  gluteal  region,  the  back  of  the  thigh,  outside  and  back  of  the 
leg  and  most  of  the  foot  by  the  gluteal  nerves  and  the  two  sciatic 
nerves.  The  lesser  sciatic  is  affected  only  in  disease  of  the  plexus :  it 
is  often  involved  in  pelvic  inflammation  and  tumors,  parturition, 
traction  in  leg  deliveries,  plexus  neuritis  and  diseases  of  the  hip. 

Great  Sciatic  Nerve. — This  is  the  largest,  the  most  exposed  through- 
out its  course  and  hence  the  most  frequently  diseased  nerve  of  the  lower 
extremity.  Paralysis  of  the  gluteus  maximus  interferes  with  rising  more 
than  with  walking.  A  lesion  near  the  sciatic  notch  paralyzes  the  exten- 
sors of  the  hip,  the  flexors  of  the  leg  and  all  muscles  below  the  knee.  If 
the  lesion  lies  below  the  upper  third  of  the  thigh,  the  flexors  of  the 
leg  may  escape  involvement,  and  walking  is  still  possible,  even  though 
all  muscles  below  the  knee  are  paralyzed,  if  the  ant.  crural  nerve  for 
the  hip  flexors  and  knee  extensors  is  intact.  Sensation  is  lessened 
over  the  outer  half  of  the  leg,  most  of  the  dorsum  of  the  foot  and  all 
of  the  sole.  Wasting  is  marked  over  the  back  of  the  thigh  and  perforat- 
ing ulcer  of  the  foot  may  develop.  It  has  two  branches:  (a)  the 
external  popliteal  or  peroneal  nerve,  involvement  of  which  causes 
paralysis  of  the  tibialis  anticus,  peronei,  long  toe  extensors,  extensor 
brev.  digitorum;  the  ankle  cannot  be  flexed  dorsally,  the  first  phalanges 
of  the  toes  cannot  be  extended,  adduction  and  lifting  the  inner  edge 
of  the  foot  is  difficult  and  abduction  and  lifting  its  outer  edge  is  im- 
possible. Foot-drop  results  and  contracture  assumes  the  equihovarus 
type.  This  nerve  is  the  analogue  of  the  musculospiral  in  the  arm. 
Wasting  is  often  observed  and  the  anaesthesia  covers  the  anterior 
outer  half  of  the  leg  and  the  dorsum  of  the  foot,  (b)  Internal  popliteal 
nerve,  involvement  of  which  affects  the  popliteus,  tibialis  posticus, 
long  flexors  of  toes  and  all  the  foot  muscles  except  the  extensors; 
plantar  flexion,  abduction  of  the  foot,  inability  to  stand  on  tiptoe, 
talipes  calcaneus  and  the  claw  foot  from  overextension  of  the  proximal 
and  overflexion  of  the  second  and  third  phalanges  result.  Sensory 
alterations  are  variable;    ansesthesia  may  be  observed  on  the  outer 


DISEASES  OF  SPIXAL  XERVES  1181 

lower  posterior  part  of  the  leg  and  on  the  sole  of  the  foot.  Its  plantar 
branches  are  rarely  affected  alone;  there  may  be  (i)  paralysis  of  the 
internal  plantar  nerve,  which  is  analogous  to  the  median;  ana?sthesia 
on  the  inner  part  of  the  sole  and  the  plantar  surface  of  the  three  inner 
toes  and  one-half  of  the  fourth;  paralysis  of  the  short  toe  flexors, 
plantar  muscles  of  great  toe  (except  the  abductor)  and  the  two  inner 
lumbricals;  the  big  toe  is  overextended,  "the  hammer  toe";  (ii)  paral- 
ysis of  the  external  plantar  nerve,  which  is  the  analogue  of  the  ulnar, 
produces  anaesthesia  of  the  outer  half  of  the  sole,  little  toe  and  one-half 
of  the  fourth,  paralysis  of  the  accessory  flexor,  small  toe  muscles,  all 
the  interossei,  two  outer  lumbricals  and  great  toe  adductor;  the  results 
are  serious,  walking  being  impaired  by  flexion  of  the  second  and  third 
and  extension  of  the  first  phalanges. 

Caudal  Lesions. — (See  Spinal  Localization.) 

Sciatic  Neuritis. — Sciatica,  Ischialgia,  Malum  Cotunnii  (Cotugno, 
1764). — Sciatica  is,  after  facial  neuritis,  the  most  frequent  isolated 
form  and  is  rarely  simply  neuralgic. 

Etiology. — General  Causes. — (a)  Sex  and  age;  88  per  cent,  of 
cases  occur  in  men;  16  per  cent,  in  persons  between  twenty  and 
thirty,  31  per  cent,  between  thirty  and  forty,  25  per  cent,  between 
forty  and  fifty,  and  18  per  cent,  between  fifty  and  sixty  years  of  age. 
It  is  very  rare  in  children.  (6)  Acute  infections,  rheumatism,  and 
grippe,  are  causative,  (c)  Intoxications;  gout,  fascial  rheumatism 
(sometimes  by  extension  from  lumbago),  and  diabetes,  are  factors. 
(d)  Anaemias  and  neuroses  are  much  less  significant  than  in  true 
neuralgia. 

Local  Causes. — These  include  (a)  spinal  affections,  tumor,  and 
neuritis  of  the  cauda;  (6)  abdominal  and  pelvic  disease,  as  aneurysm, 
abdominal  and  pelvic  tumors  or  inflammation;  (c)  cold;  exposure 
and  dampness,  favored  by  certain  occupations;  (d)  trauma  to  the 
spine,  pelvis,  hip  or  peripheral  course  of  the  sciatic  trunk  or  branches, 
as  from  the  use  of  forceps  or  pressure  of  the  head  in  labor,  fractures 
or  dislocations,  falls,  protracted  sitting  or  riding,  use  of  the  sewing 
machine,  marching,  vigorous  contractions  of  the  leg  flexors,  peripheral 
pressure  by  popliteal  aneurysm,  tumors,  callus  or  varicosities. 

Pathology. — In  the  infrequent  autopsies  or  in  surgical  stretching 
of  the  nerve,  its  sheath  shows  perineuritis  with  oedema  and  in  some 
cases  increase  of  connective  tissue  or  varicosities  of  the  sheath  vessels, 
especially  in  the  middle  thigh.     Sometimes  interstitial  neuritis  is  found. 

Symptoms. — The  symptoms  are  unilateral  and  chiefly  sensory,  as 
pain  and  tenderness  over  the  sciatic  roots,  trunk  and  branches,  (a) 
The  onset  of  pain  is  usually  gradual  but  is  sudden  and  febrile  in  some 
rheumatic  cases.  It  is  usually  constant,  with  exacerbations  which 
in  some  cases  are  agonizing.  The  pain  descends  more  often  than  it 
ascends;  it  sometimes  radiates  to  the  buttocks  and  crural  region,  even 
into  the  other  leg.  Gowers  attributes  the  local  pain  to  perineuritis, 
and  the  distant  pain  to  interstitial  neuritis.      Any  movement  which 


1182  DISEASES  OF  THE  NERVOUS  SYSTEM 

increases  sciatic  tension  increases  or  renews  the  pain  (Lasegue's 
phenomenon);  pain  is  increased  or  initiated  by  flexing  the  hip  and 
extending  the  knee,  walking,  stooping,  or  by  defecation.  The  patient 
seeks  positions  which  spare  stretching  of  the  nerve  and  its  compression 
by  the  muscles ;  he  may  lie  on  the  opposite  side  with  the  thigh  extended, 
knee  flexed  and  foot  extended,  or  on  his  back  with  hip  and  knee  flexed 
and  foot  extended;  in  standing,  he  rests  on  the  sound  leg,  and  in 
protracted  cases  scoliosis  develops  (ischias  scoliotica,  Albert,  1886),  in 
which  the  lumbar  convexity  is  toward  the  diseased  side,  heterologous 
scoliosis,  which  usually  disappears  wdth  the  disease;  a  homologous 
scoliosis  (with  the  lumbar  concavity  toward  the  affected  side)  may  result 
in  case  the  muscles  of  that  side  become  spasmodic.  (6)  Tenderness  may 
be  detected  over  the  entire  course  of  the  nerve  or  in  certain  locations 
only;  (i)  over  the  lumbar  region;  (ii)  near  the  sacrum  and  post.  sup. 
iliac  spine;  (iii)  at  the  lower  gluteal  fold  where  it  leaves  the  sciatic 
notch;  (iv)  between  the  tuber  ischii  and  trochanter;  (v)  especially 
over  the  middle  of  the  posterior  surface  of  the  thigh;  and  (vi)  in  other 
lower  areas  of  distribution  over  the  popliteal  space,  head  of  fibula, 
calf,  internal  and  external  malleoli  and  sole.  The  enlarged  nerve  may 
occasionally  be  felt.  Pain  is  often  experienced  in  the  hip  and  sciatic 
notch  when  pressure  is  made  in  the  popliteal  space,  (c)  Other  symp- 
toms are  less  frequent,  as  vasomotor  changes,  herpes,  muscular 
cramps,  twitchings,  fibrillation  or  wavy  movements  (myokymia); 
there  is  usually  some  diminution  in  the  electrical  excitability  or  perhaps 
an  increase,  but  there  are  rarely  marked  evidences  of  the  degenerative 
reaction;  muscular  atrophy  may  occur  from  disuse  or  neuritic  atrophy; 
sciatic  paralysis  may  occur;  hypersesthesia,  parsesthesia,  or  in  severe 
cases  anaesthesia,  may  develop  in  the  posterior  part  of  the  thigh,  leg 
or  foot;  very  rarely  there  is  polyuria  or  glycosuria.  The  patellar 
reflex  is  usually  normal,  the  Achilles  reflex  is  often  decreased  or  absent 
and  Gibson  found  the  cremasteric  usually  increased. 

Diagnosis. — (a)  The  etiological  factor  should  be  sought,  (b)  The 
pelvis  should  always  be  examined  in  women  and  the  rectum  in  both 
sexes,  because  compression  produces  more  distant  than  local  pain; 
the  urine  should  always  be  examined  for  sugar  and  albumin;  and 
free  catharsis  and  bowel  lavage  should  always  be  given,  (c)  Bilateral 
sciatic  pain  suggests  disease  of  the  cord,  especially  tabes,  a  lesion  of 
the  Cauda,  in  both  of  which  there  is  no  sciatic  tenderness,  or  it  prompts 
examination  for  sugar,  (d)  Coxitis,  sacro-iliac  or  psoas  disease  present 
appropriate  local  signs,  without  however  Lasegue's  sign  or  sciatic 
tenderness,  both  of  which  are  also  absent  in  (e)  hysteria.  (/)  Muscular 
rheumatism  is  irregular  and  is  chiefly  confused  with  pain  over  the 
sciatic  branches. 

Prognosis. — The  prognosis  is  generally  good,  in  regard  to  the  ulti- 
mate outcome.  It  depends  on  (a)  whether  the  affection  is  primary,  as 
from  cold,  or  secondary,  as  from  disease  of  the  cord,  or  pelvic  neo- 
plasm; (b)  the  amount  of  rest  which  the  patient  accepts;  (c)  the 
intensit}'  of  the  neuritis,  which  may  extend  to  the  lumbosacral  plexus; 


DISEASES  OF   SPIXAL   XERVES  1183 

and  id)  the  chance  (in  33  per  cent.)  of  relapse.  The  average  course 
is  from  two  to  eight  weeks,  but  cases  may  last  over  a  year,  indeed  one 
to  three  or  exceptionally  six  to  thirty  years. 

Treatment. — (a)  Treatment  is  that  of  the  cause;  the  salicylates, 
in  some,  but  unfortunately  few,  cases  afford  relief;  gouty  or  syphilitic 
taints  may  be  benefited  by  colchicum  or  antisyphilitic  remedies, 
which  are  often  given  as  a  last  resort  in  other  cases,  (b)  Rest  in  bed 
is  the  most  important  indication.  In  this,  the  use  of  Wier  Mitchell's 
long  splint  is  often  beneficial,  (c)  C ounierirritaiion  by  blisters  over 
the  nerve's  course  or  by  touching  the  tender  or  painful  points  with 
the  hot  iron,  may  give  temporary  though  rarely  lasting  relief,  id) 
Analgesics  and  narcotics  may  be  used.  Acetanilide  has  little  effect. 
Gelsemium  (fl.  extr.  ttj  ii)  at  intervals  of  two  to  four  hours,  not  in- 
frecjuently  gives  relief,  though  it  is  necessary  to  watch  for  pulse  weak- 
ness and  cutaneous  tingling.  Codeine  and  atropine  should  be  given 
before  resort  is  had  to  morphine,  though  morphine  is  often  inevitable, 
but  always  dangerous.  Chronic  morphinism  may  be  promoted  by 
severe  pain,  the  long  course,  and  the  tendency  to  relapse.  Hypodermics 
of  cocaine  are  very  beneficial,  though  this  method  is  attended  by  the 
same  danger.  Simple  hypodermics  of  water  are  sometimes  valuable, 
and  the  author  has  seen  good  results  from  deep  hypodermatic  use  of 
Schleich's  solution  given  in  quite  large  amounts  over  sensitive  points. 
Lange  recently  advises  the  use  of  160  c.  c.  of  0.1  per  cent,  eucain 
into  the  muscle  and  nerve  at  the  sacrosciatic  foramen.  Injections  of 
chloroform  and  ether  are  recommended,  but  should  be  avoided  because 
of  the  possibility  not  only  of  sloughing  but  also  of  accentuating  the 
neuritis,  (e)  Acupuncture,  the  old  Chinese  treatment,  is  recom- 
mended by  Gibson;  it  resulted  in  complete  relief  in  56  per  cent,  of 
his  cases,  much  improvement  in  32  per  cent.,  slight  benefit  in  10  per 
cent.,  and  failure  in  but  2  per  cent.  (/)  Massage  may  be  given.  Xegro 
has  obtained  results  from  frequent  and  severe  local  rubbing  and  rolling, 
over  the  nerve  trunk,  (g)  Electrotherapy  may  aggravate  the  pain  and 
is  at  least  of  uncertain  value.  Galvanism  is  reported  to  have  helped 
some  cases,  {h)  Nerve  stretching  may  be  effected  by  extension  by 
weights,  although  it  is  rarely  tolerated  by  the  patient  in  personal 
experience.  The  direct  exposure  of  the  nerve  has  justly  fallen  into 
disuse,  for  the  same  results  attend  simple  stretching,  which  should  be 
performed  under  anaesthesia.  The  hip  should  be  strongly  flexed,  the 
knee  extended,  the  foot  dorsally  flexed,  and  the  pelvis  firmly  immobi- 
lized. Ordinary  care  prevents  luxation  of  the  hip.  The  results  were 
excellent  in  half  of  twenty  personal  cases,  and  were  seemingly  curative 
in  seven. 


1184  DISEASES  OF  THE  NERVOUS  SYSTEM 

V.  NEUEOSES. 

HYSTERIA. 

Definition.— The  neuroses  are  nervous  affections,  provisionally 
isolated  and  often  designated  "functional,"  since  no  anatomical  basis 
has  yet  been  discovered.  Hysteria  is  difficult  to  define.  Mobius 
considers  it  "a  state  in  which  ideas  control  the  body  and  produce 
morbid  changes  in  its  functions."  The  school  of  Charcot  has  estab- 
lished the  psychogenic  nature  of  hysteria.  It  is  a  cerebral,  cortical 
condition,  in  which  the  sensory  and  motor  centres  are  affected,  the 
perception,  association  and  recollection  of  ideas  are  disturbed  and 
trophic  and  vasomotor  disorders  occur.  As  its  name  implies,  hysteria 
was  long  thought  to  be  due  to  the  uterus;  Sydenham  first  called  it  a 
nervous  affection. 

Etiology. — (a)  Age:  It  is  most  frequent  at  puberty  and  adolescence 
(fifteen  to  twenty-five  years).  It  is  occasionally  seen  in  children  (six  to 
ten  years  or  even  earlier),  and  rarely  in  middle  or  advanced  life.  (6) 
Sex:  Women  are  six  to  ten  times  as  frequently  affected  as  men, 
although  in  the  lower  French  classes,  it  is  more  frequent  in  males. 
(c)  Race:  The  Jewish,  Latin  and  Slavic  races  are  most  frequently 
affected,  (d)  Heredity:  Charcot,  and  most  of  the  modern  French 
school,  hold  that  this  is  the  sole  cause,  other  factors  being  only  agents 
provocateurs.  Parental  intoxications,  toxaemias,  constitutional  diseases, 
as  gout,  diabetes,  arthritis  deformans  and  a  neurotic  taint  are  im- 
portant in  the  transmission  of  a  congenitally  weak  nervous  system. 
(e)  Acquired  hysteria  may  be  due  (i)  to  various  intoxications,  notably 
lead,  alcohol  and  drugs;  (ii)  to  infections,  as  typhoid,  malaria,  diph- 
theria, and  syphilis;  (iii)  to  constitutional  maladies,  as  gout,  diabetes, 
chlorosis,  secondary  anaemias  or  cancer;  (iv)  to  exhaustion  from  mental 
or  physical  overwork  or  excesses;  (v)  to  emotional  disturbance  of  any 
kind;  (vi)  to  trauma,  especially  factors  involving  psychical  shock,  (vii) 
It  may  occur  as  an  associate  with  chronic  nervous  disease,  epilepsy, 
syringomyelia,  tabes,  brain  tumor,  and  multiple  sclerosis,  (viii)  Imi- 
tation is  an  important  factor  in  schools,  hospitals,  and  at  religious  re- 
vivals; endemics  occasionally  occur  now  as  they  did  in  the  middle  ages. 
(Reier  to  Zola,' s  Lour des.)  Reference  to  the  sexual  organs  as  causes 
and  to  refiex  hysteria  is  purposely  omitted,  because  they  have  no 
etiological  bearing.  The  factors  enumerated  under  acquired  hysteria 
are,  according  to  the  French  School,  merely  incidental  causes,  making 
manifest  the  latent  hereditary  disposition. 

Symptoms. — 'There  is  no  typical  clinical  picture,  and  the  disease  is 
much  more  commonly  polysymptomatic  than  monosymptomatic. 
French  writers  distinguish  two  main  groups  of  symptoms,  the  stigmata 
and  accidents. 

The  stigmata  are  usually  but  not  necessarily  persistent  symptoms. 


HYSTERIA  1185 

1.  Sensory  Stigmata, — Sensory  symptoms  are  present  in  85  per 
cent.,  are  more  frequent  than  the  motor  and  are  often  combined  with 
them,  (a)  Hysterical  anoesthesia  in  some  form  is  very  seldom  absent. 
It  must  often  be  looked  for,  but  the  fact  should  not  be  too  obviously 
suggested  to  the  patient.  It  varies  in  degree  and  form.  It  may  be 
absolute,  affecting  appreciation  of  touch,  pain,  heat  and  cold.  Anal- 
gesia is  its  most  common  form  and,  in  decreasing  order  of  frequency, 
there  may  be  complete  anaesthesia,  hypsesthesia,  loss  of  tactile  sense, 
loss  of  all  sensation  save  to  the  faradic  current,  or  loss  of  faradic 
response  alone.  In  the  mucosae  the  same  deficit  frequently  occurs, 
and  sometimes  the  bones,  ligaments,  joints  and  muscles  are  likewise 
anaesthetic  or  analgesic.  The  distribution  varies.  In  rare  cases  there 
is  universal  cutaneous  and  muscular  anaesthesia;  the  following  are 
more  frequent:  Hysterical  heinian(Esthesia,  which  involves  precisely 
one-half  of  the  skin,  often  the  accessible  mucosae  and  the  special  senses ; 
segmentary  or  geometrical  anaesthesia,  which  affects  one  limb  or  part 
of  it,  is  variously  described  as  "mitten,  or  stocking"  anaesthesia,  and  is 
frequently  associated  with  motor  or  special  sense  disturbance  in  the 
part  affected,  as  paralysis,  aphonia,  amblyopia,  and  deafness;  and 
insular  anaesthesia,  which  affects  small  areas,  and  is  therefore  fre- 
quently overlooked. 

Characteristics. — The  anaesthesia  is  psychical,  is  associated  with 
the  functions  of  the  part  affected  and  does  not  follow  the  area  of 
distribution  of  the  peripheral  nerves  or  the  spinal  segments;  it  is  not 
noted  by  the  patient,  at  least  until  suggested;  fine  movements  may  be 
conducted  with  the  aid  of  the  eyes,  as  the  using  of  a  pen;  it  may  be 
localized  because  of  injury  or  disease  in  the  part.  Most  of  the  reflexes 
which  are  usually  altered  by  organic  disease,  remain  normal,  as  the 
pupillary,  lachrymal,  epigastric,  cremasteric,  patellar  and  organic 
reflexes,  while  the  pharyngeal  in  90  per  cent,  of  cases  is  lost  as  well  as 
the  plantar  (though  the  knee  reflex  remains);  the  anaesthetic  areas 
may  last  during  life,  but  they  vary,  move  even  under  examination 
(Patrick),  or  disappear  from  emotion,  strongly  aroused  attention, 
drugs  or  on  application  of  various  indifferent  substances,  as  metal  or 
wood   (transferring  it  to  the  opposite  side). 

Hysterical  hyperoesthesia  and  hyperalgesia  are  very  common  in 
localized  areas,  but  never  in  universal  or  hemiplegic  distribution. 
They  occur  spontaneously,  or  from  attention  directed  to  a  part  or 
organ,  as  by  traumatism.  A  joint  may  be  affected  with  or  without 
contracture  (Brodie's  joints),  and  this  often  leads  to  great  and  un- 
fortunate errors.  There  is  sometimes  hypaesthesia  in  the  sphere  of  any 
of  the  special  senses.  The  feeling  of  a  nail  in  the  top  of  the  head 
(clavus  hystericus),  sensitive  spots  in  the  mammae,  epigastrium,  groins 
or  spine  are  the  most  common  forms  and  may  occur  in  the  midst  of  anaes- 
thetic areas.  The  so-called  ovaralgia  is  found  more  often  in  the  left  side 
and  is  cutaneous;  it  has  no  relation  to  the  location  or  to  disease  of 
the  ovary;  it  occurs  also  in  men  and  in  women  normal  as  to  the  pelvis. 
Because  hysterical  attacks  have  been  initiated  and  sometimes  stopped 

75 


1186  DISEASES  OF  THE  NERVOUS  SYSTEM 

by  pressure  over  this  and  other  sensitive  areas,  they  have  been  called 
hysterogenic  points  or  zones,  but  attacks  are  only  so  produced  in  patients 
already  hysterical  and  the  hysterical  seizure  on  pressure  results  only 
from  some  associated  memory  on  the  part  of  the  patient ;  they  are  often 
the  result  of  suggestion.  The  special  senses.  Taste  and  smell  may  be 
dulled  or  hypersensitive,  and  hearing  may  be  blunted,  or  more  rarely 
complete  central  deafness  results,  which  is  usually  associated  with 
anaesthesia  in  and  about  the  auditory  meatus.  Complete  loss  of  vision 
is  both  rare  and  transitory.  Hemiopia  and  scotomata  are  almost 
always  organic  and  not  hysterical.  Partial  stigmata  are  more  com- 
mon. In  most  cases  there  is  concentric  contraction  of  the  visual  field, 
which  is  usually  bilateral,  but  unequal  on  the  two  sides,  and  generally 
greater  on  the  side  of  the  cutaneous  defects.  Concentric  contraction 
of  the  field  for  colors  (dyschromatopsia)  is  more  characteristic,  even 
pathognomonic.  In  the  normal  eye,  blue  has  the  largest  field,  then 
yellow,  orange,  red,  green  and  violet;  in  hysteria  the  red  field  is  often 
wider  than  the  blue  and  is  the  last  color  lost.  Achromatopsia  designates 
the  complete  loss  of  color  perception.  Errors  in  accommodation 
(always  excluding  abnormal  corneal  curvatures)  may  cause  double 
images  in  one  eye — -the  other  being  closed — -(monocular  diplopia,) 
triple  images  (polyopia),  or  large  or  small  images  (macropsia,  mic- 
ropsia). In  hysterical  amblyopia,  impairment  of  vision  in  the  affected 
eye  is  decreased  when  the  other  eye  is  opened. 

2.  Motor  Stigmata. — These  are  much  less  conspicuous  but  fore- 
shadow the  motor  accidents  described  later.  Voluntary  movements 
are  weaker,  more  clumsy,  slower,  less  coordinate  than  normal,  and 
there  is  a  slight  tendency  toward  contractures. 

3.  Mental  Stigmata. — These  are  in  certain  cases  so  pronounced 
as  to  justify  the  term  psychosis.  Hysteria  is  always  a  psychical  affec- 
tion. The  most  conspicuous  alienation  is  impairment  of  memory 
(amnesia),  which  concerns  memory  in  the  ordinarily  accepted  sense, 
as  memory  for  persons,  things,  words,  hysterical  paroxysms  experi- 
enced, etc.,  or  concerns  memory  and  associations  for  speech,  writing, 
walking  or  standing.  The  amnesia,  like  the  paralysis  or  anaesthesia, 
is  functional,  and  like  them,  returns,  save  in  rare  cases.  Mental  power 
is  distinctly  decreased,  will  power  is  lost  (aboulia)  or  lessened,  and  the 
patient  becomes  the  ready  victim  of  impulses,  impressions,  sugges- 
tions, fixed  ideas  and  misconceptions  both  on  his  own  part  and  on 
that  of  others  who  incorrectly  consider  him  deceitful,  vain  or  erotic. 

Accidents. — The  accidents  of  hysteria  are  the  incidental  attacks, 
also  called  seizures  or  paroxysms.  They  are  usually  transient  or  inter- 
mittent, but  may  become  fixed  and  are  then  ranked  as  stigmata, 

1.  Motor  Accidents. — (a)  Convulsions  occur  in  54  per  cent, 
of  all  and  84  per  cent,  of  female  hysteria.  They  are  much  less  fre- 
quently the  hysteria  major  (grande  attaque  of  Charcot)  than  the  partial, 
modified  type  (hysteria  minor).  The  "grand  attack"  (Charcot, 
Richer)  comprises  (i)  a  prodromal  stage,  with  mental  depression  or 
exaltation,   palpitation,   vasomotor  symptoms,   nausea,   polyuria,   an 


HYSTERIA  1187 

aura  beginning  in  the  epigastrium  and  culminating  in  feelings  of 
choking  (globus  hystericus),  vertigo,  and  unconsciousness;  (ii)  a 
period  of  epileptiform  convulsions  (so-called  hystero-epilepsy)  in  which, 
in  exceptional  cases,  there  may  be  biting  of  the  tongue  or  even  the  cry 
of  epilepsy;  the  face  is  at  first  pale,  then  red;  the  teeth  are  ground; 
the  convulsion  is  most  pronounced  on  the  anaesthetic  side,  toward 
which  the  face  turns;  the  tonic  spasm  lasts  less  than  two  minutes,  and 
is  often  characterized  by  stupor,  stertor  and  slow  wide  movements  of 
supination,  circumduction,  and  overextension,  for  the  trunk  and  body 
are  tetanically  rigid;  then  the  clonic  spasm  develops,  with  sobbing 
respiration,  audible  swallowing,  abdominal  rumbling  and  small 
clonic  movements.  Resolution  follows  slowly,  (iii)  There  is  a  period 
of  "clownism,"  characterized  by  contortions  and  grand  movements, 
as  opisthotonos  (arc  de  cercle),  bowing  movements,  violent  struggling, 
screams,  strikes  and  bites,  (iv)  There  is  next  a  period  of  "passional 
attitudes,"  in  which  the  subject  mimics  terror,  rage,  joy,  and  love; 
this  is  followed  by  (v)  a  stage  of  delirium  with  hallucinations,  perhaps 
of  animals  (zoopsia).  The  entire  attack  covers  fifteen  to  thirty  minutes 
and  frequent  repetitions  constitute  the  "status  hystericus." 

The  'partial  attack  contains  some  of  the  elements  of  the  major  type, 
and  infinite  variations  occur;  in  the  vertiginous  type,  there  is  vertigo 
and  sometimes  the  other  features  of  Meniere's  disease;  the  globus 
type  is  extremely  common;  the  epileptiform  variety  closely  resem- 
bles epilepsy;  there  are  also  tetanic,  emotional  and  syncopal  types; 
trance-like  sleep,  with  catalepsy  in  which  the  limbs  retain  any  atti- 
tude given  them,  with  sleep,  which  is  apparent  only,  for  the  subject 
later  recalls  everything;  there  may  be  attacks  of  somnambulism,  in 
which  patients  run  miles  or  even  undertake  distant  travel  without 
recollection  of  the  transpired  interval,  (b)  Paralysis  is  an  accentua- 
tion of  the  stigmatic  muscular  weakness.  In  over  50  per  cent,  it 
develops  after  convulsive  paroxysms;  again  it  follows  emotional 
causes,  traumatism  or  organic  brain  disease.  It  develops  suddenly 
or  gradually;  it  assumes  the  paraplegic  five  times  as  often  as  the 
hemiplegic  form;  the  monoplegic  variety  is  less  frequent;  the  tri- 
plegic,  diplegic  (quadriplegic)  or  crossed  forms  are  most  common. 
They  are  rarely  complete;  often  automatic  (gesticulatory)  movements 
may  be  seen;  the  antagonistic  muscles  are  also  involved,  thus,  in 
attempted  flexion  of  the  knee  the  knee  extensors  contract;  remissions 
and  relapses  may  occur;  the  paralyzed  part  may  be  limp  or  contrac- 
tured;  the  paralyses  may  be  ephemeral  or  life-long  in  duration; 
paralysis  may  be  "ideal,"  i.  e.,  only  for  standing  or  walking.  Vaso- 
motor changes  and  oedema  are  rare;  Wier  Mitchell  described  a  hemi- 
oedema;  the  tendon,  skin  and  electrical  reactions  are  usually  normal, 
although  the  tendon  reflexes  may  be  increased.  Hysterical  hemiplegia 
occurs  three  times  as  frequently  on  the  left  as  on  the  right  side.  Its 
differentiation  from  organic  hysteria  is  based  on  Babinski's  table 
on  the  following  page.  j 


1188 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Organic  Hemiplegia. 


-Hysterical  Hemiplegia. 


Coma:   often  complete. 


Reflexes:  tendon  and  bone  reflexes  abol- 
ished at  first;  later  increased.  Ankle 
clonus. 

Cutaneous  reflexes  (abdominal  and 
cremasteric)  early  lessened  or  abol- 
ished; Babinski  toe  sign;  lachrymal 
reflex  abolished. 

Paralysis:  (1)  Unilateral  ;  (2)  not  sys- 
tematized; face,  arm  and  leg  are 
weak  during  bilateral  synergetic 
movements.  (3)  Involves  subcon- 
scious as  well  as  conscious  voluntary 
movements,  producing  the  platysma 
sign  (lessening  of  its  contraction  on 
the  hemiplegic  side,  e.  g.  on  opening 
the  mouth  forcibly),  and  the  com- 
bined flexion  of  the  thigh  and  trunk 
(when  the  patient  attempts  to  sit  up). 
(4)  Paralysis  slowly  improves  some, 
but  is  not  variable. 

The  tongue  deviates  slightly  toward  the 
paralyzed  side. 

Lower  -muscular  tone,  as  lowering  of  the 
eyebrow  or  exaggerated  flexion  of  the 
forearm,  especially  in  early  cases. 

Contracture  cannot  be  voluntarily  repro- 
duced; at  first  flaccid  paralysis,  then 
contracture. 


Hemiancesthesia:  rarely  total;  mostly 
of  stereognostic  and  muscle  sense;  in 
general  rare;  coarser;  more  lasting 
when  present;  often  with  bilateral 
hemianopsia. 


Rarely  complete  (automatic  movements 
often  persist). 

Never  abolished;  no  clonus  (or  only  a 
spurious  ankle  clonus  due  to  contrac- 
tion of  the  calf  muscles,  Gowers). 

Skin  reflexes  normal;    no  toe  sign. 


Never  abolished   (Spiller). 

(1)  Not  always  unilateral;  if  face  in- 
volved, usually  on  both  sides.  (2) 
Paralysis  sometimes  systematized; 
and  hemiplegic  side  functionates 
perfectly  in  bilateral  synergetic  move- 
ments. (3)  Subconscious  voluntary 
movements  are  not  involved;  ab- 
sence of  the  platysma  sign  and  that  of 
combined  flexion  of  the  thigh  and 
trunk.  (4)  Variable  paralysis,  im- 
provement alternating  with  relapses. 
Absolute  aphasia  with  ability  to 
write  (Charcot). 

Very  slightly,  very  greatly  or  even 
toward  the  sound  side. 

None.  Asymmetry  of  the  face  is  due  to 
spasm,  and  exaggerated  flexion  of  the 
forearm  is  absent. 

May  be  reproduced:  variable  paralysis, 
now  persistently  flaccid,  now  spastic 
froin  onset;  flaccidity  with  increased 
reflexes  highly  characteristic. 

Often  total,  involving  special  senses, 
mostly  involving  pain  and  pressure 
sense;  frequent;  variable  in  duration 
and  location;  usually  witli  concentric 
contraction  of  visual  field,  and  some- 
times with  crossed  amblyopia. 


In  hysterical  paraplegia  there  are  usually  no  trophic  changes,  no  bed- 
sores, no  electrical  alteration,  no  incontinence  of  urine  or  faeces,  and 
rarely  retention  of  urine;  concomitant  sensory  changes  are  significant, 
but  many  errors  in  diagnosis  are  made.  Hysterical  monoplegia  usually 
occurs  with  anaesthesia  of  even  greater  extent  and  segmental  distri- 
bution; it  is  lawless  and  illogical,  viewed  from  the  standpoint  of 
organic  disease.  In  astas ia-ab as ia  (Charcot  and  Blocq),  the  patient 
is  unable  to  stand  or  walk,  although  the  muscles  concerned  may  be 
efficient  in  other  movements.  The  condition  is  essentially  hysteria, 
although  it  was  thought  to  result  from  neurasthenia  and  hypochon- 
driasis. Lesser  degrees  are  called  dystasia  or  dyshasia.  The  term 
stasobasophobia  is  self-descriptive.  Mobius'  akinesia  algera  is 
similar,     (c)  Hysterical  contractures  precede,  succeed  or  alternate  with 


HYSTERIA  1189 

paralysis,  or  occur  alone,  but,  as  Church  well  says,  they  are  "rigid 
palsies";  they  usually  persist  during  sleep  and  yield  to  ether  ana?sthe- 
sia,  save  in  severe  protracted  cases  with  great  fibrous  transformation 
and  irremediable  deformity;  they  develop  and  terminate  suddenly  or 
gradually;  their  causes  of  onset  and  distribution  are  as  in  paralysis. 
In  the  arms,  contracture  of  the  flexors  predominates ;  in  the  legs,  that 
of  the  extensors  (club  foot).  Various  spinal  deformities  may  develop, 
most  frequently  from  pseudosciatica.  Wier  ^Mitchell  has  seen  the 
muscles  so  contracted  as  to  resemble  actual  muscle  tumors.  It  is  still 
stated  that  the /ace  always  escapes  paralysis,  but  its  lower  portion  may  be 
weak;  more  often,  however,  it  is  contracted  early,  even  when  paralyzed; 
hemispasmus  glossolabialis  and  trismus  have  been  observed.  Spastic 
or  pseudo-ptosis  may  resemble  the  paralytic  form,  but  spasticity,  the 
lowered  or  more  level  eyebrow,  and  the  concentric  or  parallel  folds  in 
the  lid,  are  distinctive  of  contracture.  The  ocular  muscles  are  seldom 
involved;  voluntary  movement  may  be  impossible,  but  associated  and 
reflex  movements  are  normal;  convergent  squint  may  occur,  but  never 
the  divergent  type  nor  contracture  of  a  single  rectus  or  oblique  muscle; 
pain  suggests  hysteria.  The  pupils  are  usually  said  to  be  normal  but 
Karplus  maintains  that  the  light  reflex  is  lost  during  convulsive  seizures. 
Organic  disease  of  the  hip  may  be  simulated;  local  hysterical  oedema 
may  occur.  Brodie  (1827)  first  drew  attention  to  this  group  of  cases, 
and  later  Duchenne.  Many  avoidable  diagnostic  errors  are  constantly 
made,  (d)  There  may  be  rhythmical  spasms,  tremor,  or  tic.  Rhyth- 
mical spasms,  chorea  major,  the  saltatoric  chorea  {v.  i.)  and  local 
manifestations,  as  barking  cough  or  the  various  tics,  may  occur. 
Hysterical  tremor  is  wholly  a  "rest  tremor";  that  is,  it  occurs  without 
voluntary  movement.  It  may  resemble  the  senile,  Basedow^,  or  lead 
tremors,  or  that  of  paralysis  agitans  or  may  be  combined  with  them. 
It  rarely  simulates  the  intention  tremor  of  multiple  sclerosis. 

2.  Sensory  Accidents. — These  are  frequent,  and  are  often  severe 
and  painful.  Headache  may  occur;  it  is  often  dull  or  may  be  severe;  it 
may  be  superficial  or  deep;  it  may  resemble  trigeminal  neuralgia, 
migraine  or  the  headache  of  organic  disease  as  tumor.  Meningitis 
(hysterical  pseudomeningitis)  may  be  closely  counterfeited.  Spinal 
or  vertebral  pain  is  frequent  and  sometimes  suggests  tumor  or  caries. 
One  and  three-tenths  percent,  of  cases  of  sciatica  are  said  to  be  hysteri- 
cal. Joint  disease  and  various  visceral  lesions  (u.  i.)  may  be  closely 
mimicked.  Dieulafoy  (1905)  collated  59  cases  of  hysterical  blindness, 
in  5  of  which  this  accident  was  the  only  symptom. 

3.  Visceral  Accidents. — (a)  Cardiac  accidents  include  tachycardia, 
palpitation  and  pseudo-angina  pectoris.  (6)  Respiratory  accidents: 
Aphonia,  usually  attended  by  normal  capacity  to  cough  and  often  also 
to  sing,  has  been  described  under  paralysis  of  the  vocal  cords.  It  is 
usually  due  to  an  "idea, "  as  in  aphasia  of  the  motor  type,  which  allows 
the  patient  to  write.  Stammering,  cough,  and  cries,  may  be  provoked 
by  local  nasopharyngeal  disease.  Dyspnoea,  resulting  from  paralysis 
of  the  diaphragm,  and  laryngeal  spasm  have  already  been  considered. 


1 190  DISEASES  OF  THE  NERVOUS  SYSTEM 

Rapid  breathing  (tachypnoea)  also  occurs.  The  combination  of 
dyspnoea,  aphonia  and  paralysis  of  the  diaphragm  constitutes  Briquet's 
syndrome.  Haemoptysis  may  occur,  usually  in  the  course  of  phthisis, 
but  sometimes  without  it,  possibly  as  a  vasomotor  derangement,  since 
the  blood  is  thin;  one  fatal  case  is  on  record.  (c)  Digestive  Siccidents: 
Hysterical  anorexia  results  from  cortical  conception,  stomach  pain, 
dysphagia  from  spasm,  or  simple  sensory  perversion;  it  may  endure  for 
weeks  and  cause  extreme  inanition  or  even  death.  Hysterical  (pseudo-) 
hydrophobia  is  an  analogous  aversion  to  water.  Vomiting  is  sometimes 
simulated  by  protracted  globus  or  oesophageal  spasm,  in  which  the 
food  is  simply  regurgitated.  Vomiting  itself  may  be  occasional,  or 
attacks  may  last  weeks  or  months,  often  with  remarkably  little  malnu- 
trition; it  is  rarely  fsecal  but  substances  injected  by  rectum  may  be 
vomited  in  a  few  hours,  or  again  may  be  blood-tinged,  possibly  from 
vasomotor  disturbance  or  more  often  from  actual  disease,  as  round 
ulcer.  Ulcer  may  also  be  simulated  by  pain  and  tenderness,  which 
are  surprisingly  well  confined  not  to  one  spot,  but  to  the  exact  outlines 
of  the  stomach.  The  vomitus  contains  vicariously  large  amounts  of 
urea  when  the  urine  is  suppressed.  Eructations  are  frequent  and  so 
much  gas  escapes  that  one  must  conclude  that  air  has  been  swallowed; 
this  also  probably  causes  tympanites,  in  which  swallowed  air  reaches 
the  gut  through  the  incompetent  pylorus  (Ebstein).  Phantom  tumors 
or  spurious  pregnancy  (pseudocyesis)  are  explained  by  Gowers  as 
protrusion  of  the  distended  bowel  by  tonic  contracture  of  the  diaphragm. 
Peristaltic  unrest,  diarrhoea  on  eating,  enteritis  membranacea,  spastic 
constipation,  simulation  of  peritonitis,  rectal  stricture  or  intestinal 
obstruction  also  occur,  (d)  Genito-urinary  accidents :  Anuria  in  some 
cases  has  existed  for  ten  days  without  uraemia.  Renal  pain  is  not 
frequent,  but  hyperaesthesia  of  the  bladder  is  common.  The  urine  is 
often  greatly  increased,  with  low  specific  gravity  and  solids.  During 
attacks  of  the  major  type,  the  solids  are  reduced,  the  urea  one-third 
and  phosphates  one-half;  the  phosphates,  which  normally  have  a 
proportion  of  3  of  the  alkaline  to  1  of  the  earthy  phosphates,  show 
rearly  an  equal  proportion  of  each.  Depression  of  the  genital  functions 
is  more  common  than  exaltation;  anaesthesia  is  frequent;  vaginismus 
may  be  observed.  Lower  has  found  that  the  hysterical  ovarian  and 
other  genital  pains  have  no  relation  to  local  pelvic  disease,  a  rather 
gratifying  gynaecological  observation. 

Hysterical  fever  is  a  disputed  topic.  It  is  an  established  fact  that 
severe  forms  may  suffer  a  rise  to  105  or  110°  or  higher.  With  visceral 
manifestations,  this  may  lead  to  a  diagnosis  of  meningitis  or  peritonitis; 
but  on  the  other  hand  the  possibility  of  simulation  by  the  patient  rub- 
bing the  thermometer,  or  more  important  still,  the  possibility  of  con- 
fusion with  tuberculosis  or  typhoid,  must  always  be  kept  in  mind. 

4.  Vasomotor  and  Trophic  Accidents. — These  are  rare.  Ery- 
thema is  the  most  common.  Gangrene,  falling  out  of  the  hair  or' 
nails,  Raynaud's  local  asphyxia,  cutaneous  hemorrhages  (crucifixion 
stigmata,  stigmata  diaboli),  bloody  sweats,  lachrymation,  haemoptysis. 


HYSTERIA  1191 

lisematemesis,  sudden  tender  swellings  in  the  mammfe,  and  angio- 
neurotic oedema,  which  is  sometimes  blue  in  color,  have  been  recorded 
in  exceptional  cases. 

Course  and  Prognosis. — The  course  is  always  chronic.  If  we  look 
on  the  disease  as  congenital,  the  prognosis  is  poor  as  to  total  recovery, 
especially  with  fixed  psychical  alteration  and  major  manifestations. 
Jolly  remarks  that  complete  recovery  is  as  rare  as  death,  which  rather 
overstates  the  facts.  In  mild  forms  practical  recovery  may  follow,  but 
relapses  may  occur  on  disproportionately  slight  provocation.  The  out- 
look is  better  in  infantile  and  adolescent  forms  than  in  those  of  middle 
or  advanced  life.  The  stigmata  may  be  ephemeral  or  life-long.  Mar- 
riage may  prove  beneficial  in  light  cases,  but,  with  maternity,  it  is 
injurious  in  the  severe  types;  marriage  must  never  be  regarded  as  a 
therapeutic  agent. 

Diagnosis. — The  stigmata,  mental,  motor  and  sensory,  are  highly 
characteristic.  The  accidents  are  either  unequivocally  hysterical,  or 
prove  hysterical  after  consideration  of  their  associations  or  history. 
The  real  danger  lies  in  overlooking  concomitant  disease  (a)  nervous,  as 
multiple  sclerosis,  brain  tumor,  paretic  dementia;  (b)  postinfectious 
hysteria  as  hysteria  plus  neuritis;  (c)  lung,  heart  and  other  visceral 
diseases,  all  of  which,  as  Sydenham  remarked,  may  resemble  hysteria. 
Simulation  does  not  include  the  common  borrowing  or  mimicry  of 
symptoms  by  hysterics ;  simulation  of  hysterical  stigmata  and  accidents 
is  practically  impossible. 

Treatment. — 1.  Prophylaxis. — This  is  possible  when  the  earliest 
manifestations  occur  in  childhood.  Home  treatment  is  frequently 
impracticable  because  of  the  family  tendency.  The  etiological  factors 
must  be  studied,  especially  the  hygiene  and  the  hours  of  sleep.  Useful 
occupations,  as  out-of-door  gardening,  are  preferable  to  less  whole- 
some and  more  artificial  plans  of  distraction.  Cultivation  of  the  car- 
dinal virtues,  courage  and  self-control,  is  sought.  Servants  who  teach 
fear  of  the  dark  and  tell  fairy  stories  should  be  watched.  Self-control 
should  be  insisted  upon  in  adult  cases. 

2.  General  Treatment  of  the  Cause. — As  the  disease  depends 
on  disturbed  cortical  relations  between  the  psychical  and  material 
processes,  the  principal  treatment  must  be  psychical.  The  "fixed 
idea"  must  be  grasped  and  eradicated,  which  is  best  accomplished  in 
ordinary  circumstances  by  isolation  of  the  patient  from  home  or  from 
other  psychical  or  emotional  circumstances  surrounding  the  inception 
of  the  disease.  Then  the  undue  susceptibility  incident  to  the  disease 
may  be  turned  to  therapeutic  advantage  by  the  self-confidence  of  the 
physician  and  by  his  covert  suggestions.  The  Wier  Mitchell  rest-cure 
may  result  in  great  benefit,  and  later  "vague  hints  regarding  the 
curative  power  of  nature,"  and  fresh  air  and  sunlight  may  captivate  the 
patient.  Symptoms  must  not  be  suggested  to  the  subject,  as  anaes- 
thesia or  pelvic  disease,  and  examinations,  especially  of  the  pelvis, 
should  be  omitted.  Hysterics  should  not  be  allowed  to  associate  with 
each  other  for  obvious  reasons.    This  general  plan  is  psychotherapy, 


1192  DISEASES  OF  THE  NERVOUS  SYSTEM 

which  of  course  might  include  hypnotherapy,  as  advocated  by  the 
Nancy  school,  Bernheim  and  others.  Hypnotism  is  generally  dan- 
gerous in  its  ultimate  and  often  in  its  immediate  effects;  though  the 
definition  of  hypnotism  may  be  a  matter  of  difference  or  of  dispute, 
its  danger  is  shown  by  the  fact  that  Striimpell  considers  it  an  "artificial 
hysteria,"  and  Fere  defines  it  as  a  "transformation  of  hysteria."  "It 
is  easier  to  make  a  sound  person  hysterical  by  hypnosis  than  to  cure  a 
hysterical  one  by  it"(Liebermeister).  Treatment  is  sometimes  frus- 
trated by  the  patient's  vanity.  Successful  treatment  requires  unusual 
tact,  profound  knowledge  of  human  nature,  strong  sympathies  (but 
dominance  of  the  patient)  and  enormous  optimism.  Of  course  certain 
single  qualities,  in  an  ignorant  quack,  may  effect  cures. 

3.  Special  or  Symptomatic  Treatment. — (a)  In  relieving  pain, 
the  physician  should  first  acknowledge  its  existence  and  intensity  in 
order  to  soothe  the  patient,  and  should  then  apply  blisters,  liniments, 
or  the  galvanic  current,  with  the  anode  on  the  painful  area.  Ovaralgia 
in  most  cases  should  be  ignored ;  in  exceptional  cases  pelvic  surgery  has 
given  relief;  Lower's  position  has  already  been  mentioned  (v.  s.). 
(b)  Convulsions  are  treated  by  dashing  cold  water  into  the  face,  by 
suggestive  measures,  or,  if  severe,  by  etherization.  Bromides  are  of 
little  value,  valerian  is  sometimes  beneficial  and  turpentine  is  recom- 
mended by  Gowers  as  most  efficient,  10  drops  of  the  oil  being  given 
until  slight  vesical  symptoms  appear.  Pouring  water  into  the  mouth  or 
nose,  which  causes  coughing,  or  Hare's  method  of  holding  a  towel  over 
the  nose  and  mouth  for  15  to  20  seconds,  may  also  serve,  (c)  Paralysis 
and  contracture  should  receive  early  treatment,  for  late  neglected  cases 
may  necessitate  surgical  intervention,  as  tenotomy.  ]Massage,  faradism, 
blisters,  and  fixation  in  new  postures  are  indicated,  and  especially 
should  their  significance  be  minimized  and  the  patient  be  assured  that 
thev  are  not  organic.  In  two  cases  the  author  has  seen  the  paralysis 
disappear  at  once  on  administration  of  asafoetida  in  an  efl^ervescing 
mixture,  (d)  Anoesthesia  should  be  ignored,  {e)  Aphonia  is  treated 
by  intralaryngeal  faradization.  Laryngeal  and  other  respiratory 
spasms  usually  answer  to  energetic  traction  on  the  tongue,  and  anses- 
ihesia  or  tracheotomy  is  rarely  necessary.  (/)  For  insomnia,  the 
patient  should  retire  at  an  absolutely  regular  hour;  nervines  should  be 
given  rather  than  bromides,  and  hot  milk  should  be  very  slowly  sipped. 
ig)  Dysphagia,  vomiting  and  anorexia  may  be  treated  by  rectal  feeding, 
or  by  forced  feeding  through  the  stomach  tube,  which  is  the  better 
method.  Constipation  is  often  obstinate,  and  its  mixed  spastic  and 
paretic  character  is  shown  by  the  fseces  which  are  like  those  of  sheep. 
Free  administration  of  olive  oil  by  mouth  and  rectum,  cold  abdominal 
compresses  and  endorectal  galvanization  are  usually  effective. 


\EURA  ST  HEX  I A  1 1 93 


NEURASTHENIA. 

Definition. — Neurasthenia  is  a  diffuse  neurosis,  which  affects  the 
entire  nervous  system,  but  chiefly  the  brain;  it  is  characterized  (a) 
by  morbid  irritabihty  of  the  nervous  system  vv^ith  a  tendency  to  its 
rapid  exhaustion  ("irritable  w^eakness"),  and  (6)  particularly  by 
psychical,  motor,  sensory,  vasomotor,  secretory  and  vegetative  distur- 
bances in  function.  The  nervous  tissue  responds  unduly  to  stimuli, 
its  reaction  time  is  short,  and  ready  exhaustion  results.  It  seems 
probable  that  the  slight  cellular  and  protoplasmic  changes  in  nerve 
cells,  noted  by  Hodge  to  follow  fatigue,  may  have  some  bearing  on 
its  pathology.  The  affection  was  described  and  named  by  Beard  in 
1869,  whose  description  was  first  received  with  some  skepticism 
and  ridicule  abroad,  but  later  gained  universal  recognition.  It  is 
possible  that  the  disease  is  at  present  more  frequent  than  formerly 
because  of  the  more  strenuous  life  and  methods  of  education.  The 
difference  between  "nervousness"  and  neurasthenia  is  only  quantita- 
tive, and  while  nervousness  is  no  disease  in  itself,  it  is  also  charac- 
terized by  a  short  reaction  time  (irritability)  and  precipitate  fatigue 
(weakness). 

Etiology. — Neurasthenia  is  the  most  common  neurosis,  constituting 
25  to  45  per  cent,  of  all  nervous  diseases  and  fully  50  per  cent,  of  all 
neuroses,  (a)  A  neuropathic  tendency  is  observed  in  40  to  60  per 
cent,  of  cases,  especially  among  Hebrews  whose  proneness  to  nervous 
diseases  is  referred  by  Erb  to  inbreeding  and  to  desire  of  gain.  Other 
neuroses,  as  hysteria,  epilepsy  or  migraine,  the  psychoses,  and  parental 
infirmities  or  intoxications  may  be  obtained  in  the  family  history, 
(b)  Age  and  sex:  It  is  a  disease  of  adults  (  75  per  cent,  of  cases  occur 
in  persons  between  the  twentieth  and  fiftieth  year).  It  is  a  question 
whether  men  are  more  often  neurasthenic  than  women;  we  may  say 
women  are  more  disposed,  men  more  exposed,  to  the  disease,  by  their 
excesses  in  work,  sexual  activity  and  alcoholism,  (c)  Psychical 
causes  include  sorrow  and  care;  hard  mental  or  physical  work  rarely 
produces  neurasthenia.  Worry  is  a  prolific  factor;  it  is  the  irritable 
weakness  of  work.  Hard  work  is  injurious  when  combined  with 
excesses  in  tobacco,  alcohol,  coffee,  drugs  or  venery.  Certain  occu- 
pations entailing  responsibility  or  emotional  factors  predispose  to 
nervous  weakness,  as  in  railway  or  telegraph  employes,  board-of-trade 
men,  teachers,  actors,  artists,  and  musicians,  but  even  then  it  is  ques- 
tionable whether  the  work  itself  is  most  injurious.  Trauma  operates 
chiefly  through  psychical  causes,  as  in  the  traumatic  neuroses  {q.  r>.). 
(d)  Intoxicati(ms,  as  from  the  stimulants  above  mentioned,  from  drug 
habits,  lead  or  arsenic  poisoning,  acute  infections,  especially  typhoid 
or  grippe,  from  chronic  affections,  notably  malaria  and  syphilis,  and 
altered  condition  of  the  blood,  as  gout,  anivmia  or  diabetes,  may  be 
indirect  factors,  {e)  Sexual  life:  Masturbation,  excessive  coitus,  and 
coitus  interruptus,  sometimes  promote  neurasthenia,  but  their  inipor- 


1194  DISEASES  OF  THE  NERVOUS  SYSTEM 

tance  is  enormously  overestimated.  Masturbation  probably  produces 
less  direct  physical  than  psychical  injury,  for  it  leads  to  brooding  over 
its  possible  results.  Continence  is  never  injurious,  as  sexual  indulgence 
is  rather  a  habit  than  a  necessity.  In  neurasthenic  women  gynecolog- 
ical complaints  are  more  often  subjective,  secondary,  and  neurasthenic, 
than  objective,  primary  and  organic.  The  same  statement  usually 
holds  true  in  male  neurasthenics  with  chronic  urethritis,  or  prostatitis. 
Pregnancy  and  lactation  are  sometimes  apparent  causes.  (/)  Organic 
diseases  may  possibly  be  factors,  but  it  is  questionable  to  what  extent 
enteroptosis,  chronic  gastric  or  other  somatic  lesions  promote  neuras- 
thenic symptoms,  (g)  Climate:  Neurasthenia  is  more  common  in 
northern  climates  with  relatively  high  altitude  than  in  southern  zones. 
It  is  possible  that  alcoholism  with  nervous  tension  is  more  potent  than 
either  climate  or  altitude. 

Symptoms. — A  clinical  description  holding  for  all  cases  is  impos- 
sible. A  patient  presents  himself  for  the  treatment  of  some  single  vis- 
ceral complaint,  or  describes  symptoms  in  his  head,  heart,  lung, 
stomach,  sexual  or  other  organs.  The  various  types,  which  are  often 
separately  described,  will  be  considered  in  the  general  picture,  for 
pure  forms  are  rare;  they  are  the  cerebral  (cerebrasthenia) ,  spinal 
(jnyelasthenia),  cerebrospinal  {the  general  type),  the  sympathetic  or 
vasomotor  and  the  visceral  (cardiac,  sexual,  gastric)  types.  Some 
varieties  concern  the  course,  as  (a)  the  acute  form  from  simple  nervous 
exhaustion  in  normal  individuals,  or  in  those  with  neurotic  stigmata; 
(b)  the  subacute  or  chronic  acquired  form,  and  (c)  the  chronic  consti- 
tutional neurasthenia,  which  is  usually  hereditary. 

1.  Cerebral  Symptoms. — These  are  most  important,  because  the 
disease  is  really  a  psychoneurosis.  Headache  is  almost  invariable,, 
is  more  often  dull  than  acute,  and  produces  a  sense  of  pressure  ("lead 
cap  "  headache)  or  intracranial  paraesthesia,  and  in  localization  is  most 
often  occipital.  Vertigo  is  frequent.  Insomnia  is  extremely  common^ 
but  rarely  absolute  which  always  suggests  organic  brain  disease ;  sleep 
is  slow  in  onset,  the  patient  being  kept  awake  by  his  fear  of  sleepless- 
ness, by  a  rapidly  moving  circle  of  uncontrollable  memory  pictures  or 
by  indigestion  or  palpitation;  sleep,  when  once  attained,  is  not  resting 
or  is  too  short,  and  the  patient  awakes  in  the  night  or  early  morning. 
It  is  broken  by  dreams,  startings  or  sometimes  emissions.  In  mild 
cases  distinct  alterations  in  temperament  and  character  develop,  as 
loss  of  courage  and  confidence,  depression,  irritability,  undue  response 
to  emotional  stimulation,  as  on  seeing  sad  plays  or  hearing  hard-luck 
stories,  slight  ethical  blunting,  tendency  towards  extremes,  and  develop- 
ment of  quiet  self-concentration  or  obtrusive  egotism.  The  brain 
tires  readily  on  mental  or  bodily  exertion,  especially  as  the  irritable 
patient  is  often  prodigal  of  time  and  energy.  It  is  remarkable  how 
in  some  cases  the  morning  depression  may  disappear  before  an  after- 
noon or  evening  excitement,  but  this  is  notably  followed  by  reaction. 
Psychical  processes  are  disturbed;  perception  is  blunted  and  memory 
is    weakened    or    often   temporarily  lost    (dys-,   para-,    amnesia),   as. 


NEURASTHENIA  1195- 

shown  by  the  copious  notes  of  his  symptoms  which  the  patient  pro- 
duces in  the  physician's  office  {'T  homme  aux  petits  papiers,"  as  Charcot 
called  him);  association  and  combination  are  difficult,  as  in  thought, 
composition,  judgment  or  conclusions,  whence  the  speech  is  often  slow 
and  disjointed,  names  are  forgotten  and  the  patient  re-reads  addresses, 
runs  repeatedly  to  see  if  the  door  was  closed,  etc.  Compulsory  con- 
ceptions may  lead  to  homicide  or  suicide  in  highly  psychopathic  types. 
Fear,  being  an  attribute  of  the  weak,  is  common  enough,  and  may  in 
marked  types  assume  the  form  of  various  phobias,  as  the  fear  of  open 
places  (agarophobia),  of  enclosures  (claustrophobia),  rivers  (potomo- 
phobia), high  places  (acrophobia), stars  (asterophobia), railways  (sider- 
dromophobia),  dirt  (mysophobia),  of  high  things  falling  (batophobia), 
of  standing  (stasophobia),  or  walking  (basophobia),  of  darkness  (nyc- 
tophobia), of  a  single  thing  (monophobia),  of  all  things  (pantophobia), 
of  places  (topophobia),  of  men  (anthrophobia)  or  of  disease  (noso- 
phobia). The  special  senses  are  Involved.  Fibrillation  of  the  lids, 
and  wide,  variable,  sensitive  and  unequal  (3  per  cent.)  pupils  are  fre- 
quent, although  permanent  irregularity  almost  always  results  from 
organic  disease.  Asthenopia  is  very  common,  especially  in  hyper- 
metropia  from  weakness  of  the  ciliary  and  int.  recti  muscles.  The 
field  of  vision  may  be  concentrically  limited  but  this  is  rarely  marked 
or  permanent,  and  Foerster's  shifting  type  may  be  found,  in  which 
objects  brought  from  without  into  the  field  are  better  seen  than  those 
moved  from  within  the  field  outward.  Hyperaesthesia  of  the  retina 
and  ear,  ringing  in  the  ears,  Meniere's  complex,  and  disturbance  of 
taste  or  smell  are  not  common. 

2.  Spinal  Symptoms. — These  include  the  so-called  "spinal  irrita- 
tion." Many  symptoms  ranked  as  spinal  are  essentially  cerebral. 
In  women  they  are  more  common  and  are  localized  chiefly  to  the  upper 
dorsal  and  coccygeal  regions;  in  men  they  are  lumbodorsal  and  most 
frequent  in  the  sexual  type.  Sensory  symptoms  are  practically  con- 
stant. Hyperesthesia  is  more  common  in  the  bodies  of  the  muscles 
than  in  their  attachments  or  in  the  skin;  paraesthesia  is  frequent,  as 
tinglings,  girdle  sensation  or  even  a  sense  of  itching.  Paralgesia  in  the 
form  of  backache  (rhachialgia)  is  as  frequent  as  headache  and  the  pain 
may  radiate  into  the  various  nerve  plexuses ;  it  is  very  often  sacral ;  the 
spine  may  be  exquisitely  sensitive  to  pressure.  Paralgesia  is  common  in 
the  skin  about  the  hair  roots,  in  the  trunk  and  extremities.  Neuralgia  is 
rare,  although  it  sometimes  occurs  as  a  form  radiating  from  the  spine 
into  the  limbs.  Anaesthesia  is  no  part  of  neurasthenia.  Of  the  motor 
symptoms,  muscular  weakness,  or  myasthenia,  is  the  rule.  It  is  prob- 
ably spinal  and  cortical  in  origin  and  is  especially  conspicuous  in  the 
morning.  The  muscles  often  show  fibrillary  contractions  and  a  tremor 
(85  per  cent.)  which  is  as  fine  and  frequent  as  that  of  alcoholism  or 
Graves'  disease.  Muscular  fidgets,  starts,  cramps  and  increased  irrita- 
bility of  the  nerve  trunks,  as  in  tetany,  are  also  observed.  Actual 
ataxia  is  most  rare,  although  suggested  by  the  writing.  The  akinesia 
algera  (Mobius)  or  the  abasia-astasia  of  Blocq,  as  in  hysteria  or  the 


1196  DISEASES  OF  THE  NERVOUS  SYSTEM 

psychoses,  is  the  result  of  a  phobia  or  a  fixed  conception.  One  of 
Erb's  patients  remained  in  bed  for  fourteen  years.  The  skin,  tendon 
and  periosteal  reflexes  are  increased. 

3.  Vasomotor  Symptoms. — These  produce  many  central,  visceral 
and  peripheral  manifestations.  It  has  been  proved  by  Mosso  that 
during  brain-work  the  cerebral  vessels  normally  dilate  while  those  of 
the  arm  contract.  According  to  Anjel  this  does  not  occur  in  neuras- 
thenia. The  manometer  in  normal  cases  reveals  no  essential  variation 
during  work,  while  in  neurasthenia  marked  manometric  variations 
occur,  as  also  shown  by  Weber  by  the  sphygmograph.  These  findings 
furnish  some  diagnostic  and  prognostic  aid,  for  their  intensity  parallels 
the  prognosis,  but  they  are  especially  valuable  because  they  explain 
many  otherwise  vague  findings.  Neurasthenics  often  suffer  from 
cold,  and  wear  more  clothes  than  is  necessary;  their  skin  is  cold,  even 
cyanotic  or  locally  asphyxiated.  On  the  other  hand,  the  skin  may  be 
flushed  and  hot.  Cold  and  clammy  sweats  over  the  forehead,  hands 
and  feet,  develop  without  exertion.  Salivation  or  a  dry  mouth, 
polyuria,  pseudo-angina  pectoris  (vasomotor  changes  in  the  cardiac 
and  brachial  plexuses),  the  wide  temporal  vessels,  the  epigastric  pul- 
sation, circumscribed  oedema,  urticaria,  and  dermographism  are  but 
vasomotor  manifestations. 

4.  Visceral  Manifestations. — -(a)  Some  of  the  cardiovascular  signs 
and  symptoms  have  already  been  treated.  The  arteries  are  relaxed 
and  often  throb,  the  pulse  may  be  slightly  of  the  "water-hammer"  type 
and  capillary  pulsation  is  often  apparent  in  the  lips  or  under  the  nails. 
Palpitation  and  precordial  anxiety  or  dyspnoea  are  frequent.  The  pulse 
is  frequently  faster  and  may  increase  10  or  20  beats  on  pressure  over 
some  sensitive  area  (v.  i.  Traumatic  Neuroses).  Many  neurasthenics 
seek  consultation  for  cardiac  disease,  (b)  Gastric  symptoms  (in  50 
to  66  per  cent.)  are  functional  in  character,  and  were  first  described  by 
Leube.  The  chemism  may  be  normal  or  show  either  achlorhydria,  or 
hyperchlorhydria.  The  stomach  is  frequently  hypersesthetic.  Anorexia 
is  usually  mental,  as  are  polyphagia,  polydipsia  and  adipsia  (see 
Neuroses  of  Stomach),  (c)  Intestinal  symptoms  vasijdewelo-p.  Diar- 
rhoea is  less  common  than  constipation,  which,  like  previous  sexual 
abuses,  often  occupies  the  patient's  thoughts.  They  "would  be  per- 
fectly well  if  they  could  only  have  one  natural  movement,"  and  when 
they  do,  they  complain  of  "exhaustion  during  the  entire  day  after- 
ward." Assimilation  is  often  incomplete,  as  shown  by  the  stools;  a 
sense  of  pressure,  Kussmaul's  peristaltic  unrest,  hypersesthesia,  burn- 
ing and  flatulency  torment  the  patient.  Enteritis  membranacea  and 
Glenard's  enteroptosis  are  not  infrequent,  {d)  The  amount  of  the 
urine  is  often  increased,  or  seemingly  so,  yet  equally  often  the  24-hour 
quantity  is  decreased.  The  specific  gravity  is  lowered,  but  the  urates, 
uric  acid  and  urea  are  increased.  Phosphaturia  and  oxaluria  occur; 
the  latter  is  often  attended  by  flatulent  dyspepsia,  melancholia  and 
nervous  depression.  Indicanuria  is  not  constant,  and  glycosuria  and 
albuminuria  are  accidental.     Vesical  tenesmus  is  an  occasional  com- 


NEURASTHEXIA  1197 

plaint,  (e)  Genital  symptoms  may  be  marked.  Fear  of  the  results  of 
previous  excesses  or  of  self-abuse  may  dominate  the  patient's  mind,  but 
the  trouble  is  more  a  matter  of  conception  than  of  reality,  since  the 
sexual  appetite  is  actually  decreased  as  a  rule.  In  most  cases  there  is 
premature  ejaculation  and  in  some  patients  there  is  actual  or  psychical 
impotence.  Emissions  are  frequent,  but  their  importance  is  greatly 
overestimated. 

Course  and  Prognosis. — Acute  cases  are  rare  smd  fatal  cases  extremely 
exceptional.  The  usual  chronic  course  is  one  of  slow  onset,  it  is 
attended  by  evidences  of  nervous  fatigue  which  are  at  first  relieved  by 
rest,  but  which  later  persist  in  spite  of  rest  and  incline  the  patient  to 
stimulants  or  drug  habits.  Later  the  signs  of  cerebral  irritability,  dis- 
turbed sleep,  vasomotor  disorders,  reduced  mental  and  psychical 
capacity,  pains,  spinal  tenderness,  parsesthesia  or  paralgesia,  sym- 
pathetic dyspnoea  or  palpitation  develop,  sometimes  with  temporary 
remissions.  The  outlook  is  poor  in  severe  hereditary  forms,  or  when 
there  are  complicating  psychoses  or  drug  habits.  In  other  types 
recovery  is  usual,  although  it  is  generally  long  deferred.  Complication 
with  hysteria,  epilepsy,  migraine,  and  other  neuroses  must  naturally 
modify  the  prognosis. 

Diagnosis. — The  diagnosis  is  generally  made  with  ease,  but  several 
rules  must  be  borne  in  mind :  (1)  No  single  symptom  is  pathognomonic; 
(2)  there  must  be  no  sign  of  organic  disease;  (3)  neurasthenia  may  pre- 
cede, follow  or  complicate  organic  nervous  or  visceral  disease.  The 
subjective  signs,  irritable  weakness,  emotivity,  muscular  weakness, 
headache,  backache,  insomnia,  amnesia,  impaired  psychical  coordina- 
tion, and  the  phobias,  together  with  objective  findings,  as  asthenopia, 
insufficiency  of  the  internal  recti,  tachycardia,  epigastric  pulsation, 
vasomotor  alteration,  as  disturbed  secretion  of  urine  or  sweat,  increased 
reflexes,  fibrillation  and  tender  muscles  cannot  be  mistaken.  The 
neurasthenic  prodromes  of  progressive  paralysis,  (q.  v.)  are  usually 
distinguished  on  careful  search  for  organic  disease.  Hysteria  in  its 
stigmata  and  accidents  is  so  typical  that  elaborate  differentiation  is 
superfluous;  anaesthesia,  persistent  contraction  of  the  fields  of  vision, 
dyschromatopsia,  achromatopsia,  monocular  diplopia,  convulsions,  par- 
alyses, contractures  a,nd  anuria  are  foreign  to  neurasthenia.  Hypo- 
chondriasis differs  from  neurasthenia  in  these  essential  points:  it  is  a 
pure  psychosis,  its  concepts  are  primary,  they  are  ill-based,  illogical 
or  absurd  and  cannot  be  eradicated  even  for  a  time. 

Treatment. — Prophylaxis. — Prevention  is  difficult,  for  the  neuras- 
thenic cannot  control  his  ancestry,  but  even  with  hereditary  stigmata 
much  may  be  done.  Treatment  starts  with  the  education  of  both  child 
and  adult.  Children  are  mimics  and  the  clearest  of  all  observers.  The 
inculcation  of  self-control,  fearlessness,  self-sacrifice,  moderation  in  all 
things,  truthfulness,  prompt  decision  and  constancy  of  purpose  must  be 
based  on  actual  parental  example,  and  in  this  way  the  child  should  also 
educate  the  parent.  The  child  must  learn  to  give  up,  to  sleep  alone, 
to  stop  at  the  right  time,  to  finish  what  he  has  begun,  to  obey,  and  to 


1198  DISEASES  OF  THE  XERVOUS  SYSTEM 

learn  that  lie  is  not  the  centre  of  the  family.  He  should  be  taught 
mthout  being  forced.  Out-door  living  is  more  important  than  the 
school  room.  The  English  method  of  treating  children  with  reserve 
has  some  advantages  over  American  demonstrativeness.  Simple 
varied  food,  without  tea,  coffee  or  alcohol,  and  long  sleeps  develop  a 
strong  nervous  system.  The  sexual  instinct  requires  attention.  Parents 
or  patients  would  do  well  to  read  Patrick's  small  classic,  "How  Not  To 
Be  Nervous";   Jour.  Amer.  Med.  Assn.,  Feb.,  1903. 

Therapy. — When  once  manifested,  the  disease  should  be  treated 
as  above  outlined  and  causal  factors  should  be  investigated.  Work 
alone  is  seldom  injurious,  and  while  it  is  said  that  the  modern  com- 
plexity in  the  struggle  for  existence  is  increasing  the  number  of  neuras- 
thenics, work  should  not  bear  the  stigma  nor  should  disappointment, 
for  both  make  character.  Work  must  be  systematic  but  not  sla^ash. 
Worry,  hurry,  failure  to  learn  individual  limitations,  uncontrolled 
planning  beyond  the  immediate  day's  work,  and  worry  (the  irritable 
weakness  of  work)  cause  the  damage,  especially  when  work  produces 
some  indifference  to  nature,  family  life,  exercise,  rest,  and  the  things 
higher  and  above  one's  own  small  life  and  ambition.  The  time  for 
exercise  should  be  taken  from  the  work  hours,  it  should  not  follow 
them,  nor  should  it  be  enforced  in  every  case,  for  some  people  are  hurt 
by  it.  Of  course,  work  under  stimulation  is  injurious.  It  is  held  that 
the  chief  element  in  treatment  is  psychical  and  surely  the  physician 
accomplishes  more  than  do  drugs.  He  carefully  examines  and  re- 
examines the  patient,  and  his  assurance  that  no  organic  disease  exists, 
has  its  weight  for  the  time.  Conversely,  careless  diagnoses,  as  of  fatty 
heart,  with  no  objective  justification,  work  damage  to  the  patient's 
mental  balance.  The  patient's  hygiene  should  be  regulated.  Strict 
dietaries  and  stimulants  should  be  avoided,  moderate  out-of-door  life 
or  exercise  enjoined,  and  in  very  pronounced  cases  absolute  rest  from 
work,  with  sojourn  near  the  sea  or  at  a  moderate  altitude  in  a  place 
not  subject  to  sudden  changes  or  high  mnds,  is  recommended.  Sexual 
matters  should  be  left  alone  unless  gross  violations  are  found.  The 
patients  need  sympathy,  which  they  should  receive — in  moderation  for 
their  sake,  and  lest  the  physician  become  "touched"  with  neuras- 
thenia; but  important  as  is  the  psychical  element  in  therapy,  the 
patient  must  be  taught  that  he  alone  can  cure  his  malady  by  self- 
control,  and  by  avoiding  extremes  in  each  and  every  thing. 

Pronounced  cases  in  thin  women,  especially  those  with  gastric 
symptoms,  are  often  helped  by  the  Wier  Mitchell  rest-cure,  which  con- 
sists of  absolute  rest  in  bed,  isolation,  forced  feeding,  massage  and 
faradization.  The  patient  is  not  allowed  to  lift  a  hand,  and  sees  only 
the  nurse,  who  is  selected  for  her  strength,  optimism  and  lack  of  nerves. 
The  patient  is  fed  milk  every  two  or  three  hours,  and  the  muscles  are 
rubbed  and  faradized.  Thus  weight  and  strength  are  gained  without 
muscular  degeneration.  Few  men  will  tolerate  this  method,  and  obese 
do  not  fare  as  well  as  lean  women.     In  certain  cases  it  is  of  distinct 


THE   "TRAUMATIC   XEU ROSES"  1199 

benefit.  However,  no  greater  mistake  is  made  than  to  give  all  cases  the 
rest-cure;  they  often  want  work  and  occupation,  harmonized  with 
rest. 

Diet. — That  no  one  dietary  is  essential  is  shown  by  the  different 
recommendations;  some  physicians  favor  a  meat  diet,  others  avoid 
meat,  especially  in  cardiac  types,  and  give  well-cooked  vegetable  albu- 
mins, cooked  fruit,  fats,  milk  and  eggs.  In  mental  anorexia,  feeding 
by  mouth  or  rectum  must  be  forced.  Water  in  abundance  is  indicated. 
Gastric  hypercesthesia  should  be  relieved  by  small  dos6s  of  carbolic 
acid  and  gelsemium.  Eructations  must  be  controlled,  since  the  air 
admitted  exceeds  the  gas  expelled;  asafoetida  is  excellent  because  it 
makes  as  strong  an  impression  when  swallowed  as  when  eructed. 
Electricity  in  general  is  largely  suggestive  in  its  effects;  cerebral  gal- 
vanization gives  uncertain  results.  With  massage  and  vegetable  diet, 
endorectal  faradization  relieves  constipation.  In  cardiac  types  alcohol 
and  tobacco  are  interdicted,  and  small  doses  of  belladonna  and  bromide 
usually  control  palpitation;  other  vasomotor  symptoms  are  relieved 
by  these  remedies,  or  by  ergotin  or  nitroglycerine,  according  as  they  are 
angioparetic  or  angiospastic.  Arsenic  is  valuable  in  vasomotor 
troubles  with  anaemia. 

Sexual  symptoms  are  treated  by  psychical  measures  and  by  sitz- 
baths.  hisomnia  is  often  difficult  to  relieve.  In  the  order  named,  the 
following  measures  are  valuable:  avoidance  of  evening  work,  stimu- 
lants or  excitement;  a  cool  bath,  the  wet  pack  or  an  ice-bag  over  the 
heart;  small  doses  of  bromide  with  valerian  for  the  "expectant  at- 
tention" w^hich  wards  off  sleep;  20  grains  of  sulphonal  in  hot  milk, 
which  should  be  slowly  sipped;  codeine  with  hyoscine;  and  chloral 
(the  continued  use  of  which  induces  vasomotor  disturbance).  The 
habit  of  sleep  is  like  the  habit  of  insomnia;  it  must  be  cultivated,  and 
the  patient  must  not  get  up  to  read.  Local,  urethral,  and  uterine 
affections  usually  receive  excessive  therapeutic  attention. 


THE   "TRAUMATIC  NEUROSES." 

This  is  a  practical  grouping  of  traumatic  neurasthenia,  hysteria, 
chorea  or  hypochondriasis.  Hysterical  forms  were  first  described  by 
Walton  and  Putnam,  Erichsen  (1866)  wrote  on  the  subject  of  trauma  to 
the  spine,  on  which  the  illogical  name  of  railway  spine  was  later  conferred, 
and  Oppenheim  (1887)  termed  the  group  the  "traumatic  neuroses." 
All  organic  affections  must  be  excluded,  whether  trauma  may  seem 
directly  or  indirectly  causal,  as  vertebral  caries,  tumor,  Bechterew's 
chronic  ankylosis,  Kummel's  rarefying  osteitis  which  Kocher  refers  to 
fracture;  hsematorrhachis,  meningeal  hsematoma,  or  pachymeningitis; 
and  cord  affections,  as  poliomyelitis,  myelitis,  or  lateral  sclerosis.  Experi- 
mental trauma  may  produce  molecular  nervous  changes  (Schmauss, 
Striimpell,  Bruns,  Vibert  and  Crocq),  a  fact  which  may  be  of  clinical 
importance,  and  trauma  is  thought  to  hasten  arteriosclerosis  (Fried- 


1200  DISEASES  OF  THE  NERVOUS  SYSTEM 

mann).  Alcoholism  and  syphilis  are  predisposing  factors.  "  Traumatic 
neuroses"  are  purely  functional  affections  caused  by  trauma,  which 
operates  psychically  rather  than  somatically.  The  symptoms  are  those 
of  hysteria,  neurasthenia,  and  hypochondriasis,  singly  or  in  combination. 
The  patient  may  feel  well  for  a  day  or  two  and  then  pain  develops  at  the 
seat  of  injury  or  in  the  spine;  anxiety,  fear  for  his  financial  future,  or 
for  his  family,  a  "fixed  idea"  of  his  incapacity,  and  the  development  of 
"litigation  symptoms"  are  typical  of  hypochondriacal  neurasthenia. 
The  psychical  symptoms  are  usually  but  not  always  prominent; 
they  are  accentuated  by  the  effect  on  the  patient  of  repeated,  sometimes 
suggestive,  physical  examinations,  visits  of  lawyers  or  adjustors,  court 
room  suspense,  reversals  of  judgment  or  appeals.  Vertigo,  backache, 
headache,  sleepiness  by  day,  and  nocturnal  insomnia  may  cause  great 
distress.  Sensory  symptoms  may  be  present.  Pain,  which  seems  to  be 
nervous,  may  prove  organic  on  examination  by  the  ^--rays;  it  may  be 
simulated,  but  is  often  real,  as  shown  by  persistence  after  award  of 
damages.  Tender  areas  are  difficult  to  pass  upon,  because  of  exagger- 
ation or  simulation ;  Mann,  Kopf  and  Rumpf  found  that  pressure  on 
areas  which  are  actually  tender  increases  the  pulse  rate  by  10  to  30 
beats;  this  sign  is  subject  to  several  conditions:  (a)  it  is  not  always 
present  in  real  pain;  (6)  its  absence  is  no  proof  of  simulation;  (c)  in 
simulation,  the  agony  and  writhing  which  occur  when  certain  areas  are 
touched  may  increase  the  heart's  action.  Parsesthesia  and  hyperaes- 
thesia  of  the  skin  or  special  senses  are  frequent.  Aneesthesia  indicates 
traumatic  hysteria.  Hysteric  or  neurasthenic  contraction  of  the  visual 
fields  may  remain  the  same  from  day  to  day,  and  not  vary  with  ap- 
proach or  withdrawal  of  the  test  object;  this  is  not  a  sign  of  simulation 
as  suggested  by  some  writers;  Forster's  type  {v.  Neurasthenia)  can- 
not be  assumed.  In  all  cases  the  influence  of  suggestion  must  be  borne 
in  mind.  The  pupils  may  vary,  especially  by  dull  illumination;  reflex 
immobility  indicates  organic  disease.  Motor  symptoms  may  embrace 
all  those  of  hysteria  or  neurasthenia,  abasia,  astasia,  paralyses,  con- 
tractures suggesting  vertebral  injury  (Kummel's  rarefying  osteitis)  or 
joint  disease  (Brodie's  joints),  pseudo-spastic  or  -tabetic  gaits,  tremor 
{forme  trepidante) ,  or  sometimes  muscular  atrophy  (especially  about  the 
joints).  Hysterical  convulsions  are  rare;  the  author  has  twice  seen 
choreiform  affections  in  telephone  girls,  who  sustained  slight  shocks 
and  once  a  genuine  chorea.  Patients  must  often  be  watched;  one  of 
the  author's  cases,  with  spastic  gait,  shuffled  out  of  the  office,  but 
walked  perfectly  well  around  the  corner.  The  reflexes  are  often  in- 
creased, perhaps  asymmetrically;  ankle  clonus,  which  is  probably 
spurious,  is  sometimes  reported.  Cardiac  symptoms  may  be  prominent 
and  cannot  be  simulated.  When  there  is  albuminuria  and  glycosuria, 
the  question  naturally  arises  whether  they  were  present  before  the 
trauma. 

Diagnosis. — The  diagnosis  concerns  several  points  which  are  often 
difficult  or  impossible  to  establish,  because  objective  findings  are  fre- 
quently few.     (a)  It  is  usually  possible  to  state  whether  one   of  the 


EPILEPSY  1201 

neuroses  is  present  or  whether  organic  disease  obtains.  (6)  Exagger- 
ation and  simulation  are  difficult  to  estimate,  as  shown  by  the  change  of 
professional  opinion  from  the  idea  that  all  or  most  cases  are  simulated 
to  the  present  statement  of  some  writers  that  these  factors  are  present 
in  4  (to  10)  per  cent,  of  cases  only,  (c)  If  disease  is  present,  is  it  di- 
rectly due  to  injury  ?  (d)  If  so,  the  most  difficult  of  all  questions  is 
presented,  namely,  the  degree  and  duration  of  the  disease,  and  the 
damages  to  be  awarded. 

Prognosis. — (a)  As  to  life,  the  outlook  is  usually  good,  though  some 
cases  become  insane  or  suicidal.  (6)  As  to  complete  recovery,  it  is  less 
favorable.  In  most  cases  it  is  surprising  how  soon  symptoms  disappear 
after  satisfactory  legal  settlement  is  made;  this  is  said  without  cynicism. 
Many  persons  do  not  then  recover  completely  and  symptoms  may 
endure  in  those  who  persistently  shrink  from  litigation.  Hysterical 
symptoms  are  more  favorable  in  prognosis  than  the  neurasthenic  or 
hypochondriacal.  It  is  maintained  by  some  that  cardiac  overaction 
may  induce  organic  myocardial  changes,  and  that  arteriosclerosis 
may  develop  into  precocious  senility  (dementia  prsecox). 

Treatment. — Treatment  is  similar  to  that  of  hysteria  or  neurasthenia 
and  is  therefore  largely  psychical.  The  physician,  as  a  rule,  dreads  the 
effect  of  litigation  on  the  patient,  assures  him  that  the  symptoms  are 
seldom  severe  or  enduring,  that  there  is  no  organic  lesion,  and  advises 
early  settlement  and  speedy  return  to  work. 

EPILEPSY. 

Definition. — Epilepsy,  by  derivation,  means  "being  seized  upon"; 
it  has  been  called  the  "falling  sickness,"  and  morbus  sacer.  It  does 
not  ^include  Jacksonian  or  symptomatic  epilepsies,  which  will  be  con- 
sidered in  its  differentiation.  Though  it  is  classified  with  hysteria  and 
neurasthenia  as  one  of  the  "three  great  diffuse  neuroses,"  it  will  pro- 
bably be  finally  shown  to  include  more  than  one  disease.  It  is  a  dis- 
turbance of  balance  between  the  central  exciting  and  inhibiting  nervous 
processes  attended  by  (a)  a  typical  chronic  convulsive  disorder,  affecting 
all  parts  of  the  central  nervous  system,  each  attack  being  followed  by 
loss  of  consciousness,  (b)  partial  or  atypical  manifestations  of  these 
characteristics,  or  (c)  concomitant  or  consecutive  psychical  or  other 
symptoms.    It  occurs  in  from  one  to  six  persons  per  thousand. 

Etiology.^ — The  ultimate  causes  must  be  separated  from  the  inciting 
causes  (Nothnagel).  Of  the  former,  the  neuro-  or  psychopathic 
tendency  of  Griesinger  is  the  most  important,  being  found  in  35  to  50 
per  cent,  of  cases  and  causing  lessening  of  the  nervous  resistance.  As 
in  tuberculosis,  only  the  tendency  is  transmitted  by  inheritance,  rarely 
the  disease  itself.  Neurotic  or  psychopathic  antecedents,  parental 
alcoholism  (51  per  cent.),  morphinism,  plumbism,  syphilis,  tubercu- 
losis, gout,  arthritism,  diabetes,  or  ovarian  and  testicular  disease, 
lessen  the  nervous  resistance  of  the  offspring.     Trauma  during  labor 

76 


1202  DISEASES  OF  THE  XERVOUS  SYSTEM 

may  be  included  under  this  head.  Though  the  disease  may  appear  at 
any  age,  it  rarely  occurs  after  the  thirtieth  year.  Seventy-five  per  cent, 
of  cases  (Gowers)  develop  before  twenty;  46  per  cent,  between  ten 
and  twenty,  mostly  at  puberty;  28  per  cent,  before  ten.  The  sexes 
are  about  equally  affected. 

Inciting  causes  include  (a)  infections  as  malaria  or  typhoid;  syph- 
ilis may  be  hereditary,  induce  malnutrition  in  the  secondary  stage, 
of  the  Jacksonian  type  from  cortical  gumma,  or  it  may  be  parasyphi- 
litic;  (6)  intoxications,  especially  alcoholism;  (c)  exhausting  affections 
as  rickets,  and  diseases  of  the  blood  or  of  metabolism;  and  (d)  trauma 
or  fright.  Inciting  causes  are  found  in  only  37  per  cent,  of  cases 
(Gowers). 

Reflex  epilepsy  is  said  to  occur  from  painful  scars,  nerve  tumors,  or 
foreign  bodies  in  the  ear,  nose,  nasopharynx  or  larynx;  from  diseases 
of  the  teeth,  digestive  tract,  uterus,  and  heart;  from  onset  of  the  menses 
or  their  monthly  appearance,  pregnancy,  phimosis,  or  onanism;  from 
gall-stones,  colic  or  abdominal  paracentesis.  While  these  factors  may 
appear  in  certain  cases  and  attention  must  be  given  to  the  general 
examination  and  health,  the  importance  per  se  of  reflex  disturbances 
is  daily  lessening. 

Pathology. — The  fact  that  there  is  no  characteristic  macro-  or 
microscopic  change  is  not  proof  that  some  cortical  change  will  not 
later  be  demonstrated.  The  usual  finding  after  death  from  an  attack 
is  that  of  any  convulsion,  viz.,  venous  engorgement  and  punctate 
ecchymoses.  Induration  of  the  cornu  ammonis  (Meynert)  (3  to  38 
per  cent.),  induration  in  the  medulla,  neurogliar  increase  in  the  cortex, 
thickening,  asymmetry  or  deformity  of  the  skull,  or  persistence  of  the 
thymus,  have  not  yet  been  proven  to  exist  constantly  in  epilepsy,  nor 
are  they  proven  causal. 

Symptoms. — The  symptoms  are  best  studied  from  the  completely 
developed  attack,  in  which  there  are  three  component  parts:  (a)  The 
prodromal  stage  is  not  always  present.  Its  "  warnings  "  are  either  distant 
or  immediate.  The  distant  warnings  (in  4  to  17  per  cent,  of  cases) 
may  precede  the  seizure  by  hours  or  days,  are  possibly  due  to  metabolic 
changes  in  the  cortex,  and  take  the  form  of  restlessness,  dispositional 
changes,  depression,  thoracic  or  cephalic  oppression,  insomnia, 
vertigo,  nausea,  grinding  of  the  teeth,  hyperaesthesia  of  the  special 
senses,  angioneurotic  palpitation,  or  cerebral  congestion.  The  im- 
mediate warning  is  the  anra  proper,  which  is  the  beginning  of  the 
convulsion  rather  than  a  warning.  It  is  a  central  cortical  irritation; 
its  frequency  ranges  between  30  and  50  per  cent. ;  it  is  rarer  in  sudden, 
stormy,  generalized  seizures.  Its  forms  are  varied.  The  psychical 
aura  is  rare,  and  is  manifested  by  emotional  or  intellectual  alteration 
and  anxiety.  The  sensory  aura  consists  of  parsesthesia,  and  a  sense  of 
deadness  in  a  limb  or  joint,  attacks  of  migraine,  and  epigastric  sensa- 
tions (from  the  pneumogastric  nerve,  pressure  or  irritation  of  which 
sometimes  inhibits  the  convulsion).  The  special  senses  may  be  irritated 
or  blunted;    for  instance,  there  may  be  flashes  of  light  or  colors, 


EPILEPSY  1203 

hallucinations,  blackness  before  the  eyes,  and  less  often  anomalies  of 
hearing,  taste  or  smell.  The  motor  aur*  are  circumscribed  clonic  or 
much  less  often  tonic  twitchings,  as  in  the  signals  of  Jacksonian 
epilepsy,  from  which  they  are  distinguished  by  a  rapid  loss  of  con- 
sciousness; automatic  movements,  like  stamping,  or  buttoning  the 
coat,  are  rarer,  and  motor  weakness  and  singultus,  coughing  or  sneezing 
are  least  frequent.  Vasomotor  aurse  may  be  localized  or  generalized, 
as  rushing  of  blood  to  the  head,  palpitation,  ana?sthesia,  increased 
temperature,  increased  arterial  tension,  pallor  or  chilling.  The  patient 
then  falls,  jpale  and  unconscious,  or  is  thrown  with  force,  often  on  his 
face  (Trousseau),  when  (6)  the  convulsive  stage  begins.  There  is  first 
a  tonic  convulsion,  which  affects  all  voluntary  muscles,  and  is  due  to  infra- 
cortical  irritation.  The  initial  cry  is  gutteral  or  groaning,  results  from 
tonic  abdominal,  thoracic  and  laryngeal  spasm  and  is  heard  in  50  per 
cent,  of  cases.  The  head  is  held  back;  the  eyes  are  open  and  staring, 
the  jaw  set,  the  face  flushed,  the  neck  tense,  the  body  usually  opistho- 
tonic,  breathing  is  suspended,  the  muscles  are  hard  but  slightly 
vibrating  to  the  palpating  hand,  the  arms  are  turned  tetanically  inward, 
the  hands  are  clenched  with  the  thumb  adducted  and  under  the  fingers, 
the  legs  are  extended,  the  thighs  adducted  and  the  toes  flexed  or 
extended  and  spread  apart.  In  some  cases  the  head,  eyes  or  even  trunk 
deviate,  and  in  a  few  instances  the  tetanic  spasm  spreads  gradually, 
instead  of  the  patient  having  the  usual  instantaneous  tonic  spasm. 
The  tonic  phase  lasts  ten,  fifteen  or  thirty  seconds,  relaxing  in  inverse 
order  from  the  limbs  to  the  neck  and  face.  The  second  phase  of  clonic 
convulsion  occurs  at  once,  appearing  first  in  the  limbs,  which  are  not 
yet  quite  free  of  the  tonic  spasm.  This  stage  is  usually  bilateral, 
highly  irregular  and  violent,  with  very  short  remissions,  leading 
perhaps  to  injury,  fracture,  luxation,  breaking  of  teeth,  laceration  of 
skin,  tongue  and  cheek,  or  rupture  of  muscles.  It  consists  largely  of 
alternating  flexion  and  extension;  the  head  strikes  the  ground,  the 
body  turns  violently,  the  eyes  jerk  and  protrude,  the  face  is  distorted, 
the  tongue  is  bitten  as  it  is  thrust  out,  bloody  saliva  is  expressed  by  the 
masseters,  inarticulate  sounds  arise  from  the  movements  of  the  dia- 
phragm and  respiratory  muscles,  and  gurgling  results  from  intestinal 
movements;  vomiting  movements,  filling  of  the  stomach  with  air, 
cyanosis,  swelling  of  the  jugular  veins,  ecchymoses  in  the  conjunctiva, 
skin,  retina  or  larynx,  involuntary  and  sometimes  forcible  evacuation 
of  the  bladder,  less  often  of  the  rectum,  and  occasionally  ejaculation, 
occur.  The  clonic  phase  lasts  one-half  to  three  minutes,  ending  in  a 
fine  generalized  tremor,  (c)  The  comatose  stage  often  begins  with  a 
deep  sigh;  respiration  and  circulation  become  normal,  the  limbs  relax 
and  the  condition  resembles  a  sound  sleep,  from  w^hich  the  patient 
awakes  in  from  fifteen  minutes  to  several  hours,  sometimes  suddenly, 
more  often  gradually,  and  in  a  more  or  less  dazed  condition.  He 
recalls  nothing  of  the  attack  and  the  loss  of  memory  may  extend  back 
of  the  seizure  (retrograde  amnesia).  He  experiences  pain  in  the 
muscles,  joints  or  head,  nausea,  mental  irritability  or  depression  and 


1204  DISEASES  OF  THE  NERVOUS  SYSTEM 

finally  a  group  of  exhaustion  symptoms,  to  which  Fere  has  especially 
directed  attention;  these  are  (i)  sensory  exhaustion,  expressed  by 
hypsesthesia,  anaesthesia,  hypalgesia  or  analgesia,  (ii)  Exhaustion 
of  the  special  senses,  as  concentric  limitation  of  the  visual  and  color 
fields,  especially  in  abortive  attacks,  dulling  of  hearing,  taste  or  smell, 
and  (iii)  motor  exhaustion  which,  like  (i)  and  (ii),  is  due  to  cortical 
fatigue.    The  reflexes  are  often  weak  or  abolished. 

The  seizure  has  been  described  with  special  reference  to  the  dominant 
motor  changes,  but  during  the  attack  other  findings  are  observed. 
Vasomotor  constriction  often  occurs,  as  shown  by  the  initial  pallor  of 
the  face,  cardiac  overaction  or  perhaps  irregularity.  The  ecchymoses 
and  retinal  congestion  are  probably  due  to  the  convulsion.  The 
reflexes  are  affected.  The  pupil  is  almost  always  reactionless,  is  often 
narrow  at  the  onset,  and  usually  dilates  widely  in  the  second  stage; 
afterwards  it  may  oscillate;  the  pupils  are  sometimes  unequal  (20 
per  cent..  Fere).  The  tendon  and  skin  reflexes  are  weak  or  lost  in 
complete  attacks  and  for  hours  afterwards,  whence  we  may  judge  of 
the  severity  of  the  seizures.  The  temperature  is  usually  considered 
normal,  but  may  be  elevated  2  or  3°.  In  the  urine,  Voisin  found 
albumin  in  50  per  cent.,  though  others  consider  it  infrequent.  The 
author  has  often  noted  transient  albuminuria  and  cylindruria  (granular 
casts)  after  marked  paroxysms;  glycosuria  is  uncommon.  The  toxicity 
of  the  urine,  the  phosphates  and  the  nitrogen  are  increased;  polyuria  is 
common  in  the  third  stage.    The  sweat  is  increased. 

Types  of  Epilepsy. — 1.  The  completely  developed  attack  {epilepsia 
gravior,  haul  or  grand  mal)  consists  of  (a)  the  classic  type  (29  per  cent.), 
as  above  described,  with  complete  loss  of  consciousness,  and  tonic 
followed  by  clonic  convulsions;  or  (b)  the  well  developed  but  slightly 
atypical  type  (19  per  cent.),  in  which  all  the  components  of  (a)  are 
present  but  vary  somewhat;  for  instance,  the  spasm  may  not  always 
be  generalized. 

2.  The  rudimentary  attack  (21  per  cent.),  consists  of  loss  of  con- 
sciousness, plus  tonic  or  clonic  spasms,  but  not  both.  This  includes 
the  apoplectiform  cases,  especially  the  senile  (arteriosclerotic)  form; 
the  forms  resembling  myoclonus;  the  cases  which  do  not  fall  but 
stumble  along  at  the  onset  (epilepsia  procursiva)  or  turn  (epilepsia 
rotatoria). 

3.  The  third  form  is  the  abortive  attack  (epilepsia  mitior,  petit  mal, 
31  per  cent.).  Its  importance  is  underestimated  by  the  profession 
and  the  public;  two  main  types,  with  endless  variations  are  distin- 
guished: (a)  one  with  loss  of  consciousness  with  few  or  no  motor 
signs,  and  (6)  motor  and  vasomotor  signs  with  no  loss  of  conscious- 
ness, or  very  slight  clouding  of  the  intellect.  The  loss  of  conscious- 
ness is  often  very  slight,  or  may  last  for  a  few  seconds,  so  that  a 
scarcely  perceptible  break  occurs  in  the  patient's  occupation,  read- 
ing, speaking,  playing  the  piano  or  a  game  of  cards;  it  is  described  by 
the  French  as  "absence."  He  may  move  his  lips  inarticulately  or 
there  is  slight  nystagmus,  a  chewing  or  swallowing  movement,  tremor 


EPILEPSY  1205 

or  twitching  of  the  face,  monospasm,  or  vertigo.  In  children,  a  cry 
may  be  the  sole  symptom.  Some  patients  seem  to  fall  suddenly  asleep. 
Nothing,  or  everything,  may  be  remembered.  Aiirse  are  very  common 
and  may  constitute  the  whole  attack,  which  aborts  without  loss  of 
consciousness  or  spasms.  Vasomotor  symptoms  are  very  common. 
Some  would  include  the  rudimentary  type  under  this  head. 

4.  The  psychical  equivalent  of  Sammt,  which  is  also  known  as  trans- 
formed or  larvated  epilepsy  or  the  epileptoid  condition  (Griesinger), 
is  often  mistaken.  Mental  symptoms  may  precede,  succeed,  alternate 
with  or  replace  the  ordinary  convulsive  type,  which  must  be  first 
recognized  to  establish  this  variety.  The  mental  changes  are  slight 
(petit  mal  intellectuel)'  or  marked  {grand  mal  intellectuel)  and  include 
excitement,  emotional  outbursts,  narcolepsy,  incoherent  conceptions, 
amnestic  attacks  or  even  mania.  The  patient  may  act  like  an  hypno- 
tized subject;  he  may  take  sudden  long  journeys,  or  commit  assault, 
arson  or  murder,  whence  the  great  medico-legal  significance  of  this 
variety.  Milder  forms  are  said  to  occur,  as  sweats,  stupor  or  vacuity 
at  the  menstrual  epoch. 

The  Interparoxysmal  State. — If  the  patient  is  not  to  be  seen  during 
his  seizures,  evidences  of  epilepsy  should  be  looked  for  carefully.  Signs 
of  psychical  degeneration,  poor  differentiation  of  the  ear,  very  large, 
small  or  prominent  ears,  hematoma  of  the  ear,  deformed  teeth,  lips 
or  palate,  coloboma,  congenital  strabismus,  nystagmus,  small  eyes, 
irregular  pigmentation  of  the  iris,  deformed  genitals  or  fingers,  dis- 
orders of  speech  or  irregular  facial  innervation  may  indicate  heredi- 
tary taint.  Neurasthenic  symptoms  are  not  unusual.  The  expression 
is  often  dull.  When  idiocy  occurs  with  epilepsy  there  are  two  possi- 
bilities; first,  that  both  are  coordinate  results  of  a  common  cause,  or 
second,  that  early,  chronic  and  repeated  attacks  have  initiated  mental 
degeneration.  However,  many  brilliant  men  have  been  epileptics, 
as  Julius  Ceesar,  Napoleon,  Carl  V,  Peter  the  Great,  St.  Paul,  Mo- 
hamed,  Petrarch  and  Rousseau.  The  importance  of  organic  disease 
of  the  heart,  lungs,  stomach,  and  kidney,  is  difficult  to  estimate.  It  is 
possible  that  the  future  study  of  metabolism  may  establish  the  auto- 
intoxication theory.  Epileptics  often  sweat  profusely,  are  usually 
constipated  and  frequently  become  obese  from  inordinate  eating  and 
from  the  bromide  treatment. 

Diagnosis. — The  diagnosis  concerns  the  convulsive  seizures  and 
the  abortive  types.  Similar  convulsions  occur  in  numerous  other  con- 
ditions and  must  first  be  excluded.  They  occur  in  (a)  organic  brain 
disease,  as  syphilis,  tumors,  vascular  lesions,  paretic  dementia,  multiple 
sclerosis,  and  infantile  cerebral  paralysis.  These  affections  may 
produce  generalized  or  Jacksonian  fits.  Jacksonian  epilepsy  is  more 
clonic  (from  cortical  irritation)  than  tonic  (due  to  infracortical  irrita- 
tion), is  often  associated  with  paresis  or  sensory  alteration,  occurs  less 
often  with  coma  unless  its  generalization  is  unusually  wide,  and  in  50  per 
cent,  of  cases  is  due  to  small  cortical  tumors.  Epilepsy  rarely  (E. 
tarda)  develops  after  thirty  years  of  age,  and  90  per  cent,  of  cases  which 


1206 


DISEASES  OF  THE  NERVOUS  SYSTEM 


occur  after  thirty, — excluding  alcoholism  and  uraemia, — are  syphilitic 
(Fournier,  H.  C.  Wood).  After  forty-five,  vascular  lesions  are  a  very 
common  cause.  In  some  cases  true  epilepsy  appears  to  follow  the 
Jacksonian  type.  (6)  Convulsions  may  occur  in  altered  conditions  of 
the  blood,  as  alcoholism,  urcemia  (eclampsia),  plumbism  or  drug 
poisonings,  (c)  Reflex  epilepsy  results  from  dentition,  worms,  or 
digestive  disorders;  in  some  cases  genuine  epilepsy  seems  to  follow 
the  reflex  form  (which  perhaps  is  epilepsy  in  itself). 

Simulation  of  epilepsy  is  impossible.  In  the  complete  type,  the 
tongue  biting,  cry,  stertor  or  involuntaries  may  be  absent.  Scars  are 
often  of  diagnostic  value.  Nocturnal  epilepsy  occurs  in  33  per  cent., 
often  coming  on  when  the  patient  drops  off  to  sleep  or  on  awakening 
in  the  morning;  it  easily  escapes  recognition  for  years,  but  the  de- 
pression, bitten  tongue,  ecchymoses  and  involuntary  evacuations  are 
unmistakable. 

Differentiation  from  hysteria,  which  is  usually  easy,  may  be  difficult, 
indeed  the  two  affections  sometimes  co-exist;  the  following  table  is 
combined  from  Gowers  and  Biswanger: 


Epilepsy. v 

Distant  warnings:   few,  mental. 
Aura:      more     frequent,     momentary, 
oftenest  unilateral  or  epigastric. 

Cause:  none. 

Onset:  always  sudden,  often  with  pallor, 
cry  which  is  never  verbal,  immediate 
falling  and  complete  unconsciousness, 
with  rigidity,  etc. 


Tongue  biting,  frothing:  very  common. 

Convulsions:  generalized,  tonic  followed 
by  clonic  spasms,  very  rarely  tonic 
alone;  flexor  spasm  predominates. 


Reflexes:  pupils  contracted  at  onset, 
dilated  later,  immobile  (in  clonic 
period).  Tendon  and  skin  reflexes 
absent  during  and  after  attack. 

Involuntary  evacuations:    frequent. 

The  urine:  solids  always  increased, 
both  nitrogen  and  phosphates. 

Temperature:  sometimes  elevated,  2-3°. 

Coma:   complete. 

Duration  oi  seizure:  very  short. 

Post-paroxysmal:  sensory  and  motor  ex- 
haustion, ecchymoses,  absent  reflexes, 
mental  incapacity,  with  no  memory 
of  transpired  events. 


-Hysteria. 


Frequent,  emotional. 
Less    frequent,    longer,    bilateral    foot 
aura,  globus. 

Emotional. 

More  gradual,  rarely  with  pallor  or  cry. 
which  may  be  repeated  or  verbal,  and 
recurs  later.  Rarely  brusque  falling, 
slower  and  far  less  complete  uncon- 
sciousness, and  may  react  to  sugges- 
tion or  pressure  on  hysterogenous 
zones. 

Exceptional,  or  seemingly  purposive. 

Rigidity,  to  carry  out  semi-intentional 
movement;  struggling;  clonic,  irreg- 
ular spasms,  seemingly  fragments  of 
partial  movements  of  emotion;  ex- 
tensor  spasm  predominant  "arc  de 
cercle,"  clownism,  passional  attitudes, 
etc. 

Pupils  usually  wide  and  react  (may 
be  immobile,  Westphal,  Karplus). 
Sometimes  convergent  strabismus. 
Reflexes  not  absent  or  increased. 

Absent  or  most  exceptional. 

All  solids  decreased  and  altered  ratio 
between  earthy  and  alkaline  phos- 
phates. 

Practically  never. 

No  real  coma. 

Longer,  recurrent,  relapsing. 

Depression,  fatigue,  pain  in  head  or 
stomach,  nausea,  some  memory  of 
attack 


EPILEPSY  1207 

The  most  difficult  forms  to  differentiate  are  petit  mal  and  trans- 
formed epilepsy,  in  which  the  history  or  observation  of  major  attacks 
is  important.  Petit  mal  may  be  confused  with  cardiac  syncope, 
labyrinthine  vertigo,  etc. 

Course  and  Prognosis. — ^When  one  attack  has  occurred,  a  second 
may  be  expected  in  33  per  cent,  of  cases  in  less  than  one  month,  in 
33  per  cent,  in  from  one  to  twelve  months,  in  33  per  cent,  in  over  one 
year;  and  when  epilepsy  is  once  established,  daily  attacks  occur  in  10 
per  cent.,  in  50  per  cent,  they  occur  at  intervals  of  less  than  two  Weeks, 
and  in  75  per  cent,  they  occur  at  intervals  of  less  than  one  month 
(Gowers).  The  mode  of  life,  stimulation,  excitement,  pregnancy,  and 
sexual  excesses  may  increase  their  frequency,  and  cessation  during 
fevers  is  not  uncommon.  In  some,  though  fortunately  rare,  cases,  the 
attacks  occur  in  quick  succession  (status  epilepticus,  etat  de  mal),  as 
many  as  10  or  30  or  over  100  occurring  in  one  day.  In  one  case  2,500 
seizures  occurred  during  a  month;  the  stage  of  coma  may  last  from 
two  or  three  days  to  a  week,  with  a  temperature  of  105-7°  and  death 
then  results.  The  outlook  (a)  as  to  recovery  is  poor.  Five  to  10  per 
cent,  of  cases  may  recover  spontaneously  (Huf eland,  Dana,  Miiller). 
The  prospects  are  best  in  cases  which  begin  before  twenty,  in  males,  in 
cases  with  long  intervals,  and,  though  it  may  seem  strange,  in  hereditary 
forms.  After  two  years'  duration,  the  outlook  is  unfavorable,  (b) 
As  to  life,  the  prognosis  is  more  favorable.  A  few  cases  drown,  suffo- 
cate from  turning  on  the  face,  or  are  fatally  burned  during  the  seizure. 
Some  patients  die  during  the  insult  from  vascular  lesions  of  the  brain, 
or  less  often  from  heart  rupture,  respiratory  cramp,  oedema  of  the 
lungs  or  vomiting  into  the  larynx.  The  status  epilepticus  and  delirium 
tremens  are  dangerous.  Epileptics  frequently  become  tuberculous.  In 
10  per  cent,  dementia  occurs.  The  average  duration  of  life  is  probably 
shorter  than  normal.  Bodily  health  and  intellectual  vigor  may,  how- 
ever, be  remarkably  preserved. 

Treatment. — 1.  Treatment  of  Cause. — This  has  a  limited  scope. 
Syphilitic  epilepsy,  unless  due  to  a  gumma  or  to  the  secondary  anaemia, 
does  not  respond  to  antisyphilitic  remedies.  Avoidance  of  alcohol 
may  be  almost  curative  in  this  form.  Reflex  factors  should  be  removed. 
In  Sweden  epileptics  cannot  marry;  50  per  cent,  of  hereditary  epileptics 
transmit  some  transformation  of  the  taint  to  their  offspring. 

2.  Hygienic  Therapy. — New  cases  in  children  should  receive  the 
general  care  outlined  under  the  other  neuroses.  Work  in  school  should 
be  limited  to  a  few  hours,  and  country  life  is  generally  preferable  to 
that  in  the  city.  For  very  poor  subjects,  institutional  treatment  is 
indicated.  Erb  uses  galvanization  through  the  head.  Most  neurolo- 
gists greatly  restrict  the  consumption  of  meat,  although  Gowers  allows 
it  once  or  twice  a  day.  Toulouse  and  Richet  withdraw  salt,  and  give 
a  milk  and  cereal  diet,  which  they  think  promotes  the  affinity  of  the 
bromides  for  the  brain  cells. 

3.  Bromide  Treatment. — This  was  introduced  by  Laycock  (1853), 
and  was  developed  by  Voisin.     The  bromides  act  directly  on  the 


1208  "        DISEASES  OF  THE  XERVOUS  SYSTEM 

nervous  tissue;  they  depress  the  cortical  cells,  with  which  they  organ- 
ically unite,  inhibit  reflex  action  in  the  brain  and  cord,  and  lessen 
centripetal  conduction.  Untoivard  symptoms  may  result  even  within 
therapeutic  limits.  Intellection  may  be  dulled  and  muscular  depres- 
sion occur,  but  these  may  often  be  counteracted  by  administration 
of  coffee;  the  frequent  stomach  symptoms  can  be  avoided  by  free 
dilution  of  the  bromide  in  water;  diarrhoea,  which  results  especially 
from  potassium  bromide,  is  relieved  by  opium  if  marked,  or  if  less,  by 
salicylate  of  bismuth  and  beta-naphthol,  aa  gr.  x,  after  meals;  in  its 
elimination  by  the  skin,  acne  is  common,  which  is  lessened  or  removed 
by  giving  large  quantities  of  water  and  small  doses  of  arsenic,  and  by 
washing  the  skin  with  green  soap.  Belladonna  in  small  doses  will 
modify  the  respiratory  catarrh  or  salivation.  The  anaphrodisiac 
effects  cannot  be  prevented.  In  some  individuals  there  are  marked 
idiosyncrasies,  as  mental  excitement,  hallucinations,  rapid  emaciation 
("bromide  cachexia")  with  lessened  physiological  resistance  to  acute 
diseases.  Toxic  symptoms  may  be  acute,  resembling  those  of  paretic 
dementia,  but  more  commonly  are  chronic;  chronic  bromism  is  most 
likely  to  develop  in  those  wdth  weak  digestion  or  circulation  and  when 
the  drug  is  given  carelessly  for  a  long  time,  because  its  elimination  is 
slow.  In  the  former,  hydrotherapy,  massage  and  tonics  should  be 
used  as  preliminary  or  concomitant  measures.  Cardiac  symptoms 
are  due  almost  wholly  to  the  potassium  salt,  but  especial  care  in  the  use 
of  all  bromides  is  indicated  in  cases  of  senile  epilepsy  (myocarditis, 
arteriosclerosis,  endocarditis)  or  of  great  nutritive  exhaustion,  in 
which,  combination  with  digitalis  or  strychnia  is  indicated.  In  bromism 
the  reflexes  are  decreased,  particularly  the  pharyngeal  reflex,  but 
Englehardt  has  shown  that  it  is  weak  in  17  per  cent,  and  absent  in  25 
per  cent,  of  normal  individuals,  whence  Ziehen  watches  the  corneal 
reflex,  which  is  never  normally  absent.  In  advanced  bromism  there  is 
low  temperature,  bronzed  skin,  vasomotor  relaxation,  somnolence, 
apathy,  paralytic  speech,  muscular  relaxation,  ataxia,  tremor,  foetor  ex 
ore,  anorexia,  slow  respiration  (the  usual  cause  of  death),  weak  heart, 
abolition  of  sensation  in  the  skin  and  mucous  membranes  and  of  all 
reflexes,  and  decrease  or  suppression  of  urine.  The  drug  therapeutically 
unites  with  the  nerve  cell  and  depresses  its  activity  and  metabolism, 
and  toxicologically  it  causes  its  degeneration  or  atrophy.  The  drug 
must  be  used  for  months  or  years,  and  the  symptoms  above  enumer- 
ated must  be  watched  for;  it  seems  that  epileptics  have  a  certain 
tolerance  for  bromides,  which  Voisin  considered  almost  as  a  food  in 
this  affection. 

Results. — Gowers  noted  immediate  relief  in  43  per  cent.,  improve- 
ment in  a  short  time  in  47  per  cent.,  and  no  effect  in  10  per  cent,  of 
his  cases.  He  gives  a  dram  a  day  of  the  potassium  salt,  for  two 
years,  for  he  finds  that  larger  doses  are  no  more  efficacious;  in 
nocturnal  epilepsy  a  large  dose  should  be  given  at  bed-time.  Seguin  's 
results  were:  cessation  of  attacks  in  23  per  cent.,  notable  decrease  in 
40  per  cent.,  no  great  effect  in  26  per  cent.,  no  effect  in  10  per  cent. 


IXFAXTILE  CONVULSIONS    '  1209 

Charcot 's  method  was  to  give  a  daily  dose  of  one  dram,  which  was 
gradually  increased  to  nearly  two,  and  was  then  slowly  decreased  to 
the  original  amount.  Erlenmeyer's  formula  is  extensively  used,  and 
gives  the  best  results  (sodium  and  potassium  bromide  each  two  parts, 
and  amnion,  bromide  one  part).  The  best  results  are  obtained  in 
cases  which  are  treated  early  in  their  course  and  early  in  life,  and  in 
those  in  which  there  are  long  intervals  between  attacks.  Opium, 
belladonna,  nitroglycerine,  digitalis  and  chloral  are  of  but  secondary 
importance,  although  with  special  symptoms  they  may  reinforce  the 
bromides.  Nitroglycerine  may  be  useful  in  fetit  mal.  Children 
tolerate  large  doses  of  bromides  (as  well  as  of  mercury,  belladonna  and 
arsenic). 

4.  Treatment  of  the  Attack. — This  is  confined  to  cases  in  which 
aurse  are  present.  The  patient  is  placed  on  the  bed  or  ground  to  avoid 
injury,  and  a  towel  inserted  between  the  teeth  to  prevent  biting  of  the 
tongue.  Compression  or  manipulation  of  the  limb  in  which  the  aura 
is  felt  may  in  a  few  instances  avert  the  spasm.  Charcot  placed  an  ice- 
bag  over  the  head  and  one  over  the  heart.  Inhalations  of  amyl  nitrite, 
ether  or  chloroform  are  sometimes  beneficial. 

5.  Surgical  Indications  in  Traumatic  Epilepsy  ( Jacksonian  or  general- 
ized).— ^^Biswanger's  conclusions  are  (a)  that  results  are  disappointing; 
only  a  small  percentage  of  cases  actually  recover;  operation  is  indicated 
(6)  when  convulsions  emanate  from  a  small  cortical  focus;  (c)  when 
the  convulsions  are  of  a  type  intermediate  between  the  Jacksonian  and 
generalized  form;  {d)  when,  with  generalized  convulsions,  there  is  a 
suggestive  scar,  bone  defect  or  localized  tenderness  on  percussion ;  (e) 
since  the  internal  lesion  does  not  always  correspond  with  the  external 
scar,  the  site  of  trephining  should  be  governed  by  focal  symptoms, 
motor  or  sensory  aurae,  or  "  exhaustion"  signs;  (/)  cysts,  tumors,  bone, 
membrane  or  scars  may  be  removed,  but  not  the  cortex  (as  recom- 
mended by  Horsley) ;  {g)  operation  must  be  followed  by  the  bromide 
treatment;    Qi)  operation  is  contra-indicated  in  ordinary  epilepsy. 


INFANTILE  CONVULSIONS. 

In  young  children  the  nervous  tissues  are  incompletely  developed, 
many  axis  cylinders  are  not  yet  clothed  with  myelin  sheaths,  and  the 
lower  dominate  the  upper  segments,  thus  predisposing  the  child  to 
disproportionate  nervous  reaction. 

Etiology. — (a)  Rickets  as  a  cause  was  especially  emphasized  by  Wm. 
Jenner.  Many  cases  of  carpopedal  spasm,  tetany  and  laryngismus 
stridulus  have  a  rhachitic  basis;  this  form  occurs  in  infants  between 
the  eighth  and  twenth-fourth  months  of  life,  is  likely  to  recur,  and  dis- 
appears after  the  second  year.  (6)  Reflex  spasms  may  be  caused  by 
peripheral  irritation,  as  from  dentition  and  worms,  though  the 
importance  of  reflex  irritation  has  been  greatly  overestimated; 
gastro-intestinal  irritation  or  auto-intoxication,  phimosis,  and  otitis 


1210  DISEASES  OF  THE  NERVOUS  SYSTEM 

media,  are  possible  causes,  (c)  They  may  be  due  to  g astro-intestinal 
intoxication,  which  results  in  debility,  malnutrition  or  a  "hydren- 
cephaloid"  condition  (Marshall  Hall),  which  has  been  described  above 
under  various  captions  and  is  usually  of  most  serious  import,  id) 
Nervous  affections,  trauma  during  delivery,  meningitis,  tumor,  sinus 
thrombosis,  severe  coughing,  acute  encephalitis  (cerebral  hemiplegia), 
or  acute  poliomyelitis,  are  etiological  factors,  (e)  They  may  result  from 
acute  injections,  as  scarlatina,  measles,  or  pneumonia,  in  which 
convulsions  and  vomiting  rather  replace  the  chill  which  is  more 
common  in  adults.  (/)  Genuine  epilepsy  may  begin  in  early  life;  12 
per  cent.,  according  to  Gowers,  and  40  per  cent.,  according  to  Osier, 
occurs  in  the  first  three  years  of  life. 

Symptoms. — The  symptoms  resemble  those  of  epilepsy  in  most  of 
its  phases,  but  they  are,  however,  less  developed  in  the  eclampsia  of 
children.  It  usually  begins  in  the  hands,  and  the  seizure  is  partial, 
tonic,  intermittent,  and  carpopedal  rather  than  generalized.  Screaming 
and  grinding  of  the  teeth  may  occur.  The  laryngeal  spasm  has  already 
been  described  under  affections  of  the  vagus. 

Treatment. — The  occurrence  of  the  convulsion  is  the  first  indication 
for  treatment,  and  should  be  met  symptomatically  by  inhalations  of 
chloroform  or  nitrite  of  amyl,  followed  by  grs.  v  to  x  of  chloral,  and  5ss 
of  bromide  by  rectum.  The  bromide  should  be  given  for  several  days, 
for  its  effects  are  cumulative  rather  than  immediate.  Opiates  should 
generally  be  avoided  in  children  under  five  years,  especially  in  nurslings; 
if  given  to  them  at  all  the  dosage  should  be  one-half  the  dose  according 
to  the  rule  of  age,  i.  e.,  h  of  the  adult  dose  in  a  child  of  one  year,  instead 
of  tV  of  the  adult  dose.  Opiates  should  not  be  used  in  weak  or  marantic 
infants.    The  hot  bath  is  of  little  service. 

The  cause  is  then  determined  and  treated,  as  (a)  the  rickets,  and  (b) 
the  peripheral  irritation;  lancing  of  the  teeth  is  practiced  less  and 
less;  (c)  in  gastro-intestinal  intoxication  the  stomach  should  be 
emptied  by  ipecac  or  by  means  of  the  stomach  tube ;  lavage  of  the 
bowel  is  indicated  in  acute  cases  and  stimulants  should  be  given  in 
cases  of  some  standing,  (d)  The  bromides  should  be  administered  as 
in  epilepsy. 

CHOREA  AND  CHOREIFORM  AFFECTIONS. 

The  name  is  given  to  several  convulsive  maladies.  Chorea,  or  St. 
Vitus  dance,  known  to  Paracelsus,  was  endemic  in  the  middle  ages  and 
is  now  often  known  as  chorea  major;  it  was  hysteria  or  possibly 
epilepsy.  Chorea  in  its  usually  accepted  sense  was  described  by 
Sydenham  and  is  known  as  Sydenham's  chorea,  chorea  minor,  or 
infective  chorea. 

Definition. — Sydenham's  chorea  is  (a)  a  neurosis  of  late  childhood; 
(&)  it  is  characterized  by  subacute  onset,  limited  duration  and,  usually, 
recovery;  (c)  it  is  probably  cortical  in  localization,  as  indicated  (d) 
by  involuntary  irregular   spasmodic   movements,   and    (e)  increased 


CHOREA   AND  CHOREIFORM  AFFECTIONS  1211 

incoordination  on  voluntary  efforts;  (/)  it  is  always  associated  with 
some  psychical  weakness,  irritability  or  alteration  in  character  and 
(g)  is  frequently  associated  with  rheumatism  and  (h)  endocarditis. 

Etiology. — (a)  Age:  80  per  cent,  of  cases  occur  in  persons  between 
the  fifth  and  fifteenth  years;  90  per  cent,  in  those  between  the  fifth  and 
twentieth  years;  it  is  most  frequent  at  the  sixth  and  seventh  year  of  life, 
or  at  puberty.  (6)  Sex :  Seventy  per  cent,  of  cases  are  in  girls  (Gowers, 
Osier),  (c)  RheumatisTYi  has  been  considered  a  cause  since  Bright's 
time  and  this  theory  has  been  established  especially  by  English  writers. 
The  French  writers  probably  overestimate  its  importance,  and  the 
Germans  apparently  underestimate  it.  Rheumatism  is  a  factor  in  at 
least  20  to  25  per  cent.  (Hughes  and  See) ;  some  consider  it  causal  in 
45  or  even  70  per  cent,  of  cases.  Endocarditis,  rheumatism  and  chorea 
are  too  frequently  associated  to  escape  serious  attention.  Rheum- 
atism occurs  mostly  before  the  chorea,  but  in  4  per  cent,  of  cases 
do  the  two  occur  simultaneously.  Their  association  is  most  frequent 
in  the  young,  but  their  exact  relation  cannot  be  established  until  the 
cause  of  rheumatism  is  known.  Rheumatism,  endocarditis  and  chorea 
are  probably  correlated,  i.  e.,  are  due  to  a  common  virus,  (d)  Other 
acute  infections  are  causes  in  43  per  cent,  of  cases  (Neumann).  Chorea 
has  been  observed  after  gonorrhoea,  puerperal  fever,  sepsis,  pertussis, 
measles,  typhoid,  etc.  (e)  Pregnancy  is  a  predisposing  cause  in  women, 
particularly  before  the  twenty-fifth  year.  Chorea  occurs  in  the  first 
three  months,  especially  in  first  pregnancies  and  is  most  severe  in 
character.  It  rarely  occurs  postpartum.  Giles  de  la  Tourette  justly 
holds  that  many  cases  classified  as  chorea  are  really  hysteria.  (/) 
Neuropathic  heredity  is  observed  in  16  per  cent,  of  choreic  subjects, 
which  probably  explains  its  frequency  in  Hebrews.  This  factor  has 
seemingly  been  overestimated.  (g)  Other  causes  are  sometimes 
operative,  as  fright,  trauma,  and  reflex  irritation  from  nasal  or  digestive 
disease,  as  worms.  It  occurs  in  the  lower  classes,  is  sometimes  due  to 
iodoform  or  mercurial  poisoning,  apparently  occurs  when  the  baro-. 
meter  is  low,  and  is  influenced  by  the  poor  hygiene,  excitement, 
exhibition  and  competition  of  the  school-room;  this  is  called  the 
"school-made  chorea"  by  Sturges. 

Pathology  and  Pathogenesis. — The  disease  is  a  provisional  neurosis, 
since  no  constant  pathological  findings  exist.  The  following  changes 
have  been  recorded;  hypertemia,  exudation  about  the  arteries,  areas 
of  softening,  punctate  hemorrhages,  round  hyaline  bodies  in  the  peri- 
vascular lymph  sheaths  (Flechsig,  Wollenberg,  Jakomenko),  and 
swelling  and  turbidity  of  the  large  pyramidal  cells  of  the  cortex  (Tur- 
ner); but  none  of  these  are  characteristic  or  constant.  In  fatal  cases 
endocarditis  is  the  most  frequent  finding  (90  per  cent.  Osier,  94  per 
cent.  Sturges),  and  Osier  notes  that  its  frequency  is  greater  even  than 
in  rheumatism.  Kirke's  theory  of  cerebral  embolism  has  been  rather 
generally  abandoned.  The  bacteriological  findings  are  negative  or 
conflicting.     It  is  probable  that  the  irritation,  whether  the  result  of 


1212  DISEASES  OF  THE  XERVOUS  SYSTEM 

exhaustion  or  of  toxaemia,  is  either  cortical  or  in  the  basal  ganglia, 
which  are  closely  connected  with  the  cortex  or  subcortex. 

Symptoms. — 1.  Onset. — Prodromes  are  infrequent,  but  sometimes 
there  is  a  subacute  onset,  with  irritability,  restlessness,  depression,  dis- 
turbed sleep,  headache,  anorexia,  rheumatic  pains  or  sensory  irritation. 
The  affection  usually  begins  with  motor  disturbance,  in  the  form  of 
involuntary  moveme^its  and  incoordinate  voluntary  movements;  the 
latter  are  often  misunderstood  and  punished,  for  the  child  cannot  sit 
still,  or  breaks  or  drops  things. 

2.  Chorea  Movements. — These  are  involuntary,  although  they  may 
seem  voluntary,  as  the  thrusting  out  of  the  tongue  or  the  reaching  of 
the  arm  at  an  object.  They  are  "irregular  in  time,  character  and 
degree,"  are  often  long,  are  not  usually  attended  by  fatigue  or  pain, 
are  incomplete  and  without  motive,  are  increased  by  attention  being 
drawn  to  them  and  by  excitement  and  almost  always  cease  during  sleep. 
They  usually  begin  in  the  arms,  and  later  extend  to  the  face  and  legs. 
Chorea  very  often  begins  on  one  side,  especially  the  right,  whence  it 
extends  to  the  other  side  but  sometimes  remains  unilateral  Qiemi- 
chorea);  both  sides,  however,  are  always  involved  to  some  extent.  The 
face  is  contorted  with  varying  expressions,  now  grimaces  or  again 
motiveless  smiles;  this  is  the  fades  choreatica  of  Sachs.  The  eyes  roll, 
are  disturbed  especially  when  attempts  are  made  to  fix  them,  and 
diplopia  is  not  uncommon.  The  pupils  are  often  wide  and  react 
slowly.  Tuckwell  describes  a  case  in  which  the  teeth  were  broken. 
The  author  recently  saw  with  Dr.  Halbert  a  similar  instance  in  which 
many  of  the  teeth  were  broken.  Speech  is  involved  in  25  per  cent.'of 
cases ;  this  is  due  rather  to  difficult  articulation  by  the  tongue  and  lips 
than  to  phonation.  Speech  is  quicker  than  normal,  like  the  movements 
of  the  arm,  and  may  be  aggravated  by  irregular  movements  of  the 
glottis  and  respiratory  muscles,  resulting  in  panting,  irregular  inspir- 
ation or  expiration  or  sobbing  sounds  in  which  the  diaphragm  partici- 
pates. Aphasia  is  less  frequent.  The  arms  are  most  involved;  they  are 
flexed,  extended,  pronated  and  supinated  in  tireless  succession. 
Bouillaud  spoke  of  the  movements  as  muscular  insanity  (folie  mus- 
culaire).  The  trunk  is  sometimes  involved  in  light  cases,  and  distinctly 
so  in  the  severe  types.  The  movements  are  sometimes  so  violent  as  to 
throw  the  patient  out  of  bed.  The  legs  are  usually  much  less  involved; 
there  is  a  zig-zag  gait,  and  walking  may  be  impossible.  Besides  hemi- 
chorea,  other  irregularities  are  at  times  encountered,  as  monochorea, 
chorea  paraplegica,  or  chorea  alternans.  The  muscular  power  and 
endurance  are  often  said  to  be  normal.  Some  writers,  as  Wallenberg, 
insist  that  paresis  is  no  part  of  chorea,  but  Gowers  and  Osier  speak  of 
marked  muscular  weakness.  Two  forms  are  distinguished :  (a)  paresis 
with  chorea,  in  which  the  muscular  power  is  reduced,  as  in  the  usual 
case,  and  (b)  limp  or  paralytic  chorea  (Todd,  West,  and  the  choree 
molle  of  French  writers).  The  paresis  may  be  of  the  mono-,  para-  or 
hemiplegic  type. 


CHOREA  AND  CHOREIFORM   AFFECTIONS  1213 

3.  Psychical  Changes. — -These  are  constant,  and  resemble  an  acute 
cerebral  neurasthenia  in  the  undue  irritability  and  ready  fatigue 
which  are  manifested.  The  subject  is  wilful,  forgetful,  emotional, 
irritable,  unable  to  concentrate  the  attention  or  to  remember  perfectly. 
Marked  alteration  in  addition  to  these  changes  may  occur,  as  com- 
plications, viz.,  delirium,  mania,  melancholia  or  hallucinations; 
chorea  insaniens  has  a  most  unfavorable  prognosis.  Combination  with 
hysteria  is  frequent,  with  epilepsy  infrequent.  Hughlings  Jackson 
found  paroxysmal  headache  in  90  per  cent,  of  cases. 

4.  Sensation. — Sensation  is  usually  normal.  Tenderness  over  the 
spine  and  peripheral  nerves  is  not  common,  though  S.  Wier  Mitchell 
and  Triboulet  described  a  painful  chorea.  Occasionally  there  is  a 
tingling  sensation  and  numbness.  Blocq  and  others  have  insisted 
that  sensory  alteration  is  referable  to  hysteria,  but  Triboulet  finds  that 
there  is  usually  some  reduction  of  sensation. 

5.  The  Reflexes. — These  are  difiicult  to  study,  and  are  often  said  to 
be  normal.  They  are  normal  in  50  per  cent.,  and  decreased  or  absent 
in  50  per  cent.,  although  Joffroy  usually  found  the  patellars  decreased 
or  absent,  and  Oddo  found  the  tendon  reflexes  (a)  rarely  increased, 
(6)  normal  in  light  cases  only,  and  (c)  as  a  rule  decreased  or  absent 
(absent  on  one  side  in  80  per  cent.,  on  both  sides  in  50  per  cent.). 
The  bladder  and  rectum  are  usually  normal  save  in  the  severest  forms. 

6.  Electrical  Reactions. — The  electrical  reaction  and  mechanical  irri- 
tability of  the  muscles  are  with  few  exceptions  unaltered. 

7.  The  Heart. — Irregularity  is  common,  and  is  often  due  to  irregu- 
larity in  breathing  (pseudo-arrhythmia).  A  slight  increase  in  rate  is 
due  to  the  general  neurosis.  It  has  been  claimed  that  chorea  may 
affect  the  "muscles  of  organic  life";  Ollivier,  Roger  and  Simon  have 
written  of  cardiac  chorea,  which  probably  does  not  exist.  Functional 
murmurs  are  frequent,  especially  in  thin  nervous  children,  from  the 
altered  condition  of  the  blood,  the  toxaemia,  and  increased  cardiac  rate. 
They  may  be  confused  with  incipient  endocarditis.  Great  conser- 
vatism must  be  exercised  in  their  prognosis  and  diagnosis  (see  Diag- 
nosis OF  Mitral  Insufficiency). 

Endocarditis  has  been  mentioned  in  the  definition  of  the  disease 
and  its  causation  and  pathology  (90  to  94  per  cent,  of  fatal  cases).  It 
was  found  in  66  per  cent,  of  Osier's  cases  without  rheumatism.  It  is 
rarely  malignant,  but  may  produce  embolism.  Mitral  lesions,  especi- 
ally insufficiency,  are  the  most  common  form.  The  importance  of 
latent  endocarditis,  i.e.,  without  clinical  symptoms,  has  been  empha- 
sized by  Osier,  Oxley  and  Grosse.  Pericarditis  is  not  frequent,  though 
it  is  found  in  20  or  even  26  per  cent,  of  cases,  in  certain  statistics. 
Heart  disease  is  found  in  50  per  cent,  of  cases  in  which  there  have  been 
two  attacks  of  chorea,  and  in  100  per  cent,  of  those  having  over  three. 

8.  The  Skin. — Herpetic  eruptions  and  pigmentation  result  from 
medication  by  arsenic.  Urticaria,  erythema  nodosum  and  purpura 
are  sometimes  observed,  as  well  as  the  rheumatic  nodes  first  described 
by  Maynet  and  later  by  Barlow  and  Warner. 


1214  DISEASES  OF  THE  NERVOUS  SYSTEM 

9.  General  Symptoms. — Emaciation  occurs  chiefly  in  the  severer 
types.  The  urea  and  phosphates  are  often  increased.  Albuminuria 
is  rare,  except  as  a  result  of  renal  embolism.  The  temperature  is  not 
often  elevated,  save  from  cardiac  and  other  complications;  even  in 
chorea  insaniens  it  rarely  passes  102°. 

Course  and  Prognosis. — The  average  course  of  mild  cases  is  from 
six  to  ten  weeks,  and  six  weeks  to  six  months  is  the  average  duration  of 
all  varieties.  In  very  rare  instances  the  disease  may  last  six  (Gowers) 
or  even  sixty  years  (Meldner).  Three  main  types  are  distinguished: 
(a)  The  mild  type,  in  which  the  patient  is  nervous,  irritable,  has  but 
slight  choreic  movements  and  is  often  dyspeptic  and  sometimes 
anaemic;  (b)  the  severe  form  in  which  the  spasmodic  movements  are 
severe  and  general;  (c)  the  maniacal  type  (chorea  insaniens) ,  which  is 
most  often  observed  in  adult  or  pregnant  women,  and  sometimes  at 
puberty.  The  movements  are  incessant  and  extreme,  and  are  often 
associated  with  fever,  constant  insomnia  and  great  psychical  disturbance. 
As  a  rule,  the  shorter  the  duration  the  more  intense  are  the  symptoms. 
The  tendency  to  recurrence  was  noted  by  Sydenham.  Relapses  occur 
in  25  to  33  per  cent,  of  cases.  One  year  is  the  average  interval,  and 
when  there  is  no  recurrence  within  one  and  one-half  years,  it  is  probable 
that  none  will  be  observed  (Gowers).  Germain  See  held  that  relapses 
were  most  likely  to  occur  at  the  sixty-ninth  day.  Recovery  is  the  rule ; 
the  mortality  averages  between  2  and  3  per  cent.  Twenty  to  25  per 
cent,  of  pregnant  cases  die.  Fatality  is  greatest  at  the  age  of  puberty  and 
in  adults.  As  Charcot  remarked,  death  occurs  less  often  from  compli- 
cations, as  endocarditis,  than  from  toxaemia,  fever,  mental  changes, 
emaciation,  delirium,  and  coma.  In  all  cases  rise  of  temperature  or 
obstinate  insomnia  is  ominous.  Though  the  immediate  outlook  is 
not  influenced  by  endocarditis,  it  is  a  most  important  feature  in  the 
ultimate  prognosis  of  a  complete  recovery.  Intercurrent  fevers  may 
dissipate  the  spasms.  While  complete  recovery  is  generally  expected, 
in  rare  instances  distinct  psychical  changes  (Jolly)  or  permanent  chorea 
may  remain  {v.s.). 

Diagnosis. — -Recognition  of  the  disease  is  usually  most  easy,  after 
one  has  seen  a  typical  case,  and  when  one  bears  in  mind  the  conception 
(definition,  q.v.)  of  the  disease. 

Differentiation. — Simple  tremor  or  the  intention  tremor  of  mul- 
tiple sclerosis  is  easily  separable.  The  hemichorea  of  hemiplegia 
(see  Diagnosis  of  Cerebral  Hemorrhage)  or  the  bilateral  chorea 
of  infantile  cerebral  paralysis  {q.v.)  is  easily  distinguished  by  the  history 
and  course.  Friedreich's  ataxia  is  differentiated  by  its  slow,  irregular, 
incoordinate  movements,  nystagmus,  its  frequent  family  incidence, 
the  scoliosis,  talipes  and  slow,  scanning  speech.  Hysterical  chorea  (so- 
called)  is  rhythmic,  more  regular  and  frequently  produces  sudden 
("electrical")  movements,  as  bowing  or  salaaming,  nodding  the  head, 
etc.  Chorea  major  is  easily  distinguished.  Chorea  in  the  original 
sense  is  chiefly  of  historical  interest;  it  was  a  pandemic  or  epidemic 
hysteria  provoked  by  religious  excitement.     Its  victims  made  pilgrim- 


CHOREA   AXD  CHOREIFORM   AFFECTIONS  1215 

ages  to  the  shrine  of  St.  Vitus  whence  the  name  of  the  disease.  Simi- 
lar outbreaks  occurred  in  Kentucky  among  the  early  settlers.  This 
form  closely  resembles  the  saltatoric  spasm  described  by  Bamberger 
in  1859,  in  which  the  legs  contract  on  attempting  to  stand,  causing 
jumping  or  springing  movements.  It  may  be  transitory,  or  may  last 
for  years,  and  occurs  chiefly  in  neurotics.  Beard  and  Thornton,  quoted 
by  Osier,  have  described  a  similar  neurosis  which  was  endemic  in 
Canada  among  the  "jumping  Frenchmen."  The  "holy  rollers,"  and 
jumpers  of  Russia  and  Java  probably  come  under  this  head,  or  under 
impulsive  tic  (v.i.). 

Huntingdon's  chorea  has  no  connection  with  Sydenham's  type. 
Chronic  chorea  comprises  two  forms:  (a)  The  senile  form,  in  which 
the  mind  is  less  involved,  the  course  more  benign  than  in  {h)  the 
hereditary  form  of  Huntingdon.  Although  it  was  described  by  Walters 
(1842)  and  Lyons  (1863),  Huntingdon  in  1872  brought  out  the  cardinal 
features  of  the  disease  as  observed  on  Long  Island.  These  are  (i)  the 
late  and  gradual  onset  after  the  thirtieth  year,  more  marked  in  males 
than  in  females;  (ii)  its  hereditary  character,  sometimes  involving  25 
or  50  per  cent,  of  the  family,  sometimes  skipping  generations,  or  lasting 
for  generations  or  even  for  two  centuries  in  a  family  (Osborn) ;  (iii)  its 
progressive  character,  and  (iv)  the  resulting  mental  degeneration,  end- 
ing in  slow  dementia,  often  with  epileptiform  attacks  or  suicidal 
tendencies.  The  precise  pathology  of  Huntingdon's  type  is  not  known. 
Pachymeningitis,  hsematoma  of  the  dura,  or  less  often  chronic  encephalo- 
meningitis,  vascular  disease  and  atrophy  of  the  convolutions  liave  been 
present  in  the  isolated  autopsies  made.  The  etiology  is  unknown. 
Clinically  it  is  characterized  by  irregular  movements,  which  usually 
begin  in  the  hands,  are  somewhat  controlled  by  voluntary  effort,  and 
are  more  irregular,  incoordinate  and  slow  than  in  acute  chorea.  Slow 
spasmodic  facial  contortions  are  observed,  and  the  speech  becomes 
first  slow  and  hesitating,  and  later  quite  indistinct.  The  gait  is  un- 
steady and  swaying.  Writing  is  interfered  with,  the  reflexes  are 
moderately  increased,  sensation  is  normal  save  that  the  muscular  sense 
is  somewhat  blunted,  and  dementia  develops.  The  disease  is  incurable, 
although  somewhat  benefited  by  opium  and  bromides. 

Tic  must  be  differentiated.  The  term  is  now  used  to  desisrnate  an 
"  habitual,  conscious,  convulsive  movement  resulting  in  the  involuntary 
contraction  of  one  or  more  muscles,  abruptly  reproducing  some  reflex 
or  automatic  action  of  every-day  life"  (G.  Guinon).  There  are  two 
forms. 

(a)  In  simple  tic,  (i)  localized  spasm,  liabit  spasm,  or  habit  chorea, 
which  is  said  by  S.  Wier  Mitchell  to  occur  in  girls  between  seven  and 
fourteen  years  of  age,  may  result  from  lesions  of  the  nose  or  throat  or 
possibly  from  eye-strain,  and  includes  movements  such  as  winking, 
drawing  of  the  mouth,  sniffing,  shaking  the  head,  and  shrugging  the 
shoulders.  It  usually  ceases,  but  may  last  into  adult  life,  and  the 
"child's  attention  should  not  be  drawn  to  the  movements,"  although 
the  writer  believes   that  judicious    reminders   and   discipline  inhibit 


1216  DISEASES  OF  THE  NERVOUS  SYSTEM 

these  habits.  Arsenic  may  be  beneficial,  (ii)  The  electric  chorea 
(Henoch  and  Bergeron)  consists  of  short,  lightning-hke  contractions 
in  special  muscles,  as  those  of  the  neck  or  shoulders,  as  though  the 
muscles  were  electrically  stimulated,  (iii)  Dubinins  disease  (1846) 
consists  of  contractions  of  the  arms  and  legs,  followed  by  hyperesthesia, 
pain  in  the  head  and  back,  muscular  atrophy,  paresis  and  sometimes 
fever  and  convulsions.  It  is  endemic  in  Lombardy,  its  cause  is 
unknown,  and  it  is  usually  fatal  from  apoplexy  or  coma,  (iv)  Para- 
myoclonus  multiplex,  or  myoclonia,  which  was  described  by  Friedreich 
in  1881,  is  an  affection  of  sudden  onset,  with  symmetrical,  involuntary, 
arrhythmic,  quick,  clonic  contractions  of  the  upper  parts  of  the  arms, 
legs  and  trunk,  sometimes  of  the  face  and  tongue,  and  occurs  without 
loss  of  consciousness.  The  contractions  number  from  10  to  150  a 
minute,  and  may  terminate  in  a  tetanic  contraction.  It  affects  male 
adults  chiefly  (75  per  cent.)  and  follows  mental  or  emotional  agitation, 
so  that  some  would  classify  it  under  hysteria.  The  myotatic  irritability 
and  reflexes  are  increased,  the  mind  is  usually  normal,  although  some- 
times fixed  ideas  are  observed,  hiccough  is  occasional  from  involvement 
of  the  glottis  or  diaphragm,  voluntary  movement  is  decreased  or  some- 
times arrested,  there  are  no  sensory  symptoms  and  the  outlook  is 
usually  good,  although  the  course  may  be  long  and  relapsing.  Treat- 
ment consists  of  administration  of  voltaic  electricity,  nervines  and  bro- 
mides. The  family  form,  described  by  Unverricht,  with  epilepsy  and 
spasms  of  the  tongue,  and  deglutition,  is  probably  a  subtype  of  heredi- 
tary chorea. 

C.  Oddo  gives  the  following  general  differentiation  between 
Tic  and  Chorea. 

Form  of  movement:  pseudo-intentional,         Incoordination  and  great  variability, 
with  repetition. 

Rhythm:      rhytlunic,     brusque,     short,         Arrhythmic,  slow,  not  synchronistic, 
synchronistic. 

Will:  suspends  movements.  No  action. 

Accessory  signs:    muscular  power  pre-         Myasthenia;      modified     reflexes     and 
served;    normal  tendon  reflexes  and  sensation, 

sensation. 

Etiology:    hereditary  degeneration.  Neuropathic  tendency. 

(6)  Tic  with  explosive  utterances,  impulsive  tic  or  Gilles  de  la  Tour- 
ette's  disease,  is  closely  aflfiliated  with  hysteria  and  monomania.  It 
occurs  in  neurotic  individuals  between  the  sixth  year  and  puberty.  ^  The 
cardinal  features  of  the  psychosis  are :  (i)  Involuntary  movements  in  the 
face  and  arms,  or  in  all  the  muscles  in  severe  types,  when  the  movements 
become  violent  or  explosive,  (ii)  Explosive  utterances,  resembling 
a  bark,  occur;  the  patient  repeats  words  he  hears  (echolalia)  or  mimics 


CHOREA   AND   CHOREIFORM   AFFECTIONS  1217 

movements  (echopraxia) ;  the  child  may  use  obscene  or  profane  words 
(corprolaha),  which  was  considered  by  de  la  Tourette  to  be  most 
characteristic,  (iii)  The  subject  has  fixed  ideas.  These  include: 
arithmomania,  in  which  every  action  is  preceded  by  counting  or  doing 
a  certain  thing  a  given  number  of  times;  a  fear  of  contamination 
(delere  du  toucher);  onomatomania,  or  repetition  of  a  given  word  or 
name;  folie  pourquoi,  demanding  the  reason  for  everything.  The 
prognosis  is  usually  unfavorable. 

(c)  In  complex  coordinate  tic,  as  thumb  sucking,  rocking  in  the  bed, 
and  bumping  the  head,  the  outlook  is  favorable  (Gee  and  Hadden) 
when  it  does  not  occur  in  feeble-minded  children. 

Treatment  of  Acute  Chorea. — 1.  Prophylaxis. — This  may  produce 
results;  sensible  methods  of  education  should  be  adopted,  the  hours  in 
the  overheated,  foul  school-room  should  be  short,  and  the  useless 
forcing  of  children  by  marks,  prizes  and  exhibition  should  be  aban- 
doned. Children  can  be  taught  more  in  an  hour  or  two  of  judicious 
individual  instruction  than  in  the  five  or  six  confining  hours  which 
their  wandering  attention  must  endure.  Prevention  may  concern  other 
etiological  factors  {q.  v.);  for  instance,  the  nose  should  be  examined 
for  sources  of  irritation,  as  adenoids. 

2.  Rest  in  Bed. — The  results  obtained  by  rest  in  bed  and  isolation 
are  as  rapid  as  those  of  any  medicinal  therapy.  It  not  only  saves  tissue 
waste,  but  is  the  best  prophylactic  and  symptomatic  treatment  of 
possible  or  actually  established  endocarditis. 

3.  Skin.- — The  skin  is  very  often  dry  and  harsh,  whence  it  must  be 
given  special  attention.  Diaphoretics  frequently  produce  beneficial 
effects.  The  stimulation  of  the  skin  by  proper  covering  and  by  hydro- 
therapy is  the  simplest  and  least  injurious  method.  The  refrigerant 
diaphoretics,  and  full  warm  baths,  give  the  best  results.  The  skin  must 
be  kept  clean,  and  in  severe  cases,  the  water-bed  must  be  used. 

4.  Trauma. — Trauma  is  prevented  in  severe  types  by  padding  the 
beds  by  mattresses  and  pillows,  since  the  violent  movements  may  even 
throw  the  patient  to  the  floor.  Sepsis  is  a  frequent  occurrence,  and  is 
most  dangerous.     The  temperature  must  be  taken  by  rectum. 

5.  Exhibition  of  Drugs. — (a)  Fowler's  solution  is  the  most  frequently 
used  and  the  oldest  remedy,  and  apparently  gives  the  best  results. 
It  should  be  given  in  increasing  doses  (see  Treatment  of 
Pernicious  An.emia,  for  detailed  action);  children  tolerate  large 
doses  of  arsenic  exceptionally  well.  It  may  be  administered  hypoder- 
matically  or  by  clyster  when  the  digestive  tract  is  irritable.  Arsenic  is 
not  without  its  dangers.  C.  Gamble,  Jr.,  records  an  instance  of  fatal 
arsenical  poisoning  in  a  case  to  whom  about  l^f  ounces  of  Fowler's 
solution  was  given  in  a  month  (including  an  intermission  of  one  week). 
It  appears  that  rest  in  bed,  and  administration  of  a  placebo,  as  nux 
vomica,  has  given  equally  good  results,  but  any  individual  series  of 
cases  may  be  misleading.  (6)  Salicylates  are  of  benefit  only  when 
rheumatism  actually  co-exists,  and  acetanilide  is  indicated  only  in  the 

77 


1218  DISEASES  OF  THE  XERVOUS  SYSTEM 

initial  stages.  In  other  words,  the  antirheumatic  remedies  are  less 
important  in  the  treatment  than  is  rheumatism  in  the  etiology,  (c) 
Depressomotors:  The  bromides  rarely  cure  the  movements,  although 
they  often  quiet  the  mild  psychical  manifestations.  Chloral  has  been 
recommended  and  given  in  large  and  continued  doses,  to  produce  sleep 
or  continuous  sleep.  This  method  merely  demonstrates  the  tolerance 
of  the  body  for  dangerous  remedies,  and  as  stated  before,  chloral  can- 
not be  given  safely,  in  amounts  exceeding  a  dram  for  adults  in  three 
divided  doses  at  intervals  of  an  hour.  Morphine  is  generally  considered 
dangerous  and  inferior  to  chloral.  Small  doses  often  accentuate  the 
mental  agitation,  but  if  combined  with  chloral,  hyoscine  and  bromide, 
it  may  give  at  least  temporary  relief,  (d)  Strychnine  is  valuable 
(Trousseau),  especially  in  the  later  stage,  when  recovery  is  slow,  (e) 
In  chorea  gravidarum,  abortion  or  premature  delivery  is  indicated. 


TETANY. 

Definition. — Tetany,  which  was  first  described  by  Steinheim  (1830) 
and  Dance  (1831)  and  named  by  Corvisart,  consists  chiefly  of  (a) 
peculiar  tonic,  intermittent,  bilateral,  painful  spasms,  mostly  in  the 
extremities,  without  involvement  of  the  sensorium  and  (b)  increased 
mechanical  and  electrical  excitability  of  the  nerves. 

Etiology. — (a)  It  occurs  endemically  or  epidemically,  especially  in 
Vienna,  Heidelberg,  Berlin  and  Syria,  and  it  is  prevalent  during  March 
and  April.  It  is  rare  in  America,  England  and  Italy.  Though  once 
frequent  (1830-1860),  it  is  now  uncommon  in  Paris.  In  the  Vienna 
outbreaks  46  per  cent,  of  cases  occurred  in  shoemakers,  and  24  per  cent, 
in  tailors  who  were  otherwise  healthy.  Tetany  occurs  among  the 
poorer  classes.  Eighty-three  per  cent,  occurs  in  persons  between  six- 
teen and  twenty-five  years  of  age.  It  may  develop  in  an  entire  family. 
(b)  Digestive  affections  may  produce  it,  as  dilatation  of  the  stomach 
(Kussmaul,  1871),  dyspepsia,  ulcer  or  cancer  of  the  stomach  or  duo- 
denum, often  with  pyloric  obstruction;  auto-intoxication  is  the  most 
probable  cause  of  this  group.  Only  80  cases  of  gastric  tetany  are  on 
record,  (c)  Rickets  is  causal  in  85  to  90  per  cent.  (Seeligmiiller)  and 
in  96  per  cent.  (Cassel)  of  the  infantile  types.  Some  writers — incor- 
rectly, we  think — consider  that  the  infantile  carpopedal  spasm  is 
tetany,  (d)  Tetania  strumipriva  is  a  type  of  tetany  which  follows 
removal  of  the  thyroid  in  15  per  cent,  of  cases  (Albert,  Mikulicz, 
Kocher).  It  disappears  when  a  new  thyroid  is  implanted,  and  re- 
appears on  its  removal.  Animals  deprived  of  the  thyroid  present 
symptoms  practically  identical  with  those  of  tetany.  If  one-fifth  of  the 
gland  is  left,  it  usually  prevents  tetany  (von  Eiselberg),  but  this  fraction 
must  be  healthy.  It  may  be  true  that  the  thyroid  is  less  important  than 
the  parathyroid  glands.  (See  pages,  895  and  896).  (e)  Tetany  occurs 
also  in  the  acw/^"  infections,  sepsis,  nephritis,  puerperal  or  nursing  women 
and  rarely  in  intoxications  with  ergot,  morphine  or  lead.     There  are 


TETAXY  1219 

recorded  only  32  cases  of  the  puerperal  form.  The  only  two  cases  which 
the  author  has  seen  in  this  country  occurred  with  florid  secondary 
syphilis.  It  may  develop  with  other  nervous  disease,  and  French  writers 
have  attempted  to  class  it  vmder  hysteria.  No  pathological  changes  have 
been  observed  in  the  brain  or  nerves;  in  a  few  cases  there  has  been 
cloudiness  with  swelling  of  the  anterior  horns.  Fifteen  cases  are  reported 
in  America  (Howard,  1906). 

Sj^mptoms. — -1.  The  earliest  and  chief  symptom  is  the  muscular 
contracture,  which  usually  commences  in  the  hand,  with  stiffness, 
numbness,  and  pain,  and  culminates  as  a  tonic,  symmetrical,  painful 
contracture.  The  muscles  of  the  hand  are  hard;  the  attitude  is  that  of 
the  accoucheur's  hand,  that  of  the  hand  in  writing,  or  that  observed 
in  paralysis  agitans;  it  is  produced  by  contraction  of  the  ulnar  flexors; 
less  often  it  resembles  the  clenched  hand  of  old  hemiplegic  contracture, 
and  the  nails  even  enter  the  palm;  rarely  the  fingers  are  tonically 
spread  apart.  Except  in  light  forms,  the  spasm  cannot  be  overcome 
by  force.  The  wTist  may  be  flexed.  The  foot  is  affected  less  often  than 
the  hand,  and  the  spasm  draws  the  foot  into  the  equino-varus  position, 
with  the  toes  flexed  and  the  sole  hollow.  The  spasm  is  usually  limited 
to  these  parts,  causes  pain,  lasts  from  minutes  to  hours  or  even  days, 
disappears,  and  usually  recurs  later.  In  rarer  and  more  severe  cases, 
the  parts  above  the  elbows  and  knees  may  participate,  with  adduction 
of  the  arms  and  thighs,  cramping  of  the  face,  neck,  chest,  tongue, 
diaphragm,  and  ocular  muscles,  with  diplopia,  spasticity  of  the  sphinc- 
ters with  retention,  dysuria,  etc. 

Laryngismus  stridulus  (Clark,  1815)  is  common  in  infantile  rickets, 
in  which  clonic  contractures  also  occur.  The  muscles  are  somewhat 
weak  and  tremor  is  frequent. 

2.  Trousseau's  sign  consists  in  producing  the  spasm  by  pressure 
over  the  nerves,  for  example,  just  above  the  elbow  or  over  the  peroneal 
nerve,  for  a  few  seconds  or  from  one  to  five  minutes.  It  is  wdiolly  due 
to  nerve  pressure,  not  to  pressure  on  the  vessels,  and  is  pathognomonic. 

3.  There  is  increased  electrical  irritability  (a)  of  the  motor  nerves 
to  the  galvanic  current  {ErVs  sign)  with  early  anodal  closing  and 
cathodal  opening  tetanus.  Anodal  opening  tetanus  is  found  in  this 
disease  alone.  There  is  also  increased  electrical  irritability  {h)  of  the 
sensory  nerves  (Hoffmann)  and  (c)  of  the  nerves  of  special  sense 
(Chvostek,  Jr.),  to  faradic  and  galvanic  currents. 

4.  Increased  mechanical  irritability  of  the  motor  nerves  {Chvostek' s 
sign)  is  observed  on  tapping  or  pressing  on  the  facial,  median,  ulnar  or 
other  nerves,  which  produces  contraction  of  the  muscles  supplied  by 
them.  It  is  quite  constant  but  may  be  absent  in  children  and  is  not 
pathognomonic,  having  been  found  in  normal  persons,  in  cases  of 
bulbar  paralysis,  in  the  major  neuroses,  and  in  convalescing  cases  of 
facial  paralysis.  (Some  of  these  may  have  been  atypical  tetany). 
The  muscles  themselves  are  not  overexcitable. 

5.  Other  symptoms  may  be  present.  The  sensorium  is  usually 
clear,  except  in  rare  cases  with  pyloric  stenosis.    The  special  senses  are 


1220  DISEASES  OF  THE  NERVOUS  SYSTEM 

normal;  optic  neuritis  is  extremely  rare.  Headache  and  malaise  are 
frequent.  In  contrast  to  the  pain  and  parsesthesia,  objective  sensory 
findings  are  absent.  In  rare  cases  epileptiform  seizures  are  seen,  which 
are  probably  due  to  thyroid  changes.  The  reflexes  are  usually  normal. 
The  temperature  is  elevated  in  10  to  15  per  cent,  of  cases,  but  may  be 
normal  or  subnormal.  In  very  rare  chronic  cases,  trophic,  vasomotor 
and  secretory  disturbances  may  occur,  as  oedema,  polyuria,  glycosuria 
or  falling  out  of  the  hair. 

Diagnosis. — The  diagnosis  in  typical  cases  is  most  easy  from  the 
cardinal  signs:  (a)  the  peculiar  spasms;  (6)  Trousseau's,  (c)  Erb's 
and  (d)  Chvostek's  signs.  In  epilepsy  these  signs  are  absent,  and  the 
aura,  the  cry,  falling,  tonic  and  clonic  convulsions,  biting  of  tongue  and 
involuntary  urination  are  characteristic ;  in  very  rare  instances  the  two 
affections  co-exist.  Hysteria  mimics  everything,  but  the  cardinal 
symptoms,  except  the  spasms,  cannot  be  reproduced;  it  has  its  own 
stigmata;  certain  reported  epidemics  of  tetany,  as  at  Gentilly,  were 
clearly  hysterical.  In  adults  atypical  forms  without  spasm  are  recog- 
nized by  the  other  cardinal  signs  (b,  c,  d)  which  easily  separate  tetany 
from  the  occupation  neuroses  and  acroparsesthesia  (v.i.)  In  children 
meningitis  and  brain  tumor  are  distinguished  on  careful  examination. 
The  rhachitic  relations  are  important  even  though  the  extreme  state- 
ment that  all  tetany  in  children  is  rhachitis,  cannot  be  admitted. 

Prognosis. — The  outlook  is  good  in  most  cases,  and  the  course 
covers  from  two  to  four  weeks  as  a  rule.  Recurrences  are  not  infrequent. 
The  etiological  prognosis  naturally  varies,  but  generally  speaking, 
death  occurs  not  from  tetany  but  from  dilated  stomach,  or  ablation  of 
the  thyroid.  Cases  may  die  from  laryngospasm.  In  a  recent  review  of 
his  cases,  Frankl-Hochwart  concluded  that  the  prognosis  is  worse  than 
is  usually  stated;  20  per  cent,  of  his  cases  died,  20  remained  well,  and 
the  balance  had  recurrences  and  serious  disabilities. 

Treatment. — The  treatment  varies  with  the  cause,  (a)  Rest  and 
quiet  are  indicated  on  general  principles,  although  cases  of  tetany  are 
influenced  very  little  by  excitement.  Massage,  strychnia  and  electricity 
should  of  course  be  avoided.  Change  of  occupation  and  location,  at 
least  temporarily,  are  advisable  in  the  endemic  form.  (6)  In  the 
digestive  form,  washing  out  the  stomach  and  bowels  in  suspected  cases 
of  auto-intoxication  may  induce  severe  spasms.  These  cases  are  both 
dangerous  and  obstinate.  The  spontaneous  mortality  in  gastric  tetany 
is  70  to  80  per  cent. ;  with  operation  for  pyloric  stenosis,  these  figures 
are  reduced  to  37.5  per  cent,  mortality,  (c)  In  the  rhachitic  form, 
dietary  regulation  and  improved  hygiene  are  necessary,  and  phos- 
phorus and  iron  are  indicated.  Inhalations  of  chloroform  in  some 
cases  irritate  the  sensitive  larynx,  (d)  In  tetania  strumipriva,  thyroid 
feeding  is  usually  of  no  value,  as  the  mortality  (80  per  cent.)  shows; 
successful  thyroid  implantation  gives  relief,  (e)  Cases  following  acute 
infections  usually  have  a  spontaneously  short  course;  those  occuring 
in  pregnancy  rarely  indicate  abortion;  in  nursing  women,  weaning 
gives  prompt  relief;    for  intoxications  there  are  obvious  indications. 


OCCUPATION  OR   FATIGUE  NEUROSES  1221 

In  general,  drugs  are  of  little  value;  chloral  is  indicated  a  priori,  be- 
cause of  its  influence  on  the  motor  nerves,  but  it  is  inferior  to  the 
bromides,  as  is  also  morphine,  except  for  pain.  Sweating  and  digitalis 
in  nocturnal  forms  of  tetany  have  apparently  helped  some  cases,  but 
the  disease  usually  runs  its  limited  uninfluenced  course. 


OCCUPATION  OR  FATIGUE  NEUROSES;  WRITER'S   CRAMP. 

The  continuous,  hard,  improper  use  of  coordinate,  functionally  asso- 
ciated muscles  may  result  in  their  cramping.  Writer's  cramp  (grapho- 
spasmus,  mogigraphia)  was  first  described  by  Charles  Bell  (1830),  and 
especially  studied  by  Duchenne  and  Benedict.  Neuropathic  tendencies 
are  noted  in  most  cases;  83  per  cent,  occurs  in  males,  93  per  cent,  occurs 
in  those  between  twenty  and  sixty  years  of  age,  and  most  of  these  cases 
develop  between  twenty-five  and  thirty-five.  Worry  is  a  frequent  factor ; 
cold,  trauma,  neuritis  and  neuralgia  are  possibly  factors.  The  disease 
practically  never  occurs  in  those  who  write  properly,  i.  e.,  move  the 
arm  from  the  elbow  or  the  shoulder,  but  develops  in  those  who  use  the 
little  finger  or  wrist  as  the  basis  of  movement.  The  affection  is  located 
in  various  centres;  some  hold  that  it  is  in  the  coordinating  cortical  or 
subcortical  centres;  it  is  clearly  not  in  the  muscles  or  nerves,  for  their 
other  movements  are  often  normal ;  the  occasional  atrophy  and  paresis 
may  suggest  localization  in  the  cord. 

Symptoms. — ^The  symptoms  come  on  gradually,  with  fatigue,  pain 
and  cramping  in  the  muscles  of  the  fore-fingers  and  thumb,  which  may 
extend  to  the  forearm  or  shoulder.  There  may  be  the  "lock  spasm" 
of  Mitchell,  in  which  the  pen  is  spastically  held  or  it  may  be  thrown  from 
the  fingers.  On  rest,  the  tonic  spasm  disappears  but  reappears  with 
attempts  to  write.  In  Benedict's  classification  we  find  the  spasmodic, 
paralytic,  tremulous  and  neuralgic  forms,  which  are  of  less  interest  as 
types  than  as  showing  the  various  symptoms,  which  are  often  combined 
in  a  single  case.  Vasomotor  symptoms  may  occur,  as  flushing,  or 
glossy  skin,  and  sometimes  the  faradic  irritability  is  decreased  and  the 
galvanic  increased. 

Differentiation,  according  to  the  type,  from  hemiplegic  weakness, 
paralysis  agitans,  musculospiral  paralysis,  and  neuralgia,  is  usually 
easy.  Similar  cramps  are  observed  in  telegraphists,  milkmaids, 
weavers,  cigarette  rollers,  tailors,  shoemakers,  watchmakers,  and 
violin  and  piano  players.  Public  speakers  may  suffer  from  similar 
neuroses  of  the  throat,  and  Archibald  Church  also  mentions  spasms 
of  the  jaw  in  gum  chewers  and  of  the  lumbar  muscles  in  physicians 
who  drive  much. 

The  outlook  is  poor,  because  the  unfortunate  sufferer  is  often  com- 
pelled to  write  until  the  affection  is  firmly  fixed,  and  when  able,  usually 
returns  to  the  same  work.     In  some  cases  the  muscles  may  waste. 

Treatment. — Rest  is  essential  to  recovery,  because  treatment  for 
the  usual  nervous  symptoms  alone  never  succeeds.     Plaster  casts  are 


1222  DISEASES  OF  THE  NERVOUS  SYSTEM 

sometimes  successfully  employed.  Even  when  the  subject  learns  to 
write  with  the  other  hand,  it  often  develops  there.  Prevention  is 
possible  by  writing  free-hand  from  the  shoulder;  holding  the  pen 
between  the  first  and  second  fingers,  use  of  pens  with  large  handles, 
of  quills  and  of  forearm  splints  with  the  pen  attached  to  the  extremity, 
are  also  helpful.  Vigouroux  and  Wolff  use  with  success  systematic 
gymnastics,   including   passive   manipulations   and   active   exercises. 


MYOTONIA.     THOMSEN'S   DISEASE. 

Myotonia  is  usually  called  myotonia  congenita  from  its  leading 
causal  element,  heredity.  It  was  first  described  by  Leyden,  but  more 
fully  by  Thomsen  (1876),  who  was  a  victim  among  20  cases  in  his 
own  family,  in  five  generations.  This  rare  affection,  of  which  there 
are  about  100  reported  cases,  occurs  chiefiy  in  males  and  in  Germany 
and  Scandanavia.  Its  pathology  is  obscure,  for  the  only  necropsy 
which  has  been  performed  (Dejerine  and  Sottas)  showed  no  nervous 
alteration.  Muscle  fibers,  excised  during  life,  show  hypertrophy, 
decreased  striation,  nuclear  multiplication  and  slight  interstitial  increase, 
leading  Leyden  and  others  after  him  to  consider  the  process  myopathic. 
Some  offer  the  objection  that  these  changes  are  artefacts. 

Sjrmptoms. — A  peculiar  transient  tonic  muscular  rigidity  develops 
when  the  muscles  are  first  used,  which  limits  or  arrests  movement, 
but  wears  off  as  their  use  is  persisted  in.  It  recurs,  or  indeed  is  most 
intense  after  rest  or  when  a  new  kind  of  movement  is  undertaken.  It 
appears  early  in  life,  perhaps  "in  the  cradle,"  but  generally  between 
the  ages  of  four  and  ten,  it  increases  as  the  muscles  develop  and  then 
becomes  stationary  for  life.  In  one  case  improvement  was  observed. 
The  legs  are  more  affected  than  the  arms,  but  any  muscle  may,  in 
exceptional  cases,  be  affected,  as  those  of  the  face,  tongue,  or  bladder  or 
the  respiratory  muscles.  They  are  usually  stronger  and  sometimes 
larger  than  normal,  although  some  writers  speak  of  muscular  weak- 
ness. The  longer  the  muscles  are  rested,  the  more  severe  is  the  initial 
spasm  on  exertion.  Rigidity  does  not  follow  passive  muscle  movement, 
although  firm  pressure  or  a  sharp  blow  initiates  it. 

Though  the  tendon  reflexes  and  the  mechanical  and  electrical 
excitability  of  the  nerves  are  practically  normal,  application  of  the 
galvanic  current  to  the  muscles  produces  sluggish,  prolonged  closing 
contractures,  which  are  easily  and  equally  obtained  with  either  pole, 
and  become  tetanic  with  strong  currents;  this  is  the  myotonic  reaction 
of  Erb.  Undulatory  contractures  follow  strong  faradic  stimulation. 
Subjects   of   myotonia    are   frequently   irritable   or   hypochondriacal. 

Treatment  is  of  little  value.  Thomsen  believed  that  exercise  retarded 
the  disease.    Cold,  dampness,  excitement  and  fatigue,  are  to  be  avoided. 

The  following  are  allied,  if  not  identical,  aft'ections:  the  congenital 
paramyotonia  of  Eulenberg,  consisting  of  tonic  spasms,  which  last 
from  fifteen  minutes  to  several  hours,  occur  especially  in  the  arms, 


PARALYSIS  AGITAXS  1223 

and  often  affect  the  eyes  and  mouth;  it  is  excited  by  exposure  to  cold 
(vasomotor  spasm  in  the  muscles);  and  the  ataxic  paramyotonia  of 
Gowers,  in  which  tonic  spasms  may  last  the  entire  day,  with  muscular 
weakness,  ataxia  especially  in  the  hands,  and  disturbed  sensation  or 
anaesthesia  in  the  fingers. 


PARALYSIS  AGITANS. 

This  affection  is  also  known  as  shaking  palsy  or  Parkinson's  dis- 
ease;   it  was  first  described  by  Parkinson  in  1817. 

Etiology. — (a)  Most  cases  occur  in  persons  between  the  ages  of 
forty  and  sixty-five,  (b)  Sixty-six  per  cent,  of  cases  are  men.  (c)  A 
neuropathic  tendency  is  present  in  15  per  cent,  (d)  It  is  doubtful  if 
trauma,  acute  infections  or  thyroid  disease  are  causes. 

Pathology. — It  is  classed  among  the  neuroses,  because  of  the  absence 
of  any  constant  pathological  finding.  It  is  not  strange  that  arterio- 
sclerosis and  perivascular  thickening  are  often  found,  since  paralysis 
agitans  occurs  in  "the  early  degenerative  period."  Gordinier's 
collection  of  cases  examined  by  recent  histological  methods,  shows 
that  (a)  general  arteriosclerosis  is  less  marked  than  that  of  the  nervous 
tissue;  (6)  the  arteries  in  the  cord  are  markedly  changed,  and  around 
them  are  (c)  increased  neurogliar  sclerosis  and  (d)  pigmentation  and 
atrophy  of  the  nerve  cells  and  fibers. 

Symptoms. — The  cardinal  symptoms  are  (a)  tremor;  and  (b) 
stiffness,  slowness  of  movement,  shortening  and  weakening  of  the 
muscles,  (a)  Tremor  in  66  percent,  of  cases  is  the  first  symptom;  it 
may  develop  after  the  muscular  rigidity,  and  is  sometimes  absent 
(paralysis  agitans  sine  agitatione).  It  usually  appears  first,  and  is 
most  marked  in  the  hands.  It  affects  first  one  hand,  and  usually  next 
reaches  the  leg  of  the  same  side,  then  the  opposite  hand,  the  opposite 
leg,  and  lastly  the  trunk,  so  that  at  different  periods  of  development  it 
is  successively  a  monoplegic,  hemiplegic,  or  finally  a  diplegic  tremor. 
It  is  slow  (4  to  7  oscillations  per  second),  rhythmic,  fine  at  the  onset, 
but  somewhat  coarser  later  and  in  the  large  muscles  is  more  marked 
in  peripheral  than  distal  parts,  persiMs  during  rest,  ceases  during 
sleep,  and  ceases  momentarily  on  voluntary  action.  In  rare  cases,  it 
appears  only  on  movement,  as  intentional  tremor;  Gerhardt  found  it 
increased  by  movement  in  50  per  cent.  It  is  difficult  to  define  precisely 
the  muscles  involved.  In  the  hands  it  may  affect  chiefly  the  flexors 
and  extensors  at  the  metacarpal  joints  or  the  interossei,  which  give  the 
spinning  or  pill-rolling  movement.  The  wrists  may  be  abducted  and 
adducted,  rarely  supinated  and  pronated,  and  the  arms  and  shoulders 
are  implicated  but  little.  The  writing  is  tremulous.  The  feet  are 
mostly  involved  at  the  ankles,  and  in  the  toes  but  little.  The  thigh 
adductors  often  tremble.  Trembling  is  infrequent  in  the  face,  neck 
and  back,  while  the  abdomen  entirely  escapes.     The  head  and  body 


1224 


DISEASES  OF  THE  NERVOUS  SYSTEM 


may  of  themselves  tremble,  but  much  of  it  is  imparted  to  them  from 
the  limbs.  In  the  rarest  cases,  the  tongue,  palate,  larynx  and  epiglottis 
tremble. 

(b)  Muscular  rigidity  and  shortening,  weakness,  and  slowness  of 
movement  usually  follow  the  tremor;  slight  symptoms  are  detected 
early,  and  anticipate  the  tremor  or  exist  without  it.  These  changes 
result  in  the  following:  (i)  The  Parkinson  fades,  which  is  mask-like 
and  devoid  of  lines  or  expression;    the  eyelids   seldom  wink.    The 

forehead  shows  transverse  folds  be- 
^^°-  *'^-  cause  of  the  bowed  head  and  body. 

The  eyes  move  tardily  in  reading, 
and  the  entire  body  must  be  turned 
to  enable  the  patient  to  look  later- 
ally. There  is  also  slow,  monoto- 
nous, monosyllabic  speech,  with 
hesitation  at  first,  but  hurried  at 
the  finish,  (ii)  The  attitude  is  char- 
acteristic, because  of  the  flexor  posi- 
tions assumed,  the  head  and  the 
chin  are  held  forward,  the  neck  is 
extended  and  rigid,  the  body  is  in- 
clined forward,  the  elbows  are  fixed 
and  brought  somewhat  forward  and 
away  from  the  body;  the  fore- 
arms are  brought  toward  the  body, 
the  trembling  thumb  and  index 
finger  are  apposed,  or  the  fingers 
deviate  toward  the  ulnar  side  as  in 
arthritis  deformans,  and  in  stand- 
ing the  knees  are  somewhat  bent  and 
at  times  closely  apposed.  The  body 
expression,  we  may  say,  is  like  that 
of  the  face,  (iii)  The  gait  is 
equally  characteristic.  Like  the 
speech,  it  is  initially  hesitant,  and 
later  hurried.  The  patient,  when 
once  started,  may  not  be  able  to 
stop  himself.  Trousseau  spoke  of 
the  patients  as  "chasing  their  cen- 
tre of  gravity. "  This  festination  or 
■'propulsion  is  probably  purely  mechanical  from  the  forward  bodily 
inclination,  although  it  was  interpreted  by  Charcot  as  a  kind  of  forced 
movement.  To  counteract  the  throwing  forward  of  the  centre  of 
gravity,  the  arms  may  be  carried  behind  the  back.  In  some  cases,  if 
the  patient  is  pushed  backward  or  sideways,  he  may  not  be  able  to 
stop  for  some  steps;  this  is  retro-  and  later o-puls ion.  (iv)  The  palsy 
is  often  slight  and  rarely  extreme,  although  it  may  be  simulated  by 
the  helplessness  caused  by  rigidity.    The  patient  is  not  inclined  to 


Side  view  of  a  case  of  paralysis  agitans,  show- 
ing forward  inclination  of  tlie  trunk.  Ten- 
dency to  propulsion.      (Dercuni.) 


PERIODIC   FAMILY   PARALYSIS  1225 

exertion,  "moves  like  a  piece  of  machinery,"  as  Parkinson  describes 
it,  and  may  not  be  able  to  turn  over  in  bed.  Patients  have  drowned 
from  falling  on  the  face  in  a  small  puddle  of  water.  Muscular  reaction 
requires  40  per  cent,  more  time  than  normal. 

Other  sijinpoms  are  subordinate.  The  mind  is  clear,  but  we  may 
say  stiff  Hke  the  face  and  limbs,  and  a  certain  restlessness,  irritability 
or  apathy  may  be  detected;  insomnia  is  common  and  headache 
occasional.  Sensation  is  essentially  normal,  although  pains,  pruritus, 
parsesthesia  and  hypaesthesia  are  seen  in  35  per  cent,  of  cases.  Vaso- 
motor disturbance  most  often  assumes  the  form  of  a  feeling  of  heat; 
indeed  the  peripheral  temperature  may  be  increased  several  degrees. 
Severe  sweats  are  quite  common.  The  pupillary,  cutaneous,  tendon 
and  organic  reflexes  are  normal. 

Course  and  Prognosis. — The  onset  is  sometimes  sudden,  but  usually 
gradual,  and  the  course  covers  several  decades.  The  outlook  is  more 
favorable  in  atypical  than  in  typical  cases.  Remissions  may  occur, 
but  the  disease  progresses  steadily.  Death  very  rarely  occurs  from 
the  affection  itself,  but  usually  from  intercurrent  pneumonia  or  ad- 
vancing arteriosclerosis,  cerebral  softening,  myocardial  insufficiency, 
nephritis  and  kindred  lesions. 

Diagnosis. — When  there  is  clear  development  of  the  cardinal  symp- 
toms, the  disease  is  unmistakable.  Confusion  is  possible  in  the  early 
hemiplegic  forms,  but  the  absence  of  a  paralytic  stroke,  and  the  later 
course  are  distinctive.  Charcot  and  Ordenstein  (1868)  clearly  differen- 
tiated the  affection  from  multiple  sclerosis  {q.  v.).  The  fine,  senile 
tremor,  the  hereditary  tremor  of  Dana,  tremors  due  to  overexertion  or 
excitement,  to  toxic  causes  (alcohol,  nicotine,  lead,  mercury,  coffee, 
opium,  or  chloral),  weakness  of  convalescence  from  acute  infections, 
paretic  dementia,  or  the  neuroses  (epilepsy.  Graves'  disease,  hysteria, 
neurasthenia)  are  easily  excluded  by  the  absence  of  the  Parkinson 
rigidity,  facies  and  festination. 

Treatment. — Treatment  of  the  probably  fundamental  arterioscler- 
osis may  possibly  retard  the  disease,  but  prophylaxis  is  possible  in  the 
early  stages  only.  All  mental  and  physical  fatigue  should  be  avoided. 
The  administration  of  full  doses  of  iodide,  chloral,  opiates,  bromides, 
hyoscine,  ergotin,  conium  or  duboisin  may  mitigate  the  tremor,  but 
always  lower  vitality  and  disturb  function. 


PERIODIC  FAMILY  PARALYSIS. 

This  affection  was  first  described  by  Cavare  (1S53),  and  more  fully 
by  Westphal  (1885);  Audibert  and  Oddo  collected  64  cases  (1902), 
which  Holzapple  brought  to  70  (1905).  It  is  a  family  affection ;  Goldflam 
collected  11  cases  in  one  family,  and  E.  W.  Taylor  12  in  another. 
Most  cases  occur  in  adolescence,  and  nearly  all  of  them  in  persons 
under  twenty-five;  it  recurs  every  few  weeks  or  months,  possibly  every 
day,  or  only  at  intervals  of  years.    Its  symptoms  are  almost  wholly 


1226  DISEASES  OF  THE  XERVOUS  SYSTEM 

motor,  producing  a  flaccid  paralysis  in  the  legs  and  arms,  less  often  in 
the  trunk,  and  exceptionally  in  the  face,  neck,  tongue  and  throat.  It 
occurs  \v4thout  apparent  cause,  usually  during  sleep,  from  which  the 
patient  awakes  with  a  sense  of  fatigue,  weakness,  or  dulness  which 
develops  into  paralysis  within  twenty-four  hours.  Mental  and  sensory 
symptoms  and  those  of  the  cranial  nerves  and  special  senses  are  rare. 
There  is  no  fever,  the  pulse  is  often  slow  and  cardiac  dilatation  has  been 
observed.  The  deep  reflexes  are  decreased  or  abolished,  often  alsa 
those  of  the  skin,  and  the  faradic  excitability  of  the  nerves  and  muscles 
is  lessened  or  absent.  The  patient  is  well  in  a  few  hours  or  days,  until 
another  attack  occurs.  The  disease  usually  subsides  spontaneously 
after  the  fiftieth  year  of  life.  Its  nature  is  not  determined.  Goldflam's 
theory  of  auto-intoxication  is  supported  (a)  by  J,  K.  ^Mitchell,  Flexner 
and  Ebersoll,  who  found  increased  secretion  of  kreatin  before  and 
during  the  attack;  (b)  by  Crafts  and  Irwin,  who  isolated  toxins  from 
the  faeces;  (c)  possibly  by  the  fact  that  potas.  citrate  sometimes  lessens 
or  aborts  the  seizure.  Dana  thought  that  the  disease  was  hysterical,  but 
Bernhardt  and  others  consider  it  affiliated  vnih  myotonia  and  progressive 
muscular  atrophy.  Holtzapple  administers  potas.  bromide  in  doses  of 
thirty  grains. 

MIGRAINE. 

^Migraine  (hemicrania,  megrim,  sick  headache)  is  an  hereditary 
degeneration  or  psychoneurosis,  with  the  paroxysmal  occurrence  (in 
a  complete  attack)  of  aurse,  headache,  nausea  and  vomiting. 

Etiology. — (a)  Heredity  is  a  conspicuous  cause  (90  per  cent.  Mobius),. 
either  directly  as  migraine,  or  indirectly  from  neurotic,  insane  or 
epileptic  antecedents.  Joint  affections,  as  gout,  are  often  noted  in 
the  family  history.  (6)  Thirty-three  per  cent,  of  cases  begin  between 
the  fifth  and  tenth,  40  per  cent,  between  the  tenth  and  twentieth  years^ 
and  the  remainder  usually  before  the  thirtieth  year.  Females  are 
affected  a  little  more  frequently  than  males,  (c)  Exciting  causes  are 
acute  infections,  constipation,  dyspepsia,  overexertion,  alcohol  or 
sexual  abuse,  emotional  factors,  pelvic  disorders,  and  lactation.  It  is 
attributed,  though  probably  incorrectly,  to  adenoids.  Refractive 
errors  may  explain  some  cases,  but  as  Mobius  states,  "this  cause  is 
epidemic  in  the  United  States. " 

Symptoms. — Preliminary  symptoms  are  often  absent,  although  the 
patient  may  feel  depressed,  or,  in  some  cases,  especially  well  and 
energetic.  They  occur  in  cases  in  which  the  sensory  symptoms  (see 
below)  are  least  marked.  Sometimes  the  pupils  are  dilated.  Most 
attacks  develop  during  the  night. 

AuR.E. — In  over  50  per  cent,  of  cases,  aurse  are  (a)  sensory,  as  visual 
aurse,  a  cloudiness  before  the  eyes,  sparks,  lightning,  zig-zag  forms, 
etc.;  they  are  most  often  bilateral,  and  affect  the  homologous  half- 
fields;  taste  and  smell  may  be  similarly  aifected;  parfesthesia  may 
occur,  usually  as  hemiparsesthesia;    (b)  motor  aurae  are  much  less 


MIGRAIXE  1227 

common,  as  aphasia,  dysphasia  or  motor  weakness  on  the  contra- 
lateral side;  in  the  very  rare  form,  ophthahnoplegic  migraine,  there  is 
fugitive  ptosis,  outward  strabismus,  double  vision  and  a  dilated  im- 
mobile pupil;  mental  aurae  are  uncommon  and  not  usually  pronounced, 
as  restlessness,  anxiety,  confusion,  and  double  consciousness.  The 
aurse  last  for  ten  or  fifteen  minutes. 

The  Attack. — (a)  Headache  is  the  cardinal  symptom.  As  first  it  is 
usually  intense  and  circumscribed,  as  over  the  eye,  temple,  occiput 
or  forehead;  then  it  spreads  over  one  side  (hemicrania),  sometimes 
affects  the  opposite  side,  or  rarely  reaches  the  neck  or  arm.  The  pain 
is  deep,  varies  in  character,  being  most  often  boring,  and  its  intensity 
may  attain  that  of  the  pain  in  brain  tumor  or  meningitis.  It  is  increased 
by  movement,  stooping  or  lying  down.  The  special  senses  are  hyper- 
sesthetic  but  the  nerve  trunks  are  seldom  tender.  The  mind  is  usually 
clear  and  often  acutely  active,  sometimes  there  is  double  consciousness, 
and  in  rare  cases  stupor,  (b)  Nausea  follows,  often  with  vomiting  of 
undigested  food  and  finally  of  bile;  this  is  the  so-called  "bilious  head- 
ache. "  Feeding  and  medication  are  quite  impossible  in  severe  cases. 
Vomiting  may  be  attended  by  hyperacidity  or  moderate  collapse,  as 
in  sea-sickness.  (c)  Vasomotor  symptoms  may  be  present.  The 
spastic  type  was  described  by  Du  Bois  Raymond  in  his  own  case;  with 
pallor,  coldness,  wide  pupils,  and  retraction  of  the  eyeballs;  Thoma 
found  the  temporal  artery  sclerotic  on  the  side  of  lesion,  and  de  Gio- 
vanni noted  a  marked  arcus  senilis  on  the  same  side.  The  pulse  may 
be  slow  and  tense  and  the  breathing  superficial.  In  the  paretic  type 
observed  by  Mollendorf  in  himself,  there  are  redness,  small  pupils, 
sweating,  and  increased  flow  of  saliva  or  tears.  Very  rarely  is  there 
erythromelalgia,  oedema  or  ecchymosis.  The  paretic  may  follow  the 
spastic  symptoms.  It  is  best  to  regard  these  sympathetic  symptoms 
rather  as  a  result  than  as  a  cause  of  the  attack. 

The  attack  ends  in  various  ways.  Relief  may  come  with  the  vomiting, 
after  which  the  patient  frequently  sleeps.  Sometimes  the  ending  is 
almost  critical,  with  sweating,  lachrymation,  polyuria  or  epistaxis. 
The  attack  lasts  from  ten  to  twelve  hours;  the  term  status  hemicran- 
iciis  is  used  for  cases  of  long  duration,  or  those  in  which  the  attacks 
overlap.  Though  the  typical  seizure  comprizes  the  aura,  lasting 
fifteen  minutes,  and  the  headache,  lasting  ten  or  twelve  hours  with 
nausea  and  vomiting,  yyiost  attacks  are  atypical.  There  is  most  often 
headache  alone,  or  headache  with  vomiting;  in  a  few  cases  the  attack 
aborts  with  the  aura,  or  vomiting  exists  alone.  The  aurse,  pain,  gastric 
and  cardiac  inhibition,  vasomotor  symptoms  and  vomiting  can  only 
be  explained  on  the  assumption  that  migraine  is  a  functional  cerebral 
affection. 

Course  and  Prognosis. — When  the  disease  has  once  been  established 
in  youth,  its  attacks  become  more  frequent  in  adolescence  and  usually 
last  until  the  forty-fifth  or  fiftieth  year.  The  periodicity,  which  was 
noted  in  early  cases  described  by  Tissot,  Trousseau  and  Liveing,  has 
not  been  explained.     Overwork,  worry,  menstruation,  or  change  of 


1228  DISEASES  OF  THE  NERVOUS  SYSTEM 

routine  may  precipitate  an  attack  at  a  regular  or  irregular  interval. 
Attacks  may  cease  during  an  intercurrent  pregnancy,  tabes  or  gout. 
The  school  of  Charcot  has  emphasized  the  fortunately  rare  danger  of 
transformation  into  epilepsy,  labyrinthine  vertigo,  or  some  psychosis. 
Complete  cases  are  more  obstinate  and  dangerous  than  the  ordinary 
light  form. 

Diagnosis. — When  there  is  a  history  of  heredity  and  development  in 
childhood,  the  full  attack  is  most  characteristic.  "Sick  headache" 
is  practically  always  migraine.  In  atypical  forms  there  may  be  diag- 
nostic confusion,  chiefly  with  various  forms  of  headache,  which  may 
be  classified  as  follows: 

1.  Those  which  result  from  nervous  affections,  as  (a)  cerebral  neu- 
rasthenia, in  which  there  is  a  sense  of  pressure  rather  than  actual 
headache,  and  which  is  often  constant,  without  nausea,  but  with 
parsesthesia,  and  in  location  is  frontal  or  usually  general,  but  some- 
times occipital  or  temporal;  (b)  hysteria,  which  is  less  common, 
(clavus  headache,  "neuralgic  headache"),  and  sometimes  is  precisely 
like  migraine  (Charcot) ;  (c)  epilepsy,  which  some  consider  as  identical 
with  migraine;  in  epilepsy  the  aura  is  shorter,  and  loss  of  consciousness 
is  the  most  constant  symptom;  (d)  meningitis,  which  in  all  types  and 
in  all  cases  is  early  and  severe;  (e)  hydrocephalus,  which  is  often 
severe,  especially  in  acquired  forms;  (/)  brain  tumor,  which  is  constant, 
generalized,  often  very  severe,  and  sometimes  typically  hemicranic; 
(g)  paretic  dementia,  in  which  migraine  is  frequent;  care  is  always 
necessary  when  migraine  occurs  after  syphilitic  infection. 

2.  Those  which  result  from  affections  of  the  sjpecial  senses,  as  eye 
strain,  hypermetropia ;  glaucoma,  which  most  often  produces  frontal 
headache;  nasal  disease,  which  may  cause  involvement  of  the  sinus 
with  frontal  headache ;  this  form  is  not  periodic  and  is  often  relieved  by 
iodide,  which  has  no  effect  in  migraine, 

3.  Those  which  result  from  toxcemia  and  autotoxcemia.  (a)  Those 
due  to  acute  infections  are  usually  frontal  and  dull,  but  sometimes 
occur  in  other  locations  and  are  severe,  deep-seated,  and  increased  by 
stooping;  in  typhoid  or  malaria  they  are  often  frontal  or  supra-orbital; 
(&)  intoxication  by  alcohol,  nicotine,  lead,  nitroglycerine,  and  opium, 
and  (c)  constitutional  states,  as  gout,  or  arthritis,  (d)  In  nephritis, 
they  are  usually  frontal,  remittent  or  continuous,  but  sometimes 
sharply  hemicranic.  (e)  In  gastric  affections  from  toxaemia  or  con- 
gestion, they  are  exceedingly  common,  mostly  occipital,  but  sometimes 
vertical  or  frontal. 

4.  Those  resulting  /row  circulatory  causes,  as  from  wearing  a  tight 
collar,  repeated  coughing,  cardiac  disease  or  arteriosclerosis  (with 
vertigo),  are  usually  increased  by  lying  down. 

5.  Those  which  result  from  anosmia,  especially  from  chlorosis,  as 
a  "tugging"  sensation  back  of  the  eyes,  or  frontal  or  generalized 
headache,  are  often  relieved  by  lying  down. 

Treatment. — Prophylaxis  is  said  to  be  of  little  value,  but  many 
subjects  learn  to  recognize  the  warnings  and  avert  the  attacks,  by 


NEURALGIA  1229 

resting  or  noting  unusual  mental  or  physical  capacity  for  work,  or  an 
unusual  appetite,  which  usher  in  some  attacks.  Migraine  subjects 
should  observe  moderation  as  do  other  neurotics;  moderation  in  eating, 
especially  of  meat,  in  work,  in  exercise  or  recreation,  in  use  of  narcotics 
or  stimulants  as  coffee  or  tobacco,  and  in  sexual  matters.  Immodera- 
tion, indeed,  is  almost  a  neurosis  in  itself.  Overwork,  hurry,  worry, 
and  tension  must  be  avoided,  and  their  first  manifestations  must  be 
learned  and  treated.  The  extract  of  cannabis  indica  gr.  j  to  ^,  given 
for  weeks  or  months,  after  Seguin's  plan,  is  almost  the  only  remedy 
which  helps  the  condition,  and  then  only  in  some  cases;  the  author 
knows  of  a  dozen  cases  in  which  migraine  has  been  benefited  or  wholly 
relieved  under  its  use.  Mobius  finds  that  salicylate  of  soda,  gr.  xv, 
in  black  coffee,  given  the  evening  before  the  attack,  often  wards  it  off. 
Nitroglycerine  in  full  doses  (Gowers)  sometimes  aborts  it,  as  may 
washing  out  the  stomach  and  following  the  lavage  with  a  saline  (Her- 
ter). 

In  the  treatment  of  the  established  attack,  bromides  constitute  the  best 
remedy;  they  are  given  not  only  during  the  attack  in  the  mild  type, 
but  continuously,  as  in  epilepsy,  when  the  type  is  severe  and  frequently 
repeated  (Liveing  and  Charcot).  AcetaniHde  and  the  kindred  coal-tars 
often  help  the  mild  forms  and  may  in  combination  with  ergotin,  lessen 
the  throbbing  pain,  but  soon  lose  their  effect.  Morphine  should  be 
carefully  avoided.  The  stomach  sometimes  rejects  all  medication 
which  must  then  be  given  by  rectum.  Application  of  cold  to  the  head, 
hot  foot  baths  and  sinapisms  to  the  nape  of  the  neck  and  epigastrium 
are  subordinate  helps. 

NEURALGIA. 

Pain  in  the  nerves  is  only  a  symptom,  usually  of  an  affection  of  a 
peripheral  sensory  nerve,  although  in  rare  cases  centric  disease  may 
cause  peripheral  pain,  as  affections  of  the  cortex,  pons,  medulla,  or 
parts  near  the  thalamus.  The  pain  of  neuralgia,  in  which  there  is  little 
or  no  organic  change  in  the  nerve,  and  the  pains  of  neuritis  may  be 
confused.  , 

Etiology. — (a)  Neuralgia  occurs  mostly  in  adult  life  (twenty  to  sixty), 
and  rarely  before  puberty  or  after  sixty,  in  which  case  it  is  usually 
severe  and  intractable,  (b)  Themajority  of  cases  occur  in  u'o??ie?i.  (c) 
Heredity  is  an  apparent  factor  in  25  per  cent,  of  cases,  especially  in 
neuropathic,  weakly  or  gouty  families,  {d)  Debility  from  exhausting 
conditions,  as  lactation,  ana?mia,  overwork,  sensory  fatigue,  as  from 
eye  strain,  sexual  or  other  excesses,  emotional  conditions  and  trauma, 
may  cause  it.  (e)  It  may  result  from  toxaemia;  (a)  acute  infections, 
notably  influenza,  typhoid,  especially  at  its  onset,  malaria,  the  causal 
importance  of  which  has  been  much  overestimated,  rheumatism  (from 
exposure  to  cold)  particularly  of  the  fascial  type,  and  sometimes 
syphilis  may  cause  it.  (6)  Alcoholism,  diabetes,  plumbism,  gout,  and 
nephritis  may  produce  it;    most  of  these  are  also  causes  of  neuritis. 


1230  DISEASES  OF  THE  XERVOUS  SYSTEM 

differentiation  from  which  inay  be  difficuk.  (c)  Nerve  affections  as 
sciatica  and  neuritis,  herpes  zoster,  reflex  irritation,  as  radiated  from 
a  carious  tooth,  compression  of  a  nerve  trunk  by  varices,  aneurysm  or 
neuromata  or  the  root  pains  of  tabes,  may  cause  neuralgia,  (d) 
Arteriosclerosis  may  affect  the  nutrient  nerve  vessels;  this  was  first 
asserted  by  Putnam  and  Dana,  and  lately  by  Thoma  and  Dehio. 

General  Symptoms. — The  paiyi  usually  presents  the  following 
characteristics:  (a)  It  is  always  paroxysmal,  mth  intervals  of  total 
cessation,  or  at  least  of  relative  relief;  intense  pain  is  never  constant. 
(b)  It  recurs  either  irregularly  at  intervals  varying  from  hours  to  months, 
or  with  surprising  periodicity  on  a  given  day  or  hour,  perhaps  at  the 
menstrual  period;  periodicity  is  as  frequent  in  non-malarial  as  in 
malarial  cases,  (c)  It  is  usually  unilateral,  is  generally  constant  in 
its  seat,  at  least  for  a  time,  and  is  most  often  found  over  the  distribution 
of  a  single  nerve,  or  several  nerves,  from  which  it  sometimes  radiates 
into  other  regions;  if  pain  is  bilateral,  it  is  usually  symmetrical.  The 
pain  may  shift  from  place  to  place,  especially  when  due  to  systemic 
causes.  It  is  probable  that  the  spinal  cord  may  be  the  medium  of 
radiation  of  pain  from  one  region  to  another  and  that  pain  may  follow 
the  distribution  of  the  spinal  segments  rather  than  that  of  the  peripheral 
nerves  as  in  herpes  zoster.  However,  the  exact  pathology  of  neuralgia 
is  still  uncertain,  (d)  Its  onset  and  cessation  are  sudden  and  spon- 
taneous; an  imminent  attack  may  be  precipitated  or  existing  pain  may 
be  aggravated  by  muscular  movements,  a  breath' of  air  or  a  simple 
touch;  the  character  of  the  pain  is  sharp,  shooting,  stabbing,  rarely 
pulsating;  if  it  travels  along  the  nerve  trunk  its  shooting  direction  is 
usually  centrifugal,  rarely  centripetal;  if  it  is  localized  it  is  commonly 
burning  or  boring,  (e)  The  pain  is  usually  deep,  but  the  skin  is  very 
hypereesthetic.  (/)  The  ''tender  points"  of  Valleix  (1811),  later  called 
maximal  points  by  Head,  are  found  in  the  nerve  (50  per  cent.)  both  in 
the  attack  and  the  free  interval,  especially  where  the  nerve  emerges 
from  the  bone  or  fasciae,  lies  on  hard  surfaces,  divides  or  anastomoses. 
The  diagnostic  value  of  occasional  tenderness  over  the  spine  at  the 
origin  of  a  nerve  (Trousseau's  point  apophysaire)  is  overestimated, 
because  it  occurs  in  many  other  conditions.  In  neuritis,  the  nerve  trunk 
along  its  entire  accessible  course  is  tender,  ig)  V asomotor  constriction, 
followed  by  dilatation,  is  fairly  common.  CEdema,  erythema,  blanching 
or  falling  out  of  the  hair,  secretory  disturbances,  herpes,  pigmentation, 
numbness  or  tingling,  trophic  alteration  of  the  skin,  localized  hyper- 
trophies and  reflex  twitchings  of  the  muscles  are  much  less  frequent 
than  they  are  in  neuritis.  Persistent  pain  or  its  etiological  factors  may 
decidedly  reduce  the  general  nutrition. 

Local  Clinical  Varieties. — 1,  Trifacial  neuralgia  (prosopalgia,  tic 
douloureux)  is  the  most  important,  severe  and  frequent  type,  because 
the  fifth  nerve  is  most  exposed  to  trauma,  compression  and  infection, 
by  way  of  the  eye,  nose,  and  ear.  The  entire  nerve  is  not  usually 
affected,  though  pain  may  radiate  from  one  division  into  another; 
indeed  only  the  secondary  branches  of  a  single  division  may  be  in- 


NEURALGIA  1231 

volved.  The  general  features  of  neuralgia  are  present,  as  already 
described,  (a)  Involvement  of  the  first  branch  is  the  most  common 
form;  pain  occurs  over  the  eye,  forehead,  and  frontal  sinus  (in  which 
the  familiar  pain  is  experienced  after  eating  ice-cream) ;  it  sometimes 
radiates  into  the  second  and  third  branches;  there  are  "tender  points" 
over  the  lower  edge  of  the  nasal  bone,  the  supra -orbital  notch,  less  often 
over  the  supra-orbital  nerve,  even  to  the  vertex,  sometimes  over  the 
occiput  or  over  the  cervical  spines;  cold,  carious  teeth,  disease  of  the 
sinus,  glaucoma,  and  errors  of  refraction  (hypermetropia)  are  causal 
factors.  (5)  When  the  second  branch  is  involved,  there  is  pain  over  the 
side  of  the  nose  and  cheek  from  the  infra -orbital  region  to  the  upper  lip; 
there  are  "tender  points"  over  the  lower  border  of  the  nasal  bone,  the 
malar  bone,  the  infra-orbital  foramen,  the  gums  over  the  canine  teeth, 
and  sometimes  in  the  hard  palate ;  among  other  causes  due  to  sclerosis 
is  the  dental  alveolitis  in  the  aged.  Diseased  teeth  may  cause  neuralgia 
without  local  dental  symptoms;  therefore  in  every  severe  case  the 
dentist  should  be  consulted,  (c)  Involvement  of  the  third  branch  is  the 
least  frequent  form;  inframaxillary  pain,  along  the  lower  teeth,  tongue, 
chin,  external  ear  and  maxillary  region;  and  tenderness  over  the 
auriculotemporal  nerve  and  inferior  dental  foramen  may  occur.  In 
old  persons  the  loss  of  the  teeth  brings  the  jaws  closer  and  therefore 
stretches  the  inf.  dental  nerve;  it  is  relieved  by  employing  proper  plates. 
In  severe  forms  vasomotor  symptoms  and  increased  secretion  from  the 
eyes,  nose  and  salivary  glands  are  usually  present.  Hyperalgesia  is 
usual  so  that  the  face  cannot  endure  simple  contact,  and  drinking, 
mastication  and  wiping  the  nose  cause  great  suffering.  Herpes  and 
trophic  changes  are  probably  neuritic  rather  than  neuralgic  symptoms. 
In  rare  instances  facial  spasm,  transient  reflex  ptosis,  internal  strabis- 
mus or  myosis  co-exist.  Differentiation.  In  headache  and  migraine 
there  are  no  tender  points;  intracranial  disease,  as  tumor  or  syphilis, 
is  usually  excluded  by  systematic  examination.  The  prognosis  is 
doubtful  in  severe  forms,  which  are  often  lifelong  in  duration  and 
agonizing  in  degree. 

2.  In  CERVico-occiPiTAL  NEURALGIA;  there  is  pain  in  the  first  four 
cervical  nerves,  especially  the  inferior  occipital  and  auricularis  magnus; 
this  pain  sometimes  radiates  into  the  fifth  nerve;  there  is  tenderness 
half  way  between  the  mastoid  and  spine,  over  the  parietal  eminence 
and  over  the  cervical  plexus  between  the  sternomastoid  muscle  and 
trapezius;  this  form  is  rarely  primary,  is  often  bilateral,  and  is  less 
intermittent  than  other  neuralgias,  which  facts  are  explained  by  its 
frequent  connection,  especially  with  cervical  caries  and  syphilis,  and 
also  with  tumors,  meningitis,  root  disease  and  affections  of  the  ear. 

3.  Phrenic  neuralgia  is  rare,  though  it  sometimes  occurs  in  peri- 
carditis and  diaphragmatic  pleurisy;  it  is  most  often  left-sided,  with 
pain  and  tenderness  over  the  insertion  of  the  diaphragm  and  nerve 
trunk  in  the  neck;  movements  involving  the  diaphragm  are  painful. 
Diagnosis  and  differentiation  are  usually  uncertain. 


1232  DISEASES  OF  THE  NERVOUS  SYSTEM 

4.  In  CERVicoBRACHiAL  XEURALGIA,  any  nerve  may  be  involved, 
but  the  ulnar  and  circumflex  are  especially  affected.  Pain  may 
radiate  over  the  entire  plexus  and  into  the  chest;  the  tender  points  are 
most  often  in  the  axilla,  over  the  shoulder  and  over  the  ulnar  distribu- 
tion; it  is  most  often  confused  with  neuritis  from  trauma,  compression 
or  other  organic  disease;   it  may  be  due  to  rheumatic  arthritis. 

5.  Intercostal  xel'ralgia  ranks  third  in  frequency  after  trifacial 
and  sciatic  neuralgia  (neuritis).  Pain  is  felt  along  the  intercostal 
spaces  and  tenderness  over  the  points  of  emergence  of  its  three  branches, 
over  the  angle  of  the  ribs,  in  midaxilla  and  near  the  mammary  line. 
It  is  more  easily  distinguished  in  the  upper  than  lower  interspaces. 
Differentiation  may  be  difficult  because  of  muscular  rheumatism  in 
which  movement  is  more  painful.  Peritoneal  disease,  gastric  ulcer, 
spinal  caries,  aortic  aneurysm,  and  tabes  must  be  distinguished.  It 
is  most  common  in  gastrohepatic  affections,  and  in  neurotic  women. 

Herpes  zoster  is  probably  an  acute  specific  inflammation  of  the 
posterior  root  gangha,  as  shown  by  Barensprung  and  Charcot  and 
later  by  Head  and  Campbell.  It  is  mentioned  in  this  connection 
because  of  the  acute  pain  preceding  and  associated  with  the  rash, 
which  appears  after  three  or  four  days;  the  pain  is  often  protracted 
and  intractable;  the  pain  on  the  trunk  follows  the  distribution  of  the 
spinal  segments  rather  than  that  of  the  intercostals.  The  ganglion  is 
the  seat  of  a  cellulohemorrhagic  exudation  and  its  fibers  to  the  posterior 
column  of  the  cord  degenerate. 

6.  Lumbar  neuralgia  is  infrequent ;  it  occurs  in  the  iliohypogastric, 
ilio-inguinaland  genitocrural  branches,  sometimes  in  the  ext.  cutaneous, 
obturator  and  crural  nerves.  The  pain  is  felt  over  the  iliac  crest,  in 
the  inguinal  canal,  labium  or  testes  (irritable  testicle). 

7.  Sacral  neuralgia  is  also  infrequent.  Coccygodynia  is  probably 
neuralgic,  and  occurs  mostly  in  women.  The  pain  is  increased  by 
sitting,  coitus,  and  defecation;  it  is  obstinate  and  resists  even  operative 
measures. 

8.  In  neuralgia  of  the  feet,  there  is  pain  in  the  heel,  which  was  called 
PODODYNIA  by  Gross;  plantar  neuralgia,  which  is  mostly  neuritic, 
occurs  in  acute  infections,  and  in  caisson  disease.  ^Morton's  meta- 
tarsalgia,  which  was  regarded  by  him  as  due  to  bony  compression  of 
the  fourth  metatarsophalangeal  nerve,  usually  occurs  in  one  foot,  and 
mostly  in  women;    operation  is  usually  indicated. 

9.  Visceral  neuralgias  are  considered  under  diseases  of  the  heart, 
stomach  and  kidneys  and  under  hysteria  and  neurasthenia.  Under 
this  caption  may  be  given  Head's  areas  of  pain  referred  to  visceral 
disease:    the  organ  is  first  mven  and  following  it,  is  the  area  to  which 

T  1 

its  pain  is  reflected :  Heart:  1st,  2nd,  3rd  dorsal  segments.  Lungs:  1st, 
2nd,  3rd,  4th,  oth  dorsal  segments.  Stomach:  6th,  7th,  8th,  9th 
dorsal;  cardiac  end  from  6th  and  7th.  Pyloric  end  from  9th.  Intes- 
tines: (a)  Down  to  upper  part  of  rectum,  9th,  10th,  11th  and  12th 
dorsal,  (b)  Rectum,  2nd,  3rd  and  4th  sacral.  Liver  and  gall-bladder: 
7th,  8th,  9th,  10th  dorsal;    perhaps  6th  dorsal.      Kidneij  and  ureter: 


NEURALGIA  1233 

10th,  11th  and  12th.  The  nearer  the  lesion  hes  to  the  kidney,  the 
more  is  the  pain  and  tenderness  associated  with  the  IGth  dorsal.  The 
lower  the  lesion  in  the  ureter,  the  more  does  the  1st  lumbar  tend  to 
appear.  Bladder:  (a)  Mucous  membrane  and  neck  of  bladder, 
1st,  2nd,  3rd,  4th  sacral.  (6)  Overdistention  and  ineffectual  con- 
traction, 11th  and  12th  dorsal  and  1st  lumbar.  Prostate:  10th,  11th,  12th 
dorsal,  1st,  2nd,  3rd  sacral  and  5th  lumbar.  Epididymis:  11th  and 
12th  dorsal  and  1st  lumbar.  Testis  and  ovary:  10th  dorsal. 
Appendages:  11th  and  12th  dorsal  and  1st  lumbar.  Uterus:  (a)  In 
contraction.  10th,  11th,  12th  dorsal  and  1st  lumbar,  (b)  Os  uteri. 
1st,  2nd,  3rd  and  4th  sacral  (5th  lumbar  very  rarely). 

Treatment  of  Neuralgia. — Logically  the  treatment  of  the  cause 
(q.  V.)  should  precede  that  of  the  symptoms,  but  practically,  pain  is 
the  prime  indication  for  therapeutic  measures. 

1.  Local  Measures. — Pressure  on  tender  points  may  diminish  or 
abolish  pain.  As  in  sciatica,  blisters  and  sinapisms  (both  of  which 
may  leave  permanent  pigmentation  on  the  face),  the  cautery,  local 
heat,  acupuncture  or  injections  of  water  or  cocaine  may  give  relief. 
Freezing  the  skin  by  ethyl  chloride  (Richardson,  Deddard)  often 
gives  better  results.  Menthol,  camphor-chloral  (equal  parts)  and 
liniments  are  of  some  value  (tr.  aconiti,  tr.  chloroformi,  tr.  belladonnae 
aa  3ijj  linimentum  saponis  ^iv).  Injections  of  1  per  cent,  solution 
of  osmic  acid  into  the  nerve  trunk  are  very  successful;  they  were 
recommended  by  Bennett  (1889)  and  later  by  Murphy;  paralysis 
sometimes  results.  Massage  is  often  beneficial,  for  the  muscles  and 
nerves  have  common  veins. 

2.  Nutrition. — A  full  diet,  with  milk,  and  cod-liver  oil,  and  also 
with  rest,  the  Mitchell  cure,  hydrotherapy  and  massage,  is  often 
beneficial,  especially  with  change  of  climate  or  surroundings.  Alcohol, 
which  is  always  dangerous,  is  most  often  indicated  in  older  subjects. 
The  beneficial  effects  of  castor  oil  are  often  great,  probably  because  it 
promotes  elimination.     Gouty  subjects  may  thrive  on  a  vegetable  diet. 

3.  General  Drug  Treatment. — There  are  numerous  remedies.  Iron 
and  strychnia,  and  possibly  phosphorus  are  valuable  in  anaemic 
subjects.  Dana  gives  strychnine  hypodermatically  in  doses  of  3^  gr. 
even  up  to  h  gr.).  Arsenic  is  excellent  in  anaemic,  malarial  and 
degenerative  types;  quinine  is  beneficial  in  non-malarial  as  well  as 
malarial  types  and  in  trifacial  neuralgia  especially,  although  its  value 
is  considerably  overestimated.  Valerian,  cannabis  indica  and  bro- 
mides should  be  given  for  irritability;  salicylates  for  rheumatism  and 
colchicum  and  cimicifuga  for  gout;  iodides  are  sometimes  of  benefit 
to  non-syphilitic  subjects;  full  doses  of  nitroglycerine  are  frequently 
helpful. 

4.  Analgesics. — Acetanilide  (gr.  v)  and  the  other  coal-tars  should 
be  used  first  in  fresh  cases.  Extr.  cannabis  indica?  (gr.  \-)  and  fluidextr. 
gelsemii  (np  ii  to  iv)  should  be  administered  every  three  to  six 
hours  in  the  less  severe  cases.  In  acute  febrile  or  rheumatic  cases, 
fluidextr.   aconiti    (tt)^  i  to  ii)   should   be  given  every  two  hours   until 

78 


1234  DISEASES  OF  THE  NERVOUS  SYSTEM 

tingling  in  the  mouth  or  extremities  and  slowing  in  the  pulse  intervenes. 
Liebreich  advocates  croton-chloral  (gr.  v),  or  with  care  even  (gr.  xx) 
for  several  doses.  Finally,  in  severe  cases,  morphine  may  be  given 
but  as  far  as  possible,  it  should  be  avoided;  sometimes  its  administra- 
tion is  inevitable;  though  some  writers  find  that  it  tends  to  prevent 
recurrence,  the  pain  often  develops  again,  intensified;  it  should  be 
combined  with  atropine,  which  may  be  given  alone,  as  it  sometimes 
more  permanently  controls  the  pain  than  does  the  morphine. 

5.  Electrotherapy. — ^This  sometimes  relieves  the  pain,  but  it  more 
often  fails.  Galvanization  with  a  weak  current,  which  should  be  just 
strong  enough  to  produce  a  sensation  of  burning,  and  should  be  applied 
with  the  sponges  warm  and  with  the  anode  to  the  painful  area,  may  be 
beneficial,  especially  in  newly  developed  cases. 

6.  Surgical  Therapy. — This  includes  section,  resection,  stretching, 
twisting  or  divulsion  of  the  nerves;  resection  should  be  tried  first,  but 
all  of  these  proceedings  may  fail.  In  incoercible  trigeminal  neuralgia, 
the  Gasserian  ganglion  may  be  extirpated  (Hartley,  Krause,  Keen, 
Gushing),  but  this  operation  is  severe,  and  loss  of  the  eye  may  result. 
Horsley  opens  the  skull  and  divides  the  root  of  the  fifth  nerve  above 
the  ganglion,  but  this  also  is  distinctly  dangerous,  and  Spiller  and 
Frazier    therefore    suggest   its    division   without    opening   the  cranial 

cavity. 

* 

VASOMOTOR  AND  TROPHIC  NEUROSES. 

Vasomotor  centres  exist  in  the  cerebral  cortex  and  medulla.  The 
fibers  probably  run  in  the  lateral  columns  of  the  cord  and  leave  by  the 
anterior  roots.  Vasomotor  paralysis  occurs  independently  or  with 
functional  or  organic  disease.  Paralysis  of  the  cervical  sympathetic 
may  result  from  trauma,  aneurysm,  tuberculous  apical  or  glandular 
disease,  or  disease  of  the  cord.  It  is  attended  by  redness,  rise  of 
temperature,  pulsation  and  tortuosity  of  the  vessels,  sweating,  unrest, 
ringing  in  the  ears  and  palpitation.  In  paralysis  of  the  cervical  sym- 
pathetic there  is  pupillary  narrowing  from  the  unopposed  action  of  the 
third  nerve,  slight  ptosis,  narrowing  of  the  interpalpebral  fissure  from 
paresis  of  Miiller's  muscle,  salivation,  lachrymation,  and  in  cases  of 
some  standing,  retraction  of  the  eye  and  flattening  of  the  cheek.  The 
pupil  reacts  somewhat  to  light  but  not  to  stimulation  by  pain  or 
pinching  of  the  skin  of  the  neck  (Mobius) ;  the  pupil  can  be  widened 
'by  atropine,  but  to  a  less  degree  than  in  the  normal  eye. 

Vasomotor  spasm  presents  converse  symptoms,  pallor,  coldness, 
■small  vessels,  and  frequently  a  sense  of  tingling  or  arterial  pain.  Two 
examples  are  nervous  angina  pectoris,  and  Raynaud's  disease;  spasm 
(contraction,  irritation)  of  the  cervical  sympathetic  produces  wide 
pupils,  an  increased  interpalpebral  fissure  and  exophthalmos. 

Little  is  known  of  the  trophic  nerves,  if  indeed  separate  nerves  sub- 
serve nutrition.  If  they  exist,  they  are  probably  closely  related  to  the 
vasomotor  tracts.    Trophic  changes  may  be  symptomatic  of  disease  of 


VASOMOTOR  AND  TROPHIC  NEUROSES  1235 

the  nerves  or  cord,  as  in  neuritis  or  nerve  trauma,  liemifacial  atrophy, 
tabes,  syringomyelia,  and  myelitis,  under  which  their  special  features 
have  been  already  discussed. 

Erythromelalgia  was  described  first  by  S.  Wier  Mitchell  (1872);  the 
term  indicates  the  chief  clinical  characters,  redness  and  pain  in  the 
extremities.  It  is  rare,  though  much  more  frequent  than  is  shown  by 
Rost's  series  of  40  cases.  It  occurs  mostly  between  the  years  of  twenty- 
five  and  forty  and  is  slightly  more  frequent  in  males  than  in  females. 
Its  pathology  is  not  wholly  clear,  although  Mitchell  and  Spiller  find 
neuritis  and  sclerosed  arteries.  The  toes  (less  often  the  fingers),  and 
balls  of  the  toes,  are  the  seat  of  severe,  usually  paroxysmal  pain, 
swelling  and  redness;  the  arteries  throb  and  the  veins  are  engorged; 
the  color  is  sometimes  blue.  Pain  is  sometimes  experienced  in  the  head 
and  neck,  and  vertigo  and  muscular  weakness  may  be  noted.  The 
symptoms  occur  mostly  in  warm  weather,  and  generally  disappear  in 
winter.  The  clinical  course  is  long,  the  prognosis  doubtful  and  the 
treatment  consists  of  electrotherapy,  cool  baths,  acetanilide  and  iodides. 

Acroparaesthesia  is  closely  related  to  erythromelalgia.  It  was  des- 
cribed first  by  Nothnagel,  and  F,  Schultze  (1890)  named  this  very 
frequent  affection;  its  derivation  signifies  parcesthesia  of  the  extremities. 
More  than  90  per  cent,  of  cases  occur  in  women  between  thirty  and 
sixty  years  of  age.  The  etiology  is  doubtful  (stasis  or  arteriosclerosis). 
Its  chief  feature  is  an  unpleasant  crawling,  tingling  sensation,  some- 
times amounting  to  actual  pain  in  the  fingers  or  hands,  less  often  in  the 
toes  or  feet.  The  discomfort  is  greatest  at  night  and  in  the  early  morn- 
ing; it  is  peripheral  and  symmetrical  but  does  not  correspond  with  any 
nerve  area.  Generally  there  are  no  objective  findings,  other  than  occa- 
sional vasomotor  disturbance  or  slight  sensory  blunting.  The  outlook 
is  favorable,  the  course  is  chronic  and  treatment  is  symptomatic ;  the 
faradic  brush  frequently  affords  relief. 

Spontaneous  symmetrical  gangrene,  or  Raynaud's  disease  was  first 
described  by  Raynaud  (1862).  Sixty-six  per  cent,  of  cases  occur  in 
women,  who  are  usually  delicate,  anaemic  and  neurotic,  and  most  cases 
develop  in  persons  between  twenty  and  forty-five  years  of  age.  In  10 
per  cent,  it  is  hereditary.  Other  causal  factors  are  uncertain;  exposure 
to  cold  and  dampness,  exhaustion,  worry  and  acute  infections  are  some- 
times considered  of  etiological  importance.  Occasional  co-existence  is 
noted  with  hysteria,  neurasthenia,  epilepsy,  tabes,  syringomyelia, 
myelitis,  angioneurotic  oedema,  peripheral  neuritis  and  acute  mania. 
Its  pathology  is  not  wholly  established,  but  arterial  spasm,  endarteritis 
and  neuritis  are  said  to  exist.  There  are  three  stages;  (a)  Local 
ischcemia  (or  syncope),  begins  with  pallor  and  coldness  of  one  or  two 
fingers,  perhaps  of  the  entire  hand,  or  of  the  toes,  and  is  attended  by 
numbness  or  severe  pains.  The  "dead  fingers"  or  toes  appear  on 
exposure  to  slight  cold  or  on  emotion,  and  reaction  occurs  after  a 
variable  period.  The  process  may  not  pass  this  stage,  (b)  Local 
asphyxia  (or  cyanosis)  develops  in  the  parts  involved,  at  times  with 
some  swelling  or  anaesthesia.    It  is  most  severe  in  winter,  and  chilblains 


1236  DISEASES  OF  THE  NERVOUS  SYSTEM 

are  regarded  as  the  mildest  type  of  this  stage,  (c)  Local  gangrene, 
which  is  spontaneous,  symmetrical  and  fortunately  rare,  is  the  last 
stage.  It  is  dry,  sometimes  vesicular,  and  its  extent  is  always  less  than 
the  area  of  ischsemia  and  asphyxia.  The  tips  of  the  fingers  or  toes  dry 
up,  fall  off  and  scars  mark  successive  attacks.  Less  often  the  tip  of  the 
nose,  ear,  buttock,  heel,  shoulder  or  abdomen  is  involved,  and  very 
rarely  the  tongue,  penis,  elbow,  or  knee.  Fever  is  usually  absent.  In 
some  instances  there  is  severe  general  disturbance,  as  fever,  chill, 
enlarged  spleen,  colic,  hsemoglobinuria,  ursemia,  stupor,  coma,  con- 
vulsions, transient  hemiplegia,  neuritis  and  spastic  retinal  vessels. 
The  severe  or  fatal  cases  occur  especially  in  children.  The  course  is 
chronic  and  consists  of  repeated  attacks,  which  often  abate  in  summer. 
Differentiation  is  usually  easy  from  hysterical  gangrene  (self-injury), 
diabetic,  arteriosclerotic  or  embolic  gangrene,  syringomyelia,  leprosy, 
ergotism  and  occlusion  by  acute  arteritis,  as  in  typhoid. 

In  treatment,  narcotics  should  be  given  for  pain;  warmth  and  ele- 
vation promote  venous  return,  and  nitroglycerine  dilates  the  arteries. 
Gushing  advises  that  Esmarch's  constrictor  be  applied  for  a  few  min- 
utes, after  which  the  circulation  is  restored.  In  actual  gangrene,  surgical 
interference  should  be  postponed  until  complete  demarkation  develops, 
because  the  area  is  usually  much  more  circumscribed  than  at  first 
indicated. 

Acute  angioneurotic  oedema  was  first  fully  described  by  Quincke 
(1882),  although  Milton  (1876)  described  "giant  urticaria."  It  occurs 
most  frequently  between  the  years  of  twenty  and  thirty-five  and  is 
slightly  more  frequent  in  women  than  in  men.  Hereditary  forms  are 
known;  22  cases  occurred  in  5  (Osier),  and  22  cases  in  6  (Milroy) 
generations  of  one  family.  It  is  allied  to  urticaria,  erythema  nodosum 
and  possibly  to  some  forms  of  purpura,  and  consists  of  a  circumscribed 
oedema,  which  is  sudden  in  onset  and  in  disappearance,  is  tense  and 
pale,  does  not  pit  on  pressure,  sometimes  causes  burning,  and  appears 
mostly  on  the  eyelids,  Hps,  cheek,  tongue,  hands  or  genitalia,  some- 
times on  the  buttocks,  pharynx,  larynx,  lung  or  digestive  tract.  It 
sometimes  attacks  several  areas  simultaneously.  Gastro-intestinal 
symptoms  occur  in  33  to  50  per  cent,  of  cases,  as  epigastric  pain,  vomit- 
ing, colic  or  diarrhoea  (see  page  867).  Hsemoglobinuria,  albuminuria 
and  polyuria  are  less  frequent.  The  outlook  is  good,  except  for  the 
dangerous  laryngeal  or  pharyngeal  localization  which  may  cause  sud- 
den death.  Recurrence  is  not  uncommon,  and  sometimes  occurs  with 
considerable  periodicity.  Treatment  is  symptomatic  and  general; 
nitroglycerine  has  been  recommended.  Bloodgood  employed  deep 
incisions  with  great  benefit. 

Twenty-two  cases  of  chronic  hereditary  trophoedema  in  six  genera- 
tions were  described  by  Milroy  (1893)  of  Omaha,  and  8  cases  in  four 
generations  by  Meige  (1898),  A  firm,  pale,  painless  oedema,  chiefly 
below  the  hip  or  knee,  develops  toward  puberty,  without  cardiac,  renal 
or  apparent  local  causes.  It  may  appear  in  the  arm  and  leg  of  the 
same  side,  including  probably  some  of  the  so-called  local  hemihyper- 


VASOMOTOR  AND  TROPHIC  NEUROSES  1237 

trophies.  The  first  cases  recorded  were  initially  thought  to  be  phle- 
bitis. Health  and  life  are  not  threatened,  although  treatment  produces 
no  results.   - 

Hydrops  articulorum  intermittens  (hydrarthrosis  intermittens)  or 
intermittent  hydrops  in  the  joints,  occurs  with  equal  frequency  in  both 
sexes,  and  71  per  cent,  occurs  in  persons  between  ten  and  forty  years  of 
age.  Its  exact  etiology  is  not  known.  Some  cases  present  malarial, 
gonorrhoeal  or  traumatic  antecedents.  The  knee  is  usually  involved 
when  several  joints  are  affected,  and  in  33  per  cent,  is  alone  involved. 
The  effusion  wholly  disappears  after  two  or  three  days,  but  it  reappears 
obstinately  every  one  to  four  weeks.  There  is  no  fever  and  usually  no 
pain.     Treatment  is  general. 

Scleroderma  was  described  by  Lusitanus  and  Alibert,  though  Thirial 
(1845)  gave  the  first  full  account  of  it.  It  is  a  chronic  thickening  and 
hardening  of  the  skin,  followed  by  atrophy.  It  is  a  rare  affection,  but 
is  more  common  than  is  generally  recognized.  The  localized  form 
usually  develops  before,  and  the  generalized  form  after,  the  twenty-fifth 
year.  Seventy-five  per  cent,  of  cases  occur  in  women.  The  causation 
is  obscure;  erysipelas,  trauma,  cold,  and  neuropathic  disposition  are 
sometimes  considered  etiological,  and  association  with  other  neuroses, 
general  and  vasomotor,  is  frequent.  Anatomically  the  skin  and  all  the 
contained  structures  are  fibrosed.  In  the  localized  form  it  occurs  in 
spots  or  streaks,  which  often  correspond  to  the  course  of  given  nerve 
trunks  or  spinal  segments.  In  the  general  form  the  body  may  be 
hterally  "hide  bound."  Its  distribution  in  order  of  frequency  is  (a) 
the  upper  extremities;  (b)  the  trunk;  (c)  the  head  and  face;  (d)  the 
lower  extremities;  (e)  generahzed.  The  skin  is  usually  first  painful 
and  sensitive,  then  reddened  and  thickened,  and  finally  pale,  glossy, 
dry,  atrophic  and  parchment-like.  It  is  rigid  and  without  folds, 
inhibiting  the  mimetic  play  of  the  features.  The  nose  is  peaked, 
the  lids  cannot  close  over  the  eyeball  and  may  become  everted.  The 
mouth  is  so  small  as  to  sometimes  necessitate  extraction  of  some  of  the 
teeth,  and  rigidity  in  the  neck  may  render  swallowing  difficult.  In  the 
fingers  it  occurs  in  5  per  cent,  of  cases,  the  condition  being  known  as 
sclerodactylia  (Ball).  The  close  skin  produces  decided  deformity  and 
loss  of  function.  Sensation  is  usually  preserved,  the  secretion  of  sweat 
is  usually  reduced,  and  pigmentation  and  trophic  changes  in  the  hair 
and  nails  are  occasionally  seen.  In  some  cases  it  occurs  with  herpes; 
this  is  the  herpetiform  morphea  of  Hutchinson.  Circumscribed 
atrophy  of  the  bones  is  said  to  occur.  Only  30  per  cent,  of  cases 
improve,  and  15  per  cent,  recover,  whence  the  outlook  is  generally 
unfavorable.  Treatment  is  unsatisfactory.  Improvement  has  followed 
administration  of  salol  and  inunctions  with  oil;  thyroid  extract  (Osier, 
Lustgarten,  Sachs  and  Bramwell),  especially  if  used  early  in  the  disease, 
may  promote  recovery. 

Ainhum  was  first  observed  by  Clark  (1860)  then  by  Da  Silva  Lima 
(1866).  It  is  a  chronic  affection,  usually  limited  to  the  great  toe,  which 
at   its   plantodigital   fold  suffers  a  slow,  painless,  non-inflammatory 


1238  DISEASES  OF  THE  NERVOUS  SYSTEM 

circular  constriction  and  spontaneous  amputation.  Ainhum  is  chiefly 
found  in  the  colored  races  of  Brazil,  Africa,  India  and  sometimes  in 
this  country.  Its  nature  is  disputed ;  an  ingrowth  of  the  epidermis  and 
scleroderma  have  been  thought  to  be  the  cause.  It  is  not  amputating 
leprosy,  as  has  been  claimed. 


YI.  DISEASES  OF  THE  MUSCLES. 

1.  MYOSITIS. 

Inflammation  in  the  muscles  may  be  single  or  multiple;  it  may  be 
an  independent  afl^ection  or  a  secondary  one.  It  may  reach  the  muscles 
by  contiguity  from  adjacent  disease,  may  result  from  trauma,  trichinosis, 
infection  with  cysticercus,  echinococcus,  sporozoa  (myxo-,  sarco-  and 
microsporidia),  sepsis,  puerperal  fever,  rheumatism,  scarlatina,  gonor- 
rhoea, syphilis,  or  erythema  multiforme.  The  muscles  are  the  seat  of 
serous  or  sometimes  hemorrhagic  or  diffuse  purulent  exudation  in 
septic  forms,  and  of  fatty  degeneration.  There  is  a  form,  endemic  in 
Japan,  in  which  the  Staphylococcus  pyogenes  aureus  occurs  in  pure 
cultures.  The  muscles  are  usually  friable  and  sometimes  fragmented. 
Polymyositis  first  described  by  Wagner  (1887),  Hepp  and  Unverricht, 
occurs  most  often  in  youth  and  adolescence  and  is  attended  by  pain 
especially  near  the  tendons,  swelling  and  often  oedema  in  the  muscles, 
the  electrical  irritability  of  which  is  decreased  as  also  are  the  tendon 
reflexes.  The  skin  may  participate,  and  herpes,  erythema,  bullae  or 
purpura  (dermatomyositis)  may  be  present;  the  infection  may  involve 
the  tissue  in  which  the  afferent  nerves  originate  (muscle  spindles)  and 
topographically  a  neuritis  and  myositis  may  co-exist  or  coincide  (neuro- 
myositis, Senator).  In  some  cases  there  is  arthritis  or  phlebitis. 
Oppenheim  describes  a  case  of  dermatomucomyositis  with  stomatitis, 
iritis  and  conjunctivitis.  The  inflammation  occasionally  reaches  the 
tongue,  pharynx,  larynx,  or  respiratory  muscles,  and  may  even  cause 
difl^cult  mastication  or  swallowing,  ptosis  or  dyspnoea.  The  systemic 
reaction  is  usually  severe,  is  marked  by  fever,  chills,  sweats,  splenic 
tumor,  sometimes  by  angina,  bronchitis,  albuminuria  or  leukocytosis. 
The  course  is  usually  fatal. 

Differentiation  concerns  multiple  neuritis  (tenderness  over  the  nerve 
trunks,  motor  and  sensory  findings);  trichinosis  (finding  trichinae  in 
the  tender,  swollen  muscles,  increase  of  the  eosinophile  cells,  and 
digestive  symptoms);  and  the  periarteritis  nodosa  of  Kussmaul  and 
Maier  (g.  i'.) 

Treatment  is  symptomatic,   and  is  identical  with  that   of  sepsis 
SAveats  and  administration  of  aspirin  are  beneficial. 


MUSCULAR  RHEUMATISM  1239 

Myositis  ossificans  is  characterized  by  a  myositis  which  usually 
develops  acutely  in  the  muscles  of  the  neck  or  back  before  the  fifteenth 
year,  and  lea^ves  residual  foci  of  infiltration,  which  gradually  calcify. 
The  thigh  and  arm  are  most  severely  and  permanently  affected.  The 
process  occurs  in  the  strongest  muscles  and  at  an  age  when  they  develop 
most  actively;  it  may  affect  many  muscles  and  runs  a  chronic  course, 
perhaps  of  several  decades.  One  hundred  and  thirty-four  cases  are 
recorded  (Cahier);  there  were  101  traumatic  cases  (Werner,  1904). 
Massage  is  sometimes  beneficial. 


2.  MUSCULAR  RHEUMATISM   (MYALGIA). 

This  includes  many  vague  but  important  affections.  It  occurs 
particularly  in  men,  after  exposure  to  cold  and  dampness,  and  is  obvi 
ously  promoted  by  certain  occupations.  Muscular  overexertion,  as 
straining  and  lifting,  is  frequently  a  part  of  the  history.  Rheumatic 
and  gouty  subjects  are  specially  exposed  and  to  recurrent  seizures. 
Disorders  of  metabolism  or  mental  as  well  as  physical  overwork  mark 
some  cases.  Other  forms  are,  as  Leube  insists,  probably  infectious, 
for  fever  occurs  in  33  per  cent.,  and  is  occasionally  followed  by  endo- 
carditis; muscular  rheumatism  in  this  sense  does  not  usually  involve 
many  muscles,  but  usually  one  muscle  or  a  single  group.  The  pain  is 
not  paroxysmal,  as  in  neuralgia,  and  is  experienced  in  the  muscle  or 
reaches  it  from  its  tendons  or  fasciae.  In  some  cases  it  is  apparently 
a  mild  neuromyositis.  Its  varieties  are;  Myalgia  capitis,  affecting  the 
fascia  of  the  head;  omalgia,  involving  the  muscles  of  the  shoulder, 
or  rheumatic  torticollis,  which  is  usually  unilateral;  pleurodynia,  which 
affects  the  chest  muscles,  pectoralis,  intercostals,  and  serratus,  limits 
respiratory  movements  and  is  likely  to  be  confused  with  intercostal 
neuralgia,  pleurisy,  periostitis  of  the  ribs,  or  vertebral  disease;  lum- 
bago, which  involves  the  lumbar  muscles,  and  is  the  most  frequent, 
painful  and  obstinate  form,  causing  great  pain  on  movement  or  on 
efforts  of  the  uninvolved  muscles  to  maintain  quiet ;  it  is  probably  due 
in  some  cases  to  muscular  rupture,  as  after  lifting.  In  the  abdominal 
muscles  and  glutei,  it  may  simulate  pelvic  disease.  In  treatment,  rest 
is  urgently  indicated,  for  use  of  the  affected  muscles  aggravates  pain 
and  protracts  the  condition.  Involuntary  movement  is  prevented  by 
careful  strapping  with  adhesive  plaster,  especially  when  there  is  pain 
in  the  chest.  A  hypodermic  of  morphine,  into  the  muscle,  is  often 
indicated. 

Deep  injection  of  water  into  the  muscles  of  the  back  may  relieve 
pain.  Ringer's  method  of  acupuncture  with  long  needles  which  are 
pushed  three  inches  into  the  back  and  left  there  for  from  five  to  ten 
minutes  is  beneficial,  but  is  usually  vigorously  opposed  by  the  patient. 
Very  energetic  massage,  with  the  local  application  of  heat,  probably 
gives  the  best  results.  The  actual  cautery,  the  application  of  the  con- 
stant current,  and  the  use  of  Tesla's  coil  give  good  results.    The  use  of 


1240  DISEASES  OF  THE  NERVOUS  SYSTEM 

belladonna  plasters  gives  relief.     Gelsemium,  acetanilide  and  salicy- 
lates often  produce  no  effect,  but  may  instantly  relieve  certain  cases. 

CHronic  cases,  with  vague,  fugitive  pains  which  come  on  with  change 
of  weather,  are  treated  in  the  same  way — usually  without  result. 
Confusion  with  chronic  alcoholism,  tabes,  gout,  and  diabetes  is 
frequent. 


SECTION  X. 


INTOXICATIONS.    SUNSTROKE 


(A).  ALCOHOLISM. 
I.  Acute  Alcoholism. 

(a)  The  highest  brain  centres  are  first  affected.  The  judgment 
is  first  involved  (emotion  predominating),  motility  next  (as  shown 
by  the  disordered  speech,  gait  and  vision),  then  the  lower  centres 
(respiratory,  circulatory  and  spinal).  (&)  The  circulation  is  increased 
and  the  pulse  becomes  more  rapid,  though  it  is  held  that  alcohol  does 
not  stimulate  the  heart.  Full  doses  may  make  the  pulse  slow  and 
small.  The  vascular  tone  is  lax  and  the  face  is  therefore  flushed; 
for  this  reason  alcoholics  suffer  little  shock  from  coincident  trauma- 
tism, (c)  Respiration  is  slow,  deep,  and  seldom  stertorous,  (d)  The 
pupils  are  variable,  often  dilated  or  sometimes  narrow  and  reaction- 
less,  (e)  The  temperature  may  fall  markedly,  from  vasoparesis,  and 
usually  vv^ith  some  cyanosis  and  failing  of  the  bulbar  centres;  Reincke 
states  that  temperature  has  fallen  as  low  as  75°!  Involuntary  evacua- 
tions occur  in  the  severest  cases  and  there  may  be  subcutaneous  hemor- 
rhages. 

Dipsomania  is  intermittent  acute  alcoholism,  an  hereditary  psycho- 
sis in  which,  after  intervals  of  abstinence  and  of  no  craving  for  liquor, 
the  patient  becomes  intoxicated. 

Diagnosis. — The  alcoholic  breath  is  usually  suggestive  but  epileptics 
and  unemics  may  (Irink,  and  while  drunk,  a  man  may  have  his  skull 
broken  or  suffer  an  apoplexy.  Many  mistaken  diagnoses  result  from 
carelessness,  but  many  are  unavoidable,  and  the  apparently  drunk 
patient   should   be  treated   for   alcoholism,   while   other  possibilities 

1241 


1242  INTOXICATIONS.      SUNSTROKE 

should  be  carefully  considered.  As  a  rule  the  patient  can  be  aroused, 
but  in  "dead  drunks"  this  is  not  the  case,  and  incomplete  coma  may 
occur  from  other  causes.  The  condition  of  the  pupils  is  not  of  certain 
diagnostic  value,  though  they  are  usually  dilated  in  alcoholic,  contracted 
in  opium  and  ursemic,  and  unequal  in  apoplectic,  coma.  Stertorous 
breathing  is  strongly  indicative  of  apoplexy  or  uraemia.  Convul- 
sions following  delirium  and  muscular  twitchings  are  less  common 
than  in  other  similar  conditions,  but  at  the  time  of  writing,  the  author 
has  a  case  which  showed  uni-  and  then  bilateral  convulsions.  The 
urine  rarely  contains  alcohol,  as  but  one  or  at  the  most  5  per  cent, 
of  ingested  alcohol  is  excreted  by  the  lungs  and  kidneys.  One-third  of 
all  the  fatal  poisonings  in  New  York  and  Berlin  are  acute  alcoholism. 
Treatment. — Gastric  lavage  is  sufficient  in  most  cases.  Even  the 
convulsions  require  little  attention,  but  when  severe,  yield  to  a  few 
whiffs  of  chloroform.  Acute  mania  yields  to  a  hypodermic  of  apo- 
morphinse  hydrochloras  (gr.  -J).  Collapse,  cold  extremities,  and 
cardiac  and  respiratory  failure  are  relieved  by  hot  coffee,  strychnine, 
atropine,  aromatic  spirits  of  ammonia  and  local  heat,  as  will  be  more 
fully  outlined  under  acute  opium  poisoning  (v.  i.). 


II.  Chronic  Alcoholism. 

This  is  less  an  hereditary  tendency  toward  drinking  than  a  lack  of 
character.  The  constant  use  of  alcohol  has  varying  effects;  some 
people  can  take  beer,  wine  or  spirits  throughout  life  without  apparent 
injury;  in  others,  even  the  mildest  alcoholic  drinks  may  induce  visceral 
alterations,  so  that  as  in  liver  cirrhosis,  it  would  seem  that  there  is 
some  other  etiological  factor;  however,  alcohol  in  health  is  a  bad  food, 
an  injurious  narcotic  or  stimulant,  a  protoplasmic  poison  to  the  paren- 
chymatous organs  and  arteries,  and  a  check  on  metabolism. 

Sjinptoms. — (a)  There  may  be  nervous  manifestations.  Functional 
changes  include  the  alcoholic  tremor,  which  is  a  most  common  symp- 
tom; mental  dulness  and  weakness;  nervousness,  jumping  from 
slight  stimuli,  irritability,  impaired  judgment  and  feeble  will  power; 
neuralgias  and  muscular  rheumatism.  Quinquad's  sign  is  elicited 
by  having  the  patient  place  his  fingers  vertically  to  the  examiner's 
hand  or  body,  when  a  series  of  jerking  shock-like  movements  are 
noted;  Fiirbringer  decides  that  (i)  if  it  is  absent,  alcoholism  is  absent; 
(ii)  if  it  is  moderate,  there  is  uncertainty  and  (iii)  if  it  is  marked,  in 
3  cases  out  of  5,  the  patient  is  an  alcoholic.  Of  organic  nervous 
manifestations,  multiple  neuritis  is  the  most  common;  it  may  result 
from  small  amounts  of  alcohol,  when  there  is  a  coincident  metallic 
poisoning;  it  is  much  more  often  a  promoting  factor  than  an  actual 
cause  of  paretic  dementia;  epilepsy  may  result  from  alcoholism; 
hemorrhagic  pachymeningitis,  chronic  leptomeningitis,  acute  polio- 
encephalitis, degeneration  in  the  anterior  horns,  or  Clark's  columns, 
degeneration  of  the  cerebral  nervous  tissue  and  slight  optic  neuritis 


DELIRIUM  TREMENS  1243 

may  be  more  or  less  direct  sequences.  (6)  The  circulation  is  affected. 
Arteriosclerosis  often  develops  with  its  train  of  sequences,  cardiac 
hypertrophy  "and  dilatation,  angina  pectoris,  cerebral  softening  or 
hemorrhage,  (c)  Chronic  bronchitis  and  emphysema  are  frequent 
collateral  findings.  There  may  be  chronic  pharyngitis  and  laryngeal 
thickening,  (d)  The  digestive  organs  are  involved.  Alcoholic  gastritis 
iq.v.)  is  common;  the  morning  vomiting  (vomitus  matutinus)  is 
quite  characteristic,  and  is  quieted  only  by  another  dose  of  its  cause. 
Beer  drinkers  usually  have  large  stomachs.  Alcoholic  cirrhosis  has 
been  already  discussed;  fatty  degeneration,  arterial  congestion  and 
hypertrophy  may  antedate  or  accompany  cirrhosis.  Beer  drinkers 
have  lax  bowels,  while  consumers  of  spirits  are  constipated.  Hemor- 
rhoids are  common,  {e)  The  kidneys  undoubtedly  suffer.  Dickinson, 
Formad  and  Pitt  think  that  renal  disease  is  less  common  than  is  usually 
believed;  Formad  and  Pitt  found  that  the  kidneys  were  hypertrophied 
without  other  change  in  43  per  cent.  As  in  cirrhosis,  several  factors 
may  be  necessary  to  produce  indurated  kidneys.  (/)  Metabolic  mala- 
dies, as  gout,  obesity,  and,  according  to  Striimpell,  some  forms  of 
diabetes  may  result  from  chronic  alcoholism,  ig)  The  skin  frequently 
presents  the  acne  rosacea,  a  very  common  but  not,  as  Trousseau  says, 
an  "indelible  stigma."  The  vessels  of  the  nose,  cheeks  and  often  of 
other  parts  are  suggestively  dilated ;  the  conjunctivae  are  injected  and 
the  eyes  water. 

Prognosis. — The  prognosis  is  unfavorable,  both  from  the  stand- 
point of  curability  and  complications.  English  life  insurance  com- 
panies estimate  that  the  risk  is  25  to  43  per  cent,  less  in  abstainers  than 
in  alcoholics.  The  general  resistance  is  lowered,  thus  favoring  infec- 
tions, as  tuberculosis,  and  raising  greatly  the  death  rate,  most  notably 
in  pneumonia.  Twenty  per  cent,  of  suicides  are  alcoholics.  The 
offspring  of  inebriates  are  disposed  to  numerous  nervous  affections. 

Treatment. —  Treatment  consists  of  correction  of  the  habit  and  care 
of  the  complications,  the  latter  of  which  have,  in  great  part,  already 
been  considered.  The  cure  of  the  habit  is  largely  personal.  Its 
prophylaxis  is  better  than  its  cure.  No  person,  however  intellectual 
or  strong-willed,  can  safelv  drink  with  anv  regularitv.  Institutional 
treatment  is  generally  necessary.  The  vomiting  should  be  treated  in 
accordance  wdth  instructions  given  under  acute  and  chronic  gastritis; 
lavage  is  probably  the  most  reasonable  measure;  a  mixture  of  bismuth 
(see  Typhoid,  Vomiting)  and  small  doses,  (nj^  i  to  ii)  of  Fowler's  solu- 
tion and  large  ones  of  tr.  nucis  vom.  (tt)j  x)  are  valuable  just  before  the 
administration  of  hot  milk  with  tr.  capsici,  ttj  x.  Hyoscine  (gr.  ,20) 
should  be  given  two  or  three  times  at  3  hour  intervals,  chloral  hydrate 
(gr.  x)  and  sod.  bromide  (  5  ss)  for  three  or  four  doses,  before  bedtime, 
or  sulphonal  (gr.  xx)  in  hot  milk  before  bedtime,  in  order  to  induce 
sleep.  Atropine  (gr.  ti,,)  and  strychnine  (gr.  30)  four  or  six  times  daily, 
hypodermatically,  quiet  the  nervousness,  which  occurs  in  the  first  days 
of  abstinence.  Sipping  ice-water,  sucking  lemons,  or  drinking  water 
with  tr.  quassije,  may  satisfy  the  desire  to  "  (h-ink  something. "     Cocaine 


1244  IXTOXICATIOXS.      SUXSTROKE 

and  morphine  should  be  avoided,  lest  a  substitution  or  succession  of 
habits  develop.    Relapse  is  very  common. 


III.    Delirium  Tremens. 

Delirium  tremens  (mania  a  potn)  is  an  acute  accident  of  chronic 
alcoholism,  and  almost  never  follows  an  acute  debauch  in  an  other- 
wise temperate  individual.  It  was  noted  among  sailors  by  Sutton  of 
Greenwich  in  1813,  but  was  probably  best  described  by  Ware  of 
Boston  in  1831.  Sixty-six  per  cent,  of  cases  occur  in  men,  while  multi- 
ple neuritis  is  more  common  in  women  (Gowers);  most  ^'ictims  are 
between  thirty  and  forty  years  of  age.  The  stronger  spirits,  rather 
than  beer  or  wine  are  the  cause  of  delirium  tremens  as  the}^  are  of 
alcoholic  con\'ulsions.  It  may  be  precipitated  by  trauma,  mental  shock, 
the  shock  of  onset  of  an  acute  infection,  or  by  sudden  failure  of  the 
stomach  to  digest  and  assimilate  food. 

S3n2iptoms. — The  symptoms  develop  with  restlessness  and  insomnia, 
which  renewed  drinking  fails  to  allay ;  for  a  day  or  two  the  mind  wan- 
ders, but  can  be  brought  back  to  realities.  The  patient  may  be  face- 
tious, but  is  soon  disturbed  by  horrible  hallucinations.  There  is 
"great  versatility  of  ideas"  in  delirium  tremens.  The  patient  talks 
volubly,  turns  suspiciously  to  the  head  of  his  bed,  drives  his  horses 
Aagorously,  and  brushes  away  the  vermin  from  the  coverlet.  He  at 
first  knows  that  the  bugs  and  snakes  are  unreal,  but  they  soon  become 
actual  torments,  so  that  unless  watched  he  will  leap  from  the  window 
after  waiting  for  his  opportunity.  The  pulse  is  rapid  and  soft,  the 
tongue  is  tremulous  and  is  coated  white,  the  urine  is  scanty,  and  sleep 
is  constantly  absent.  There  may  be  moderate  fever,  101  to  103°, 
which  some  attribute  rather  to  complications. 

Diagnosis  and  Prognosis. — The  diagnosis  is  rarely  uncertain. 
The  chief  danger  of  error  is  in  overlooking  coincident  causal  trauma 
and  infection,  as  pneumonia.  In  heavy  and  constant  drinkers,  a 
delirium  may  be  delirium  tremens  or  an  "associated  delirium,"  as 
from  apical  pneumonia. 

The  outlook  is  always  uncertain.  The  early  convulsions  are  of  no 
great  moment  (Gowers).  The  prognosis  is  determined  by  the  pulse, 
the  general  nutrition  and  complicating  alcoholic  or  other  lesions. 
Rigidity  of  the  muscles  of  the  neck  is  ominous  (Putnam),  and  indicates 
oedema  of  the  brain.  The  average  mortality  is  15  to  20  per  cent.,  but 
varies  as  the  affection  is  (a)  uncomplicated  (relatively  good  prognosis), 
(b)  associated  with  other  affections  (grave  outlook)  or  (c)  occurs  in  the 
aged  or  debilitated  (probably  fatal  outlook).  Recurrence  after  recov- 
ery is  frequent,  and  27  attacks  in  one  case  have  been  recorded.  In 
fatal  cases  death  usually  results  from  exhaustion  and  heart  failure; 
the  tongue  becomes  dry,  the  delirium  constant,  and  the  skin  cold  and 
clammy.     The  autopsy  shows  oedema  of  the  brain   ("wet  brain"), 


OPIUM  POISOXIXG  1245 

degenerative  changes  in  the  brain  and  cord    (Bonhoeffer),  arterial 
alteration  (Collins),  and  hypostasis  of  the  bases  of  the  lungs. 

Treatment, — (a)  The  patient  should  be  kept  in  bed  and  watched 
constantly  lest  he  escape.  Strapping  the  ankles  and  wrists  and  confining 
him  by  a  straight  jacket  is  a  harsh  procedure,  and  invites  trauma  to  the 
hands  and  feet,  but  is  inevitable  in  cases  where  the  family  is  indulgent,  or 
when  the  nurses  are  negligent.  (6)  Withdraical  of  alcohol  is  usually 
advocated  but  is  a  severe  measure;  the  continuance  of  moderate  doses 
seems  to  hold  the  pulse  steady,  and  favors  the  digestion  and  is,  in  the 
author's  belief,  indicated,  (c)  Sleep  is  induced  with  great  difficulty 
and  as  Ware  first  pointed  out,  comes  when  the  disease  runs  its  course. 
Excessive  medication  should  be  avoided.  Sod.  bromide  (5ss),  tr. 
capsici  (tijj  v)  and  whiskey  (oii),  in  hot  peptonized  milk  should  be 
given  every  (two  or)  three  hours,  by  mouth  if  possible,  or  by  the  nasal 
catheter,  for  nutrient  enemata  are  difficult  to  give  and  are  seldom 
retained.  Chloral  is  always  dangerous  in  inveterate  alcoholism. 
Hyoscine  with  strychnine  may  be  beneficial  {v.  s.)  Morphine  should 
be  given  only  by  the  hypodermic  method,  for  its  absorption  can  then 
be  measured;  it  was  formerly  given  to  excess.  Protracted  warm 
baths  may  quiet  the  patient,  but  they  are  hard  to  administer.  In  6 
cases  in  which  the  violent  delirium  became  ominous,  the  writer  has 
etherized  the  patient,  and  in  3  instances  with  excellent  results,  though 
he  does  not  advocate  its  wide  use.  id)  The  circulation  should  be  treated 
as  in  pneumonia.  Large  doses  of  digitalis  are  not  indicated;  they  are 
tolerated  only  because  they  are  not  absorbed,  as  the  original  treatment 
by  digitalis  proves;  it  is  based  on  the  fact  that  a  nurse  by  mistake 
gave  a  toxic  dose  of  digitalis;  the  patient  improved  and  the  "digitalis 
treatment"  was  thus  instituted,  (e)  Cold  affusions  upon  the  neck  and 
xhest  are  recommended  by  Broadbent. 


(B).     OPIUM  POISONING. 
I.    Acute  Poisoning. 

This  is  important  chiefly  from  a  diagnostic  standpoint.  In  the 
second  stage  it  is  strongly  characterized  by  profound  sleep,  dry, 
flushed  skin,  narrow  pupils,  slow,  strong  "digitalis  pulse"  and  slow 
deep  stertorous  breathing.  The  third  or  terminal  stage  is  different; 
the  skin  becomes  cyanotic  and  clammy,  the  narrowed  pupils  may 
dilate,  the  pulse  become  weaker  (though  the  heart  centers  live  after 
the  other  bulbar  centres  have  died),  respiration  halts,  and  is  very  slow. 
Mistakes  in  diagnosis  are  made  by  attributing  undue  importance  to 
the  "  pin  point  "condition  of  the  pupils.  Morphine  may  be  detected  in 
the  stomach  washings  and  in  the  urine. 

Treatment. — This  consists  of  (a)  mechanical  evacuation  by  repeated 
gastric  lavage,  ih)  Chemical  antidotes,  such  as  large  amounts  of 
tannic  acid,  should  be  given  with  the  lavage,  and   removed   as  the 


1246  INTOXICATIONS.     SUNSTROKE 

tannates  formed  may  dissolve;  1  to  1,000  permanganate  of  potash 
(Moor,  of  New  York)  may  be  given  by  mouth  or  hypodermatically. 
(c)  Respiration  must  be  sustained  by  walking  the  patient  (the  ambul- 
atory treatment),  but  fatigue  must  be  guarded  against;  phrenic 
faradization  is  indicated,  but  care  is  necessary  lest  too  strong  a 
current  produce  paralysis  instead  of  stimulation;  strychnine  plus 
atropine  may  be  given  hypodermatically,  but  the  total  dose  of  atropine 
should  not  exceed  gr.  3^5  to  2^5 ;  pulling  slowly  and  rhythmically  on  the 
tongue  may  help  respiration;  Sylvester-Hall's  artificial  respiration  and 
oxygen  inhalation  may  be  used,  {d)  The  heart  should  be  stimulated 
by  coffee,  strychnine,  heat  and  digitalis. 


II.    Chronic  Morphinism  (Morphinomania). 

The  use  of  morphine  for  pleasure  only,  so  common  in  Asia,  is  rare 
with  us.  The  habit  is  contracted  by  its  use  for  insomnia  or  for 
mental  or  physical  pain.  Forty-seven  per  cent,  of  morphine  victims 
are  said  to  be  physicians;  women  and — in  Germany — officers  rank 
next.  It  may  be  taken  for  years  without  mental  or  physical  deteriora- 
tion, but  morphinists  are  usually  less  happy,  as  increase  in  the  daily 
dose  becomes  necessary  and  the  half-oxidized  alkaloid  produces  symp- 
toms {v.  i.  Treatment)  which  are  only  allayed  by  larger  doses.  Mor- 
phine acts  as  a  nerve  poison.  The  victim  becomes  restless  and  irritable 
without  his  dose.  The  mental  and  moral  attributes  are  anaesthetized 
and  there  is  a  "moral  insanity."  The  patients  lie  by  choice,  neurotic 
symptoms  are  common,  muscular  and  mental  asthenia  develop,  the 
pupils  are  contracted,  the  sweat  and  saliva  are  decreased,  the  appetite 
fails,  the  skin  becomes  sallow,  itchy  and  dry,  the  hair  coarse  and  gray,_ 
constipation  is  usual,  and  slight  ataxia  may  develop. 

Prophylaxis. — Physicians  should  not  give  opiates  too  freely.  When 
they  are  administered  for  severe  pain  the  habit  is  less  often  contracted 
than  when  given  to  neurotics.  At  least  70  per  cent,  of  cases  relapse 
after  a  cure. 

Treatment. — Treatment  is  almost  impossible  without  (a)  institu- 
tional confinement,  which  must  of  course  be  voluntary.  (6)  The 
morphine  may  be  withdrawn  abruptly,  rather  suddenly  or  very  grad- 
ually; the  second  method  is  the  best,  stopping  the  morphine  entirely 
in  four  to  seven  days.  Its  withdrawal  is  attended  by  awakening 
of  dormant  anaesthetized  functions;  there  is  at  first  paroxysmal 
yawning  and  sneezing;  roughening  of  the  voice,  paraesthesia,  neural- 
gias especially  in  the  legs,  clammy  skin  or  rapid  pulse,  wide  pupils, 
tremor,  sexual  excitement,  extreme  irritability,  vomiting,  colic  and 
diarrhoea  also  occur.  The  symptoms  were  attributed  by  Marme  to 
di-oxymorphine  poisoning,  the  antidote  to  which  is  morphine;  Hitzig 
believes  that  they  are  largely  due  to  hyperchlorhydria,  for  the  gastric 
nerves  under  the  influence  of  morphine  secrete  little  hydrochloric 
acid ;  relief  is  obtained  by  washing  out  the  stomach  with  a  solution  of 


LEAD  POISOXIXG  1247 

Carlsbad  salts.  The  patient  will  obtain  morphine  if  possible,  (c) 
The  patient  should  be  kept  in  bed  for  a  week  to  obviate  vasoparetic 
cardiac  collapse,  (d)  Symptomatic  treatment  is  indicated  (i)  by  the 
collapse  (aromatic  spts.  of  ammonia,  rri^  xx,  strychnia  gr.  a'o,  heat); 
(ii)  by  nervousness  (warm  baths,  sodium  bromide  in  doses  of  one 
dram  every  four  hours);  (iii)  by  the  insomnia  (hyoscine  gr.  ,20  every 
two  hours  for  two  to  six  doses,  sulphonal  or  trional,  gr.  xx);  (iv)  of 
the  gastralgia  (gastric  lavage  wdth  alkaline  salts);  (v)  hj diarrhoea  and 
colic  (as  in  enteritis,  but  vegetable  astringents,  large  doses  of  bismuth, 
and  no  opiates  should  be  used);  (vi)  by  neuralgia  (acetanilide,  gr.  v, 
fluidextr.  gelsemii.,  njjiii).  Whatever  treatment  is  instituted,  alcohol- 
ism, chloralism,  bromism  or  cocainism  should  not  be  substituted. 


(C).  LEAD   POISONING. 

Etiology. — Plumbism  or  saturnism  is  very  common,  and  its  im- 
portance is  daily  increasing,  (a)  Industrial  plumbism  is  very  common. 
Workers  in  white  or  red  lead  factories  usually  acquire  the  disease. 
^Miners  of  the  metal  generally  escape,  but  smelters  of  lead  ore,  and 
even  animals  and  birds  near  the  furnaces,  are  frequently  affected. 
Painters,  plumbers,  glaziers,  less  often  tinners,  printers,  cameo  polish- 
ers, cartridge  makers,  etc.,  may  be  affected.  (6)  Accidental  con- 
tamination of  food  or  drink  may  occur.  Poisoning  may  result  from  the 
action  of  acids  in  canned  foods  on  the  tin  or  solder,  as  in  cans  of 
sardines;  wane  or  cider  may  become  poisonous  in  the  same  way,  as 
happened  in  Devonshire,  and  in  Poitou  (colica  pictonum).  Chromate 
foil,  covering  hams  or  candy,  rubber  nipples,  bullets  in  pickled  game, 
bread  ground  in  lead  vessels,  chromate  used  to  color  buns  (D.  D. 
Stewart's  report  of  the  fatal  Philadelphia  epidemic).  Seltzer  or  other 
charged  waters,  wine,  and  eau  de  vie  sweetened  or  cleared  with  litharge, 
are  a  few  of  the  many  subtle  causes  of  saturnism.  Drinking  water 
conveyed  through  lead  pipes  is  generally  protected  by  the  deposit  of 
lime  and  other  salts,  but  poisoning  is  possible  when  the  water  is  ex- 
ceptionally pure  or  soft,  thereby  depositing  little  lime  in  the  pipes, 
or  when  it  is  saturated  with  organic  matter  or  collected  from  lead 
roofs,  (c)  IjCss  frequent  sources  of  plumbism  are  in  the  enviro7iment, 
and  in  such  things  as  hair-dyes,  powders  or  cosmetics,  linen,  freshly 
painted  walls,  candles,  sealing  wax,  brightly  tinted  toys,  false  teeth, 
and  thread,  (d)  Therapeutic  and  criminal  plumbism  is  rare;  it  may 
result  from  the  acetate  of  lead  when  given  internally  or  externally, 
and  from  impure  subnitrate  of  bismuth;  its  criminal  use  is  very  un- 
common, (e)  Predisposing  factors  are  alcoholism,  age  (it  occurs  most 
often  in  persons  from  thirty  to  forty)  and  sex  (75  per  cent,  of  cases  are 
females,  Oliver).  Susceptibility  varies  greatly;  plumbism' may  cause 
death  within  a  week,  or  may  not  develop  until  after  forty-two  years  of 
work  in  the  metal  (Tanquerel  des  Planches).  Absorption  of  lead 
usually  occurs  (i)  by  the  digestive  mucosa;   most  of  the  metal  is  pre- 


1248  INTOXICATIONS.      SUNSTROKE 

cipitated  by  the  albumin  of  the  food  and  ehminated  without  absorption ; 
(ii)  by  the  respiratory  mucosa,  by  inspiration  as  dust  in  white  lead 
factories;  or  (iii)  by  the  sound  or  diseased  skin  (cosmetics)  or  even 
the  conjunctiva  or  vagina  (lead  douches).  It  is  eliminated  chiefly  by 
the  urine;  Putnam  stated  that  he  found  lead  in  25  per  cent,  of  150 
persons  who  had  no  evidence  of  plumbism;  the  liver  and  alimentary 
mucosa  eliminate  smaller  quantities. 


I.    Acute  Poisoning. 

This  is  uncommon,  though  it  may  occur  from  therapeutic,  criminal 
or  professional  causes.  Its  symptoms  are  (a)  gastro-intestinal;  a 
styptic  burning  taste  occurs  in  the  mouth,  thirst  is  present,  there  is  a 
lead  line  on  the  gums  in  some  cases,  though  less  than  in  chronic  poison- 
ing, nausea  and  vomiting  sometimes  of  white  lead  chloride,  abdominal 
colic,  retraction  of  the  abdomen,  diarrhoea  with  black  (lead  sulphide) 
or  bloody  movements,  or  sometimes  constipation.  On  postmortem 
examination,  the  catarrhal  gastro-enteritis  may  be  wrongly  considered 
a  postmortem  change;  white  spots  may  be  seen  (Orfila's  spots). 
The  symptoms  may  be  (b)  circulatory;  the  pulse  may  be  slow  (40 
to  50)  and  irregular;  anaemia,  cyanosis  and  collapse  may  occur;  (c) 
they  may  be  nervous;  vertigo,  stupor,  delirium,  neuralgia,  cramps, 
convulsions,  and  even  cerebral  and  peripheral  paralysis  may  develop; 
{d)  nephritis  with  suppression  of  urine  may  develop. 

Treatment  consists  of  full  doses  of  sodium  and  magnesium  sul- 
phate, in  order  to  precipitate  an  insoluble  lead  sulphate,  and  to  remove 
it,  demulcent  drinks  (eggs  and  mucilages),  opium  for  pain,  and 
cardiants. 

II.  Chronic  Poisoning. 

Symptoms. — (a)  CoZic  is  the  most  common  symptom;  it  occurred  in 
88  per  cent,  of  Tanquerel's  1,390  cases.  It  is  due  to  local  deposit  of 
lead  in  the  intestines  (muscles  or  mucosa),  spasm  of  the  bowel,  changes 
in  the  nerves  or  angiospasm.  It  may  develop  early  or  late;  it  may  be 
preceded  by  malaise,  lumbago  or  pain  in  the  legs,  or  may  be  brought 
on  by  alcoholic  excesses.  It  is  a  colic  accompanied  by  constipation 
(dry  colic),  rarely  by  diarrhoea;  it  is  umbilical,  whence  it  spreads 
over  the  abdomen,  perhaps  to  the  legs  or  scrotum;  it  is  relieved  by 
pressure,  though  sometimes  the  abdominal  wall  is  hypersesthetic ; 
sometimes  vomiting  and  absolute  constipation  may  simulate  obstruc- 
tion, and  in  one  case  the  author  observed  intussusception  as  a  result  of 
lead  poisoning.  There  is  no  fever,  the  pulse  is  small  and  hard  (Riegel) 
and  the  urine  is  scanty.  Without  treatment  colic  is  protracted;  its 
relief  is  usually  marked  by  a  bowel  movement.  Relapses  are  very 
frequent,  (b)  The  gingival  lead  line,  which  is  present  in  over  90  per 
cent.,  is  a  gray-black  line,  2  to  3  mm.  wide,  which  is  seen  most  clearly 


CHROXIC   LEAD    POISOXIXG  1249 

on  the  lower  gums  ancl  is  due  to  deposition  from  the  blood  of  lead 
sulphide,  precipitated  by  the  sulphurettetl  hydrogen  of  the  tartar. 
The  coincident  anaemia  brings  it  out  very  clearly.  Similar  deposits 
may  occur  under  the  buccal  mucosa  opposite  the  molars.  It  is  very 
frequently  mistaken  for  tartar,  which  occurs  on  the  teeth,  sometimes 
for  the  black  carbon  line  seen  in  miners,  or  rarely  for  the  silver  line  in 
argyria.  (c)  Other  digestive  symptoms  are  coated  tongue,  foetid 
breath,  parotitis,  saturnine  dyspepsia  and  rarely  icterus.  Test  meals 
show  lactic  acid  and  no  HCl  (Sailer  and  Speese).  id)  Ancemia  is 
very  frequent  in  the  "lead  cachexia."  The  haemoglobin  and  erythro- 
cytes decrease  moderately;  the  red  cells  show  basophihc  granules 
(Grawitz)  and  quite  commonly  nucleation,  even  in  mild  cases  (Cad- 
walader,  1905).  The  leukocytes  may  be  increased,  ie)  The  heart 
and  vessels  are  affected.  The  heart  is  very  often  hypertrophied,  as 
is  evidenced  by  a  loud  second  aortic  tone  and  aortic  regurgitation  of 
atheromatous  origin;  the  arteries  are  often  sclerosed,  occasionally 
causing  angina  pectoris,  frequently  myocarditis,  irregular  heart  action 
and  perhaps  some  of  the  brain  symptoms  (y.  i.).  The  asthma  saturni- 
num  is  probably  cardiac  or  ursemic.  (/)  The  kidneys  are  often  sclero- 
tic, as  a  result  of  the  ehmination  of  the  metal.  It  is  said  that  the  change 
does  not  begin  around  the  vessels  but  in  the  tubules,  which  are  the 
seat  of  a  necrosing  deposit  of  carbonate  of  lime.  Nephritis,  gout  and 
plumbism  may  co-exist  {v.s.).  (g)  Nervous  manifestations  may 
develop.  Peripheral  degenerative  neuritis  occurs  in  7  per  cent., 
usually  as  a  later  symptom.  About  one-tenth  of  these  cases  have  not 
had  colic.  It  is  characterized  by  the  paralysis  of  muscles  with  the  same 
function,  by  muscular  atrophy  and  cramps,  tremor,  cutaneous  hyper- 
iiesthesia,  neuralgia,  arthralgia  (55  per  cent.),  myalgia  and  by  varying 
degrees  of  reaction  of  degeneration  (v.  Multiple  Neuritis).  The 
musculospiral  type,  "wrist  drop,"  is  the  most  common  and  is  bilateral; 
the  supinator  longus  (a  flexor)  and  the  small  extensor  of  the  thumb 
escape  involvement;  tenderness  and  anaesthesia  are  rare.  Gubler's 
tumors  are  swellings  of  the  extensor  tendon  sheaths  and  are  due  to 
backward  dislocation  of  the  carpus  or  perhaps  to  a  trophic  change; 
they  are  hard,  ovoid,  indolent,  seldom  painful  or  larger  than  a  pigeon's 
egg,  and  regress  with  the  paralysis.  A  second  but  rare  form  is  the 
brachial,  involving  the  deltoid,  biceps,  brachialis  anticus,  and  supinator 
longus,  rarely  the  pectorales.  A  third  rare  type  is  the  Aran-Duchenne, 
which  is  especially  observed  in  tailors  (Mobius),  and  involves  the 
small  muscles  of  the  hand,  the  thenar  and  hypothenar  eminences;  it 
resembles  that  of  chronic  anterior  poliomyelitis  (which  indeed  has 
been  found  in. a  few  cases  at  autopsy).  A  fourth  type,  the  peroneal, 
involves  the  peronei  and  toe  extensors;  according  to  Tanquerel,  but 
13  per  cent,  of  lead  palsies  affect  the  leg.  Lastly,  rarer  types  may 
involve  the  larynx,  vagus,  and  face;  generalized  paralyses,  either  slow 
or  rapid  like  Landry's  paralysis,  are  very  rare;  primary  muscular 
atrophy  may  occur,  is  most  often  of  the  Aran-Duchenne  type,  and 
shows  fatty  and  fibroid  muscular  changes. 

79 


1250  INTOXICATIONS.      SUNSTROKE 

Cerebral  forms  (eiicephalopathia  saturnina)  occur  in  5  per  cent., 
they  are  often  preceded  by  headache,  cohc,  and  insomnia,  and  are 
attended  by  amaurosis,  limitation  of  the  visual  field,  or  other  dis- 
turbance of  the  special  senses,  retinitis  albuminurica  or  saturnina 
(with  inflammation,  engorgement  and  possibly  ultimate  atrophy), 
and  paralysis  of  the  eye  muscles.  The  most  frequent  type  is  the 
delirious  encephalopathy,  which  is  variable  or  mobile  in  character, 
and  sometimes  resembles  delirium  tremens ;  the  next  type  is  the  con- 
vulsive (epilepsia  saturnina)  which  occurs  without  aurse,  is  usually 
generalized,  often  fatal,  and  is  always  to  be  considered  when  epilepsy 
develops  in  an  adult;  the  third  type  is  the  comatose.  Hysteria  fre- 
quently occurs  with  plumbic  encephalopathy.  Neglected  or  un- 
recognized cases  may  become  dements  (pseudodementia  paralytica 
saturnina).  Deposit  of  lead  in  the  protoplasm  of  the  brain  is  the  usual 
cause;  sometimes  the  cerebral  symptoms  are  arteriosclerotic  (as 
hemiplegia)  or  ursemic. 

Lead-poisoning  is  usually  recognized  (a)  by  the  etiology,  (b)  by  the 
lead  line,  (c)  by  lead  in  the  urine,  (d)  by  colic  and  (e)  by  wrist-drop. 
In  a  case  of  long  coma  with  choked  disk,  in  the  Cook  County  Hospital, 
no  cause  was  found,  until  after  a  second  examination,  the  lead  line  was 
seen.  The  man  was  a  barber,  who  regularly  dyed  the  hair  of  a  number 
of  people,  and  probably  absorbed  the  lead  through  his  hands. 

Prognosis. — The  acute  forms  are  more  favorable.  Vascular  and 
renal  changes  are  largely  incurable.  Atrophic  paralyses  are  serious. 
The  wrist-drop  usually  regresses,  though  it  is  sometimes  permanent. 
Coma,  convulsions  and  other  cerebral  symptoms  are  serious;  about 
25  per  cent,  of  cases  die,  and  after  apparent  recovery,  mental  degen- 
eration may  develop. 

Treatment. — (a)  Prophylaxis  should  be  observed.  A  mask  should 
be  worn  in  white-lead  factories  to  avoid  inhalation  of  lead  dust ;  workers 
are  careless  and  poisoning  is  frequent  despite  precautions.  Painters 
and  others  may  often  avoid  poisoning  by  carefully  cleaning  the  hands 
and  nails  before  eating,  (b)  Lead  colic  is  treated  by  hypodermic 
injections  of  morphine  and  atropine  to  control  pain  and  spasm.  Riegel 
uses  nitroglycerine  for  the  supposedly  causal  spasm  of  the  vessels. 
Spts.  of  chloroform  (tij  xx)  with  other  aromatics  may  be  given  by 
mouth,  (c)  The  constipatio7i,  and  removal  of  any  lead  salts,  unab- 
sorbed  in  or  excreted  by  the  alimentary  mucosa,  necessitate  catharsis. 
Full  doses  of  castor  oil  (oiv  or  more)  with  paregoric  (5i)  evacuate 
the  bowels,  and  relieve  pain  and  spasm;  sodium  and  magnesium 
sulphates  purge  and  coincidently  precipitate  the  lead  as  an  insoluble 
sulphate,  (d)  In  order  to  eliminate  the  lead  from  the  tissues,  with 
the  protoplasm  of  which  it  has  united,  potassium  iodide,  which  breaks 
up  this  union  and  eliminates  the  metal,  should  be  given.  In  acute  or 
severe  chronic  cases  it  should  be  given  with  care,  for  it  transforms  the 
fixed  tissue  metal  into  free  metal  in  the  circulation.  Nevertheless, 
small  doses  of  potassium  iodide  (grs.  iii  to  v  )  should  be  given,  and  some 
writers  obtain  even  better  effects  from  potassium  bromide  (grs.  v  to  x). 


FOOD  POISONING  1251 

Warm  baths  and  pilocarpine  (gr.  -g)  promote  excretion  by  diaphoresis, 
and  plenty  of  water  stimulates  the  renal  elimination,  (e)  Iron  (not 
arsenic)  should  be  given  for  anfemia.  (/)  For  treatment  of  neuritis, 
see  Multiple  Neuritis. 


(D).   ARSENICAL  POISONING. 

iVcute  poisoning  has  been  considered  under  pernicious  anaemia. 

Chronic  Poisoning. — (a)  Criminal  poisoning  is  of  great  medico- 
legal importance,  as  in  the  unfortunate  Maybrick  case,  (b)  Poisoning 
by  reason  of  occupation  is  uncommon,  (c)  Therapeutic  poisoning 
is  not  common,  but  may  occur  in  chorea,  leukaemia,  and  pernicious 
anaemia,  (d)  Most  cases  are  accidental.  The  dyes  in  garments,  toys, 
glazed  paper  used  in  kindergartens,  wrappers,  artificial  flowers,  and 
wall  paper  are  important  sources  of  intoxications.  The  action  of 
moulds  (pencillium  and  mucor)  may  liberate  volatile  arsenical  gases. 
Contaminated  glucose  used  in  beer  caused  the  Manchester  epidemic. 
Arsenic  is  absorbed  by  the  lungs  and  alimentary  tract,  and  is  chiefly 
eliminated  by  the  kidneys,  which  may  degenerate.  Putnam  found 
arsenic,  in  the  urine  of  30  per  cent,  of  persons  who  showed  no  other 
symptoms  of  arsenical  poisoning  but  in  this  connection  it  may  be 
remarked  that  arsenic  is  widely  found  in  plants,  sea  water  and  springs. 
Smaller  amounts  are  eliminated  by  the  bowel,  milk,  and  other  secre- 
tions. 

The  symptoms  are  (a)  g astro-intestinal,  as  dry  throat,  vomiting, 
purging,  or  colic;  the  stools  may  be  like  "rice  water"  and  contain 
flecks  of  mucus;  and  (6)  respiratory,  as  dry  cough  or  chronic  bronchi- 
tis, (c)  Emaciation,  weakness,  fever  and  anaemia  may  occur,  id) 
Cutaneous  symptoms,  as  erythema,  keratosis,  pemphigus,  herpes  and 
brown  pigmentation  and  (e)  nervous  manifestations,  as  weak  memory, 
vertigo,  headache  and  multiple  neuritis  may  develop.  The  neuritis 
has  the  same  general  features  as  the  saturnine  form,  save  that  sensory 
changes  are  more  frequent,  and  the  legs  are  more  often  affected  than 
the  arms;  paralysis  of  the  peronei  and  foot  extensors  causes  the 
"steppage"  gait.  The  small  muscles  are  less  often  affected  than  in 
plumbic  or  alcoholic  neuritis;  paralysis,  ataxia,  sensory  and  trophic 
disturbances  and  the  reaction  of  degeneration  occur  as  in  other  neuri- 
tides.     Treatment  is  that  of  lead  poisoning  or  neuritis. 


(E).  FOOD  POISONING. 

Bromatotoxismus  (Vaughan)  exists  in  several  forms: 

I.  Meat   Poisoning    (Kreatoxismus). — Sausages  and  head  cheese 

are  more  dangerous  than  beef  or  mutton.    Sausage  poisoning  (botulism 

or  allantiasis)  was  known  in  Germany  a  century  ago.    Van  Ermingen 

has  isolated  an  anaerobic  organism,  the  Bacillus  hotulinus;  it  contains 


1252  INTOXICATIONS.      SUNSTROKE 

sporeSj  is  flagellated  and  mobile  and  grows  only  on  alkaline  media  at 
a  low  temperature  (18  to  25°  C) ;  it  is  a  saprophyte  and  causes  symptoms 
by  its  toxins  only,  which  are  not  destroyed  by  the  gastric  juice.  Meat 
may  seem  to  be  normal  to  the  taste  and  smell  and  yet  contain  pto- 
maines; their  nature  is  still  undetermined  though  Cobert  considers 
them  pfomatropin.  Canned  meat  has  often  caused  severe  symptoms. 
In  one  instance  botulism  was  caused  by  eating  salad  (Collatz).  The 
symptoms  of  botulism  appear  in  twelve  to  forty-eight  hours,  with  nausea, 
vomiting  and  sometimes  diarrhoea.  Paralysis  of  the  soft  palate,  larynx 
and  oesophagus  rapidly  develop,  and  somewhat  later  paralysis  of  the 
bowel,  mydriasis,  ptosis,  disordered  vision,  adynamia  and  weak  heart 
action;  the  sensorium  is  clear  and  fever  is  unusual.  The  mortality 
ranges  between  20  and  50  per  cent. ;  death  occurs  in  four  to  ten  days 
and  the  autopsy  shows  parenchymatous  degenerations  and  ecchymoses 
but  especially  degeneration  of  the  ganglionic  cells,  as  those  of  the 
vagus  or  oculomotorius;  if  the  patient  survives,  convalescence  is 
established  only  after  months.  In  the  Wellback  cases,  Ballard  noted 
as  early  symptoms,  headache,  chilliness  or  rigors  and  pains  in  the  chest 
or  back. 

The  symptoms  of  other  forms  of  meat  poisoning  are  either  those  of 
toxoemia  (the  typhoid  type)  or  g astro-intestinal  inflammation  (cholera 
type);  the  typhoidal  symptoms,  which  appear  after  an  incubation  of 
four  to  six  days,  are  fever,  status  typhosus,  and  even  roseolse;  the 
choleriform  symptoms,  which  develop  in  two  to  twelve  hours,  are 
vomiting,  incessant  purging,  watery  stools,  clammy  skin,  collapse  and 
cyanosis.     Mild    or    rudimentary    forms    occur    in    most    epidemics. 

Treatment  is  unsatisfactory.  Early  gastric  lavage  and  purgation  are 
indicated;  calomel  followed  by  castor  oil  is  the  best  aperient.  Other- 
wise symptomatic  medication  as  in  cholera  or  typhoid  is  indicated; 
champagne,  strychnia,  hypodermatoclysis,  and  opium  may  be  given. 
The  resemblance  of  botulism  to  the  diphtheria  toxins  has  suggested 
the  use  of  antitoxine;  its  efi^ects  in  animals  have  been  remarkable,  but 
to  the  author's  knowledge  it  has  not  been  used  in  man. 

II.  Poisoning  by  Milk  (Galactotoxismus)  and  Cheese  (Tyrotoxismus) 
— The  former  produces  symptoms  analogous  to  those  of  the  infantile 
affections  of  the  bowel,  as  vomiting,  bloody  diarrhoea,  fever,  and 
collapse.  In  cheese  poisoning  Victor  C.  Vaughan  has  found  tyrotoxi- 
con  and  other  more  frequent  toxins,  which  are  probably  albumoses. 
Similar  ptomaines  were  found  by  him,  by  Novy  and  by  Perkins  in 
re-frozen  ice-cream,  and  custard.  In  Norway  where  tyrotoxismus  is 
most  prevalent,  the  colon  bacillus  has  been  repeatedly  found.  Home- 
made cheese  is  more  dangerous  than  the  factory  product.  Various 
forms  of  toxaemia  result;  some  are  cholera -like,  and  others  resemble 
belladonna  poisoning.     Treatment  is  that  of  kreastoxismus. 

III.  Poisoning  by  Fish  (Ichthyotoxismus)  and  Shell  Fish  (Mytilo- 
toxismus). — (a)  Ichthyotoxismus,  described  by  Comby  (1827),  may 
be  caused  by  poisonous  fish  or  poisonous  glands  in  certain  fish,  as  the 
roe  or  testicles,  the  muscular  parts  being  harmless;    the  barben  in 


FOOD  POISONING  1253 

Europe,  and  the  tetrodon  in  Asia  are  poisonous  (i'.  Beri  Beri).  The 
poisoning  due  to  putrefaction  is  more  common.  Paralytic  symptoms 
are  most  freqyent.  ib)  Mussel  poisoning  (mytilotoxismus)  may  cause 
dyspeptic  symptoms  in  mild  infections  and  cholera-like  symptoms  or 
symptoms  of  belladonna  poisoning  in  severe  forms.  Rashes  are  com- 
mon. Brieger  isolated  a  mytilotoxin,  which  is  found  largely  in  the  liver. 
The  danger  lies  in  placing  mussel-  or  oyster-beds  near  river  mouths, 
so  that  they  feed  on  poisonous  excreta.  In  restaurants,  certain  glands 
near  the  heads  of  lobsters,  which  are  considered  toxic,  are  carefully 
excised. 

IV.  Grain  poisoning  (Sitotoxismus). 

1.  Ergotism,  which  was  described  by  Thuillier  (1S30)  and  carefully 
studied  by  Tiiczek  (1879),  results  from  eating  grain  mixed  with  the 
ergot  fungus  (claviceps  purpurea).  Ergotized  grain  is  found  largely 
in  bad  harvests,  resulting  from  wet  springs  and  hot  summers.  Epi- 
demics have  occurred  in  Europe,  and  sporadic  cases  are  not  rare. 
Acute  ergotism,  with  digestive  symptoms,  colic,  cyanosis,  weak  heart 
and  generally  lethal  outcome  is  less  common  than  chronic  ergotism,  of 
which  two  forms  exist;  the  first  is  the  convulsive  form,  attended  by 
paresthesia,  lightning  pains,  headache,  delirium,  melancholy,  demen- 
tia, muscular  relaxation  and  muscular  spasms,  either  as  generalized 
epileptiform  attacks,  or  as  local  contractures  (flexion  of  the  arms  and 
extension  of  the  toes  and  feet);  it  is  said  to  result  from  the  alkaloid 
cornutin.  The  second  form  is  the  gangrenous,  due  to  sphacelinic  acid 
and  marked  by  localized  gangrene,  usually  in  the  phalanges,  and 
less  often  in  the  tips  of  the  ears  and  nose.  Chronic  ergotism  is  char- 
acterized by  a  number  of  syiivptoms  which  suggest  tabes,  as  lightning 
pains,  ataxia  of  station  and  movement,  and  lost  knee  jerks;  and  in 
five  autopsies  Tiiczek  and  Siemens  found  degeneration  with,  later, 
sclerosis  of  the  posterior  columns ;  degeneration  in  the  anterior  cornua, 
and  minute  foci  of  softening  or  hemorrhage  also  occur.  The  clinical 
course  is  chronic,  and  death  is  frequent  from  convulsions  or  cachexia. 

Treatment  includes  avoidance  of  diseased  grain,  and  symptomatic 
therapy;  opium  should  be  given  for  convulsions,  and  nitroglycerine 
for  gangrene. 

2.  Pellagra  or  maidism  is  a  chronic  nutritional  and  toxic  affection, 
due  to  the  use  of  maize  which  has  been  improperly  stored,  or  is  decayed, 
unripe,  or  infected  with  the  aspergillus.  An  alkaloid  (pellagazein) 
is  thought  to  develop.  Pellagra  is  endemic,  chiefly  in  Italy,  France, 
Spain,  Hungary  and  Mexico.  It  occurs  among  poor  farmers.  There 
are  three  stages;  the  f.rst  consists  of  the  vernal  erythema,  which  is 
followed  by  exfoliation  and  sometimes  by  suppuration ;  dyspepsia  and 
diarrhoea  may  develop;  mild  cases  may  recover,  or  may  pass  into  the 
second  stage,  in  which  headache,  pain  in  the  back  and  muscular  spasms 
occur,  but  the  most  characteristic  symptom  is  the  ataxic  paraplegia; 
autopsies  reveal  a  posterolateral  sclerosis,  sometimes  with  atrophy 
of  the  anterior  horns,  leptomeningitis,  and  variable  brain  findings. 
The  third  stage  occurs  after  repeated  attacks  and  is  usually  incurable; 


1254  INTOXICATIONS.     SUNSTROKE 

cachexia,  epilepsy  and  dementia  develop;  it  is  said  that  10  to  35  per 
cent,  of  Italian  insanity  is  due  to  pellagra. 

In  rarer  acute  cases,  it  may  resemble  typhoid  in  symptoms  and 
pathology  (status  typhosus  and  swelling  with  ulceration  of  the  intestinal 
lymph  structures),  or  meningitis  (foci  of  acute  meningomyelitis).  Other 
findings  at  autopsy  are  atrophy  of  the  digestive  mucosa,  parenchy- 
matous degeneration  and  pigmentation,  the  latter  of  which  is  thought 
to  occur  from  adrenal  inflammation.  Treatment  is  prophylactic 
(proper  storage  of  the  grain);  change  of  diet  or  of  locality  is  indicated, 
and  arsenic  should  be  given  internally. 

3.  Lathyrism  (lupinosis)  is  produced  by  meal  made  from  vetches, 
chiefly  the  lathyris  sativus  and  cicera.  Ir\dng  described  the  disease  in 
India,  and  it  has  been  also  seen  in  Algiers  and  Italy.  Like  pellagra,  it 
probably  produces  a  lateral  and  possibly  some  posterior  sclerosis  of 
the  cord,  though  no  autopsies  are  reported.  Clinically  there  is  a 
spastic  paraplegia  with  increase  of  reflexes  and  some  paraesthesia, 
but  without  atrophy. 

V.  Potato  Poisoning. — Solanin  is  contained  in  potatoes  in  small 
amounts  (0.06  per  cent.)  but  larger  amounts  (0.4  per  cent.)  occur  in 
potatoes  which  lie  for  some  time  on  the  ground,  or  sprout  in  cellars. 
Fever,  chills,  general  and  cardiac  weakness,  alimentary  irritation  and 
jaundice  may  develop. 

(F).   SUNSTROKE. 

Two  forms  are  recognized,  (1)  sunstroke,  and  (2)  heat  exhaustion; 
the  difference  between  them  was  first  recognized  by  Dowler  of  Xew 
Orleans. 

Sunstroke,  also  known  as  siriasis,  insolation,  coup  de  soliel  and 
thermic  fever,  is  due  to  exposure  to  the  sun.  A  very  frequent  factor 
is  alcoholism.  There  is  thought  to  be  a  paralysis  of  the  bulbar  heat 
centres,  leading  to  excessive  production  of  heat  and  deficient  elimina- 
tion of  it.     The  theory  of  infection  has  also  been  advanced. 

Symptoms  may  develop  very  abruptly,  and  cause  early,  or  even 
immediate  death  from  asphyxia  and  paralysis  of  the  heart;  this  type 
was  long  confused  with  apoplexy.  In  most  cases  there  is  an  interval 
lasting  from  a  few  minutes  to  an  hour,  in  which  there  are  headache, 
vertigo,  visual  disturbances  or  nausea,  and  perhaps  vomiting. 

During  the  coma  which  develops  rapidly,  and  in  which  the  physician 
usually  sees  the  patient,  the  following  signs  are  observed:  the  face  is 
first  flushed,  later  rather  cyanotic,  and  sometimes  stained  with  petechise. 
The  preliminary  pupillary  dilatation  passes  into  myosis,  and  the  skin 
has  a  peculiar  odor.  The  pulse  is  rapid,  usually  over  100,  and  is 
bounding.  The  rectal  temperature  ranges  from  107  to  112°  and 
respiration  is  deep,  labored  and  stertorous.  Save  for  the  laboring 
chest,  the  patient  is  usually  quiet;  in  about  25  per  cent,  of  the  author's 
cases,  they  struggled  during  treatment  by  the  cold  bath,  and  in  about 
20  per  cent,  of  the  severe  cases  there  were  epileptiform  convulsions. 


SUXSTROKE  1255 

Lewis  and  Packard  (1901)  in  92  cases  found  convulsions  and  uncon- 
sciousness in  all  severe  cases;  immobile  pupils  and  absent  knee  jerks 
were  common.  Involuntary  evacuations  are  usual,  and  the  thin 
faeces  have  a  peculiar  odor.  There  is  a  leukocytosis  in  about  75  per 
cent,  of  the  cases.  Recovery  is  quite  frequent;  consciousness  returns 
and  the  fever  falls.  Despite  treatment,  the  Cheyne-Stokes  breathing 
may  develop,  the  pulse  may  grow  smaller  and  more  rapid,  and  death 
may  follow,  usually  in  a  little  more  than  a  day.  The  autopsy  shows 
early  rigor  mortis,  fluidity  of  the  blood,  great  venous  hypertemia, 
particularly  in  the  brain  and  lungs,  and  dilatation  of  the  right  and 
contraction  of  the  left  ventricle. 

After  sunstroke,  the  patient  becomes  extremely  susceptible  to  hot 
weather.  Epilepsy,  multiple  neuritis  and  mental  symptoms  are  among 
its  after-effects.  The  author  saw  one  case  with  a  temperature  of  109*^ 
in  which  the  fever  fell  with  hydrotherapy  but  rose  to  104°;  in  a  few 
days,  the  complication  was  recognized  to  be  typhoid. 

The  diagnosis  is  easily  made.  Practically,  there  is  but  one  possible 
cause  of  confusion,  w^hich  is  pontine  hemorrhage,  but  the  latter  never 
develops  nearly  as  high  a  temperature,  and  death  is  almost  instantan- 
eous; should  the  patient  survive  for  some  time,  the  paralysis,  which 
is  usually  of  the  crossed  type,  is  obvious. 

Heat  exhaustion  may  result  from  exposure  to  the  sun  or  to  high 
temperature  with  humidity;  the  cases  which  the  author  has  seen  came 
largely  from  laundries,  basement  stores,  or  engine  rooms;  heat  exhaus- 
tion occurs  also  among  stokers  on  steamers.  The  symptoms  are  those 
of  a  centric  vasomotor  paralysis.  The  skin  is  cool  and  livid,  rather 
than  red,  and  the  rectal  temperature  is  often  3  or  4°  subnormal;  the 
pulse  is  rapid  and  weak  and  the  breathing  is  rapid  but  not  labored. 
In  short,  the  symptoms  of  collapse  are  present.  Restlessness,  anxiety 
and  sometimes  delirium  are  noted,  though  the  sensorium  is  practically 
normal  in  most  cases. 

Treatment. — In  sunstroke  the  chief  indication  is  reduction  of  the 
retained  heat.  It  should  be  relieved  by  immersing  the  patient  in  a 
bath  which  is  gradually  cooled  by  large  pieces  of  ice.  Shock  is  averted 
by  this  means;  cerebral  congestion  is  lessened  by  placing  a  block  of 
ice  under  the  neck,  an  ice-bag  on  the  vertex,  and  an  ice-bladder  over 
the  anterior  neck;  active  friction  of  the  body  and  limbs  with  the  open 
hands  brings  to  the  surface  the  blood,  which  is  cooled  by  the  bath  and 
the  rubbing  with  pieces  of  ice.  With  this  treatment,  few  more  than 
one-third  of  the  cases  should  die.  The  patient  should  be  taken  from 
the  bath  when  his  rectal  temperature  is  102°,  for  the  fall  usually  continues 
after  cessation  of  treatment.  Laxatives  are  generally  unnecessary^ 
for  the  bowels  move  freely.  Heart  stimulants  should  be  given  pro 
re  nata.  For  convulsions,  a  little  chloroform  by  inhalation,  and  a 
hypodermic  of  morphine  are  indicated.  Asphyxia  and  distention  of 
the  right  heart  are  relieved  by  phlebotomy. 

In  heat  prostration,  the  treatment  is  diametrically  the  opposite; 
a  warm  bath  or  hot  bricks  for  subnormal  registration,  diffusive  car- 


1256  INTOXICATIONS.      SUNSTROKE 

diants  as  ammonia,  camphor  and  strychnine,  sahne  solutions  under  the 
skin,  and  apphcations  of  mustard  are  indicated;  cold  and  venesection 
are  obviously  contra-indicated. 


SECTION  XI. 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


(A).  DISEASES  CAUSED  BY  CESTODES. 

Tapeworms  were  known  to  the  Egyptians,  to  the  Hindus  and  proba- 
bly to  the  Jews.  They  may  cause  symptoms  by  the  presence  of  the 
mature  parasite  in  the  bowels  or  of  the  larval  form  in  the  viscera. 


Taenia  Solium. 

I.  The  Taenia  solium  or  pork  tapeworm  exists  as  the  cysticercus 
cellulosse  in  hogs,  and  rarely  in  dogs,  rats,  or  deer,  as  "measles" 
(measle  or  bladder  worms).  Cysticerci  (the  larvae)  are  found  in  the 
intermuscular  tissue,  particularly  of  the  under  surface  of  the  tongue, 
in  the  masseters,  shoulders,  neck  and  diaphragm.  They  are  easily 
seen  with  the  naked  eye  and  very  easily  with  a  low-power  lens,  as 
small  opaque  white  bodies.  They  are  much  more  frequent  in  Asiatic 
and  German  than  in  American  pork.  Man  is  infected  by  eating  raw 
or  partly  cooked  pork;  the  cysticerci  develop  in  the  upper  ileum  into 
the  taenia  ("band  or  ribbon-like")  solium  (referring  to  its  usual  soli- 
tary appearance,  though  2  to  3,  and  even  20  to  41,  have  been  found). 
Its  head  (scolex)  is  round,  often  gray  or  black  in  its  upper  part,  is 
smaller  than  a  pin  head,  and  is  attached  to  the  upper  ileum;  it  has 
4  sucking  disks  and  20  to  30  booklets,  arranged  in  an  anterior  more 
numerous  row,  and  a  posterior  row,  whence  the  name  "armed"  tape- 
worm; it  has  no  real  mouth.  See  figs.  81,  82,  83,  84.  Its  neck  is  thin 
and  not  jointed,  to  which  the  segments  {"proglottides")  are  attached. 
These  number  800  or  more;  the  segments  measure  1  cm.  in  length  by  7 


1258 


DISEASES  DUE  TO  ANIMAL  PARASITES 


Fig.  81. 


Ova  of  T.  solium:  a,  with  yolk;  b,  with- 
out yolk,  as  in  mature  segments.  The 
hard  brown  shell  is  indicated.  (Leuc- 
kart.) 


Fig.  82. 


mm.  in  width;  those  near  the  neck  are  narrower  and  shorter.  About  a 
yard  from  the  neck  they  become  squarer,  and  lower  down  they  are 
smaller  again.  Each  proglottis  is  hermaphroditic,  containing  male  and 
female  reproductive  elements.  The  uterus  is  central  and  vertical,  with  8 
to  10  lateral  branches;  only  a  few  of  them  mature,  chiefly  those  in  the 

lower  links;  the  ova  (0.036  x  0.03 
mm.)  are  very  numerous  in  each  ma- 
turing segment  and  each  one  shows  a 
shell  and  an  embryo  armed  with  six 
booklets.  The  taenia  reaches  its  full 
length  of  two  to  four  yards  in  three 
to  four  months,  when  the  lower  seg- 
ments are  detached  and  voided;  if 
the  worm  should  break  and  a  yard  or 
so  appear  in  the  faeces,  the  segments 
will  not  reappear  in  the  faeces  until 
three  or  four  months  later.  An  ovum  ingested  by  a  hog  or  man,  loses 
its  shell  in  the  stomach  and  the  freed  embryo  passes  into  the  tissues^ 
where,  encysted,  it  becomes  again  the  cysticercus  cellulosae  (or  larva). 
Symptoms  of  the  Taenia  Solium  in  the  Hmnan  Intestine. — ]\Iany, 
possibly  most,  cases  present  no  symptoms;  they  may  first  develop 
after  passing  segments  are  found  in  neurotic 
subjects.  In  other  cases  dyspeptic  disturb- 
ances arise,  as  anorexia  (or  less  often  increased 
or  ravenous  appetite),  nausea,  abdominal 
pains,  constipation  or  diarrhoea.  Stiles,  in  an 
experimental  infection  on  himself,  thought 
that  he  could  feel  the  parasite  move.  Vom- 
iting of  segments  is  rare,  though  several  feet 
of  tapeworm  have  been  vomited;  in  these 
instances  the  ova  (embryos)  may  enter  the 
tissues  as  cysticerci;  this  is  a  rare  condition 
in  which  one  individual  suffers  from  both  the 
intestinal  and  the  larval  stages.  Anaemia  is 
rather  uncommon.  In  children  reflex  convul- 
sions are  possible.  The  parasite  may  live  for 
even  10  to  15  years.  The  diagnosis  is  deter- 
mined by  the  segments  and  ova,  and  the 
'prognosis  is  practically  always  good. 

Treatment. — As  to  prophylaxis ;  segments 
of  the  tapeworm  should  be  burned;  meat  in- 
spection should  be  more  general  than  it  is,  though  "interstate"  meat 
is  well  inspected;  pork  should  always  be  thoroughly  cooked. 

To  cure  the  disease,  a  light  and  chiefly  fluid  diet  should  be  given 
for  two  days,  and  then  food  should  be  withheld  for  12  to  18  hours; 
this  often  causes  the  parasite  to  release  its  hold  on  the  mucous  mem- 
brane; some  writers  advise  that  a  meal  of  onions  and  herring  be  given 
just    before   drugs   are   administered.     Of   these   pomegranate   ranks 


Head  of  T.  solium:  X45. 


T.EXIA  SOLIUM 


1259 


Fig.  83. 


first;  a  decoction  is  made  of  3  ounces  of  the  root  with  8  ounces  of 
water;  this  is  reduced  to  4  ounces  by  evaporation;  it  is  taken  in  divided 
doses  within  3  to  4  hours ;  its  sole  active  principle  is  the  expensive 
pelletierine,  which  is  given  in  doses  of  3,5  or  10  grains,  and  is  followed 

by  a  purge  in  an   hour.     Male  fern    (felix 

mas)  is  almost  equally  effective;  it  is  given 

as   the    oleoresina  aspidii,   or  extr.   felicis 

■^^^^         I  ^^^  I       maris  sether.,  3iss  to  ijss,  may  be  given  in 

.-=r:^^  \  ^&  syrup;  both  are  followed  by  a  saline  purge 

in  three  to  four  hours.  Castor  oil  is  never 
used,  because  it  promotes  absorption  of  the 
male  fern,  which  causes  toxic  symptoms  as 
icterus,  or  amaurosis;  Sidler  collected  78 
such  cases  of  poisoning  with  15  per  cent, 
mortality  and  lasting  blindness  in  25  per 
cent.;  Leichtenstern  advises  (a)  that  more 
than  10  gm.  (3iiss)  of  the  ethereal  extract 
should  never  be  given  to  adults  C^i  or  less 
to  children);  (6)  that  it  never  be  given  on 
an  empty  stomach  and  (c)  that  it  never  be 
given  two  days  in  succession.  The  drug 
decomposes  easily,  whence  reliable  prepara- 
tions must  be  obtained.  Combinations  may 
be  made  by  giving  with  or  after  the  decoc- 
tion of  pomegranate,  spts.  chloroformi  (ttj  xv)  for  four  doses,  or  croton  oil 
(ttjj  ii)  for  one  dose,  but  pomegranate  and  male  fern  produce  the  best 
results.  Search  should  be  made  for  the  head  of  the  parasite,  without 
removal  of  wdiich  treatment  is  unsuccessful.  If  it  is  not  found, 
another  trial  should  be  made  after  a  number  of  days. 

Oleoresinse  aspidii 

Tr.  vanillse       aa  gtt.  xlv. 

Acacise 

Sacchari  albi aa   Si- 
Aqua    oi- 

M.  et  ft.  emulsio. 
S. — Take  in  one  dose. 


Proglottides  of  (a)  Taenia  saginata 
and  (6)  T.  solium:  natural  size, 
and  enlarged  three  times  to  show 
arrangement  of  uterus.  (After 
Leuckart.) 


Fig.  84. 


Symptoms  of  the  cysticercus  cellulosw.  These  result  when  ova  of 
the  taenia  solium  are  taken  into  the  stomach;  ova  may  reach  the 
stomach  from  the  intestines  by 
antiperistaltic  movements  during 
vomiting,  or  indirectly  by  handling 
worms  voided  from  the  bowels. 
Cysticerci  in  the  hog  produce  few 
symptoms.  In  man,  symptoms  de- 
pend largely  on  the  number  and 
localization  of  the  larvae,  (a)  In 
the  muscles  and  skin,  a  few  cvsti- 


Egg 


of    (a)    T.  saginata:  (b)    T.  solium;   (c) 
Bothriocephalus  latus:  X300.      (After  Eich- 

lior.«t.) 


1260 


DISEASES  DUE   TO   AXIMAL  PARASITES 


cerci  cause  no  symptoms;  numerous  cysticerci  cause  pain,  tenderness 
and  difficult  movement.  Diagnosis  is  possible  only  on  excision  of 
the  subcutaneous  nodules.  In  Stiles'  collection  of  155  cases,  the 
localization  was  muscular  in  20  per  cent,  and  cutaneous  in  3  per 
cent,  (b)  If  they  are  in  the  brain  (in  75  per  cent,  of  Stiles'  series) 
symptoms  depend  on  their  location;  they  are  often  absent;  if  the 
location  is  in  the  cortex,  Jacksonian  epilepsy  is  frequent,  and  if  in 
the  medulla,  diabetes  may  develop,  (c)  There  may  be  other  localiz- 
ations. They  may  be  found  clinically  in  the  eye  (v.  Graefe),  and 
a  few  other  localizations  are  found  at  autopsy,  as  pulmonary,  renal, 
or  hepatic.     There  is  no  treatment  except  surgery. 


II.  Taenia  Saginata  (Mediocanellata). 

This  form  is  most  frequent  in  America, 
but  is  becoming  more  common  in  Europe. 
It  is  the  "fat  tapeworm/'  the  "unarmed," 
or  beef  tapeworm.  Its  cysticercus  is  found 
in  masseters  of  beef,  nearly  seven  times  as 
frequently  as  in  other  muscles,  or  in  the 
heart,  or  brain.  They 


Fig.  86. 


^^°-  ^■^-  are    not  so    readily 

seen  w^ith  the  naked 
eye  as  the  cysticerci 
in  pork.  Ingestion 
of  rare  beef  contain- 
ing cysticerci  pro- 
duces the  taenia  sag- 
inata in  man. 

The  intestinal  par- 
asite differs  from  the 
T.  solium  in  the 
following  points :  (a) 
its  head  is  larger, 
measuring  2  mm. and 
is  square.  It  has  no 
booklets  but  four 
sucking  disks,  which 
are  larger,  more  forward  and  are  surround- 
ed by  pigment.  (See  figs.  83,  84,  85  and 
86.)  ib)  Its  neck  is  much  shorter,  (c)  Its 
'proglottides  are  longer  (16  to  22  mm.)  and 
broader  (5  to  10  mm.),  (d)  The  uterus  con- 
tains 20  to  30  branches,  which  are  less 
dendritic  than  pronged  or  forked,  (e)  The 
ova  are  rather  longer.  (/)  The  parasite 
is  larger  and  longer,  measuring  5  to  7  me- 
ters or  yards.     Its  symptoms  and  treatment 


Head   of    Taenia   saginata. 
(Eichhorst.) 


Toenia  saffinata    naturaK  ze.     (Af- 
ter Leuckart.) 


OTHER  T.EXLE  OCCURRIXG  L\  MAX 


1261 


are  those  of  the  taenia  soUum.  Ingestion  of  the  ova  or  segments 
produces  the  cvsticercus  mediocanellata,  which  is  common  in  beef 
but  extremejv  rare  in  man. 


III.  Other  Taeniae  Occurring  In  Man. 


The  Boihriocephalus  latus, 
or  the  Russian  tapeworm  is 
found  chiefly  in  Russia,  Po- 
land, Norway,  Sweden,  Switz- 
erland and  Japan.  Its  cysti- 
cerci  are  found  in  the  muscles 
and  peritoneum  of  the  pike, 
trout,  salmon,  and  perch  and 
in  man's  intestines  develop 
into  the  bothriocephalus.  Its 
head  is  flat  or  ovoid,  possesses 
no  booklets  and  attaches  it- 
self to  the  intestines  by  two 
lateral  grooves  (suckers).  Its 
neck  is  long  and  its  segments 
broad,  square,  and  may  even 
number  4,000.  It  is  long, 
measuring  8  to  10  yards.  It 
occurs  in  America  in  imported 
cases.  It  may  produce  a  pro- 
found anfemia  which  in  severe 
cases  closely  resembles  the 
pernicious  type  in  its  general 
symptoms  and  blood  findings. 
(See  figs.  84,  87.) 

The  Tcenia  elli/ptica  or  cu- 
cumerina  (Dipylidium  cani- 
num)  is  a  form,  the  larvte  of 
which  develop  in  the  lice  of 
dogs,  and  the  adult  form  exists 
in  the  intestines  of  dogs.some- 
times  in  those  of  cats,  and 
rarely  in  man.     (See  fig.  88.) 

The  Tcenia  na- 
na (Hymenolep- 
sis  nana)  is  the 
dwarf  tape- 
worm. It  mea- 
sures but  J  to  2 
in  ches in  length. 
Its     cysticercus 


Fig.  87. 


Fig. 


Proglottis  of  Both- 
riocephalus latus: 
natural  size,  and 
enlarged  three 
times.  (After 
Eichhorst.) 


F)':.  ri( 


Tcenia  cucumerina 
natural  size.  (Af- 
ter Leukart.) 


Ova  of  Hymenolepsis  nana.      (Siuilli.) 


Hymenolepsis  nana:  X12 
(After  Leuekart.) 


1262  DISEASES  DUE  TO  ANIMAL  PARASITES 

stage  is  in  the  intestinal  wall  of  the  rat  and  its  adult  stage  in  the 
rat's  intestine.  Stiles  has  recently  decided  that  it  is  much  more  fre- 
quent in  man  than  previous  accounts  would  indicate.  Its  head 
contains  four  suckers  and  one  row  of  hooklets.  It  may  occur  singly 
or  in  myriads.  Aspidium  alone  is  of  therapeutic  benefit.  (See  Figs. 
89  and  90.) 

Tsenia  Echinococcus. — Echinococcus  Disease. 

We  may  first  consider  the  adult  parasite  as  inhabiting  the  intestine 
of  the  dog  chiefly,  and  rarely  of  the  wolf,  fox  or  jackal.  The  head  is 
small,  and  is  provided  with  four  suckers,  and  from  30  to  50  hooklets 
arranged  in  a  double  row.  The  segments  number  only  three  or  four, 
and  only  the  end  one  matures;  it  measures  but  0.6  by  2  mm.  but  con- 
tains even  5,000  ova.  The  worm  is  small,  measuring  but  four  to  five 
mm.  in  length,  is  very  delicate  and  white,  so  that  it  readily  escapes  detec- 
tion. When  the  ovum  reaches  the  stomach  of  another  animal,  the  hog 
and  ox  chiefly,  and  less  often  the  horse,  sheep  or  man,  it  loses  its  shell 
and  migrates  to  the  various  organs  {v.  Symptoms).  The  geogra- 
phy of  echinococcus  disease  and  mode  of  infection  is  as  follows :  In 
Iceland,  where  dogs  and  men  live  together,  thedisease  in  man  is  common, 
every  seventh  person  becoming  infected.  In  Australia  both  men  and 
sheep  are  often  infected.  In  Europe  the  malady  is  much  more  common 
than  in  America,  where  the  reported  cases  in  1901  numbered  241 
(Lyon);  most  of  these  were  foreigners.  The  Icelanders  brought  the 
disease  to  Manitoba  in  1874. 

Infection  occurs  by  licking  of  the  hands  by  the  dog,  the  tongue  and 
anus  of  which  often  come  in  contact.  Infection  by  contaminated 
drinking  water  or  vegetables  is  less  common. 

General  Symptoms  and  Pathology. — The  small  embryo,  freed  of 
its  shell,  penetrates  the  intestinal  wall  and  wanders  in  various  directions, 
into  the  muscles  or  peritoneum  or  into  the  radicles  of  the  portal  vein 
or  cava,  so  that  almost  any  tissue  or  organ  may  be  infected,  and  the 
embryo  merely  stops  when  it  reaches  vessels  too  small  for  it.  Once 
lodged,  its  hooklets  disappear  and  a  cyst  develops,  which  is  small  at 
first  but  gradually  reaches  large  or  enormous  proportions;  there  are 
records  of  cysts  containing  30  and  70  pints  of  fluid.  Its  layers  consist 
of  an  inner  endocyst  which  is  granular,  and  an  outer  finely  lamellated 
structureless  capsule;  a  fibrous  layer  develops  outside  from  reaction  of 
the  tissues  to  the  foreign  body.  After  a  while  a  number  of  "  daughter" 
cysts  arise  from  the  endocyst;  these  are  first  "buds"  and  then  minia- 
tures of  the  original  mother  cyst;  from  these  daughter  cysts,  which 
number  about  a  dozen,  "granddaughter"  cysts  arise  by  an  identical 
process.  Allen  in  one  case  found  8,000  daughter  cysts.  Finally  from 
the  endocyst  of  the  maternal  and  daughter  cysts  there  develop  "  brood 
capsules,"  in  which  small  buds  arise,  which  gradually  become  scolices 
(the  heads  of  which  will  be  intestinal  tsenite  in  the  animal  which  ingests 
them).     Some  cysts  do  not  develop  scolices  and  are  therefore  called 


T^NIA  ECHINOCOCCUS.—ECHINOCOCCUS  DISEASE 


1263 


sterile.  In  animals  the  daughter  cysts  may  grow  outward  (exogenous 
cysts).  The  well-grown  cyst  contains  fluid  {v.  Liver  and  Lung  Echino- 
coccus);  it  is  clear  and  neutral,  has  a  specific  gravity  of  1005-10-15 
and  contains  succinic  acid,  inosite  (possibly  sugar)  and  much  sodium 


Human  ecliinococci.      (From  Finlayson,  after  Davaine.) 

A,  a  group  of  echinococci,  still  adhering  to  the  germinal  membrane  by  their  pedicles.  X40. 

B,  an  echinococus  with  head  invaginated  in  the  body.     X107. 

C,  the  same  compressed,  showing  the  suckers  and  hooks  of  the  retracted  head. 

D,  echinococcus  with  head  protruded. 

E,  Crown  of  hooks,  showing  the  two  circles.     X350. 

chloride  but  no  albumin,  unless  the  parasite  dies  and  cystic  inflamma- 
tion develops.  Then  the  fluid  may  become  cloudy,  buttery,  gelatinous, 
purulent,  brownish  or  grumous;  the  cysts  disappear  as  well  as  the 
membrane,  though  the  booklets  of  the  scolices  remain  a  long  time. 
When  the  parasites  are  alive  a  toxin  seems  to  be  present,  for  collapse 


Fig.  92. 


1^     i?    f 


c:;^ 


^ 


'^ 


Hooks  from  Taenia  ecbinococcus.    X350.    (Corti.) 

often  develops  when  the  cyst  ruptures  or  is  punctured   (see  Lung 
Echinococcus). 

The  parasite  is  said  to  live  for  years,  in  one  instance  it  survived  for 
20  years;  after  a  variable  time,  unless  suppuration  intervenes,  the 
cysts  become  cheesy  and  perhaps  calcified  or  ossified. 


1264  DISEASES  DUE    TO  ANIMAL   PARASITES 

The  parasite  may  rupture  into  the  serous  sacs,  bloodvessels  (causing 
embolism),  into  the  air  passages,  urinary  tracts  or  externally   (see 

ECHINOCOCCUS  OF  THE  LUNG,  LlVER  AND  KiDNEY). 

Visceral  Localization. — In  1,912  cases  (the  total  reported  by  Davaine, 
Finsen,  Mosler,  Neisser  and  Cobbold)  the  liver  was  involved  in  51 
per  cent.,  the  genito-urinary  organs  in  10  per  cent.,  the  intestinal  canal 
in  9  per  cent.,  the  lungs  or  pleura  in  9  per  cent.,  the  brain  or  cord  in  7 
per  cent.,  the  bones  in  3  per  cent.,  the  heart  and  vessels  in  3  per  cent., 
and  other  organs  in  8  per  cent.  Vegas  and  Cranw^ell  (1902)  reported 
970  Argentine  cases  of  which  64  per  cent  occurred  in  the  liver  and  7 
per  cent,  in  the  lungs.  In  statistics  from  single  observers,  percentage 
of  cases  with  localization  in  the  liver  often  runs  higher  (69  to  72  per  cent). 
Thomas,  in  809  Australian  cases  of  single  hydatid  cyst,  found  the  lungs 
involved  in  16.5  per  cent.  Hooklets  have  been  obtained  by  lumbar 
puncture  (Jacobs).  There  are  reported  142  cases  of  renal  echinococcus, 
78  cases  with  localization  in  the  bones  and  23  in  the  pelvic  bones 
(Baradulin,  1906).  Grulee  in  1905  found  55  cases  with  cardiac  or 
pericardial  localization.  Echinococcus  cyst  of  the  thyroid  has  been 
reported  23  times  (Ehrhart,  1905). 

There  is  an  unusual  form  of  echinococcus,  the  multilocular  form, 
probably  due  to  a  separate  worm,  the  clinical  features  of  which  are 
described  under  hydatid  disease  of  the  liver  to  which  it  is  almost 
exclusively  confined.  Virchow  first  described  it  in  1856.  It  occurs 
in  Bavaria,  Wiirtemburg,  Switzerland,  Austria,  Austrian  Tyrol  and 
Russia.  Few  imported  cases  have  occurred  in  America.  It  is  un- 
known where  the  ordinary  form  is  most  common.  It  is  rare,  few  more 
than  100  cases  being  recorded.  Sixty  per  cent,  occurs  in  males  between 
20  and  50  years  of  age.  The  ova  are  spheroidal  and  measure  100  to 
170  micro-millimeters.  The  great  difference  from  the  ordinary  form 
is  the  outward  (exognous)  growth  of  the  cysts.  The  irregular  and 
diffuse  cystic  proliferation  is  an  unfavorable  feature.  The  cysts 
contain  a  gelatinous  material  (which  sometimes  causes  confusion  with 
colloid  cancer),  surrounded  by  intersecting  fibrous  strands,  which  gives 
the  liver  a  porous  appearance,  like  a  sponge  or  cheese  with  air  cavities. 
In  some  vesicles  there  is  cheesy  material,  with  some  resemblance  to 
the  granulomata.     The  vesicles  sometimes  suppurate. 

Echinococcus  cysts  which  cause  symptoms  belong  largely  to  sur- 
gery, though  as  described  elsewhere,  spontaneous  recovery  is  not 
infrequent. 

(B).     DISEASES   CAUSED  BY  NEMATODES. 
I.     The  Ascaris  Lumbricoides. 

This  is  the  most  common  intestinal  parasite  in  man.  It  occurs 
oftenest  in  children  and  with  relative  frequency  in  the  insane.  Unlike 
the  cestodes,  no  intermediate  host  is  required.  The  female  measures  7 
to  12  and  the  male  4  to  8  inches  in  length;  it  is  smooth,  pointed  at  botli 


THE  ASCARIS  LUMBRICOIDES 


1265 


Fig.  93. 


ends  and  has  transverse  rings  and  four  longitudinal  ridges,  a  white  one 
dorsally  and  ventrally,  and  two  brownish  ones  laterally.  (See  fig.  93.) 
The  ova  measure  0.075  x  0.  058  mm.,  are  oval  and  reddish  and  have  a 
thick  capsule.  It  is  said  that  60,000,000 
eggs  may  develop  in  a  single  female.  It 
lives  in  the  upper  small  intestine;  its  mode 
of  infection  is  obscure.  Though  they  usu- 
ally occur  singly  or  in  pairs,  they  may 
exceptionally  develop  in  such  numbers  that 
by  intertwining,  they  may  obstruct  the  in- 
testine. The  ascaris  may  rarely  rupture 
through  an  intestinal  ulcer  or  perforate  the 
sound  gut.  It  has  passed  through  a  per- 
forated appendix.  With  or  without  vomit- 
ing, ascarides  may  pass  from  the  stomach 
into  the  oesophagus,  nose,  bronchi,  lungs 
or  middle  ear,  causing  asphyxia,  gangrene 
of  the  lung,  etc.  They  may  migrate  into 
the  common  or  hepatic  duct. 

Symptoms  are  not  usually  pronounced, 
though  anorexia,  salivation,  offensive  breath, 
constipation,  colic  or  diarrhoea  occur  in  some 
cases.  Malnutrition  is  sometimes  marked. 
The  parasite  secretes  an  irritating  substance 
which  is  often  noted  to  emanate  from  it.  It 
is  suggested  that  this  secretion,  if  absorbed, 
may  cause  constitutional  symptoms  (Peiper). 

Such  manifestations  as  irritability,  grind- 
ing the  teeth,  muscular  twitchings  and  con- 
vulsions may  develop  in  nervous  children; 
they  are  said  even  to  resemble  meningitis. 
The  author  always  doubted  the  existence 
of  the  typholumbricosis  of  Chaffard,  Marie 
and  Tauchon,  until  in  one  adult  case,  in 
which  there  were  fever  and  nervous  toxaemia, 
with  otherwise  negative  findings,  instan- 
taneous subsidence  of  all  symptoms  oc- 
curred when  the  parasites  were  removed; 
this  strongly  suggested  a  relation  between 
the  fever  and  other  symptoms  and  the 
lumbricosis. 

Treatment.: — After  a  fast  of  one-half  to 
one  day,  santonin  should  be  given  in  doses 
of  gr.  ss-i,  for  a  child,  and  gr.  ii,  iii,  or  v, 
for  an  adult;  it  should  be  followed  by  a 
saline^  cathartic ;  if  unsuccessful  it  may  be 
repeated  on  two  or  three  successive  days,  though  toxic  symptoms 
sometimes   develop,  as  xanthopsia   (yellow  vision),  urticaria  (which 

80 


Ascaris'lumbricoides.'dissected  and 
walls  thrown  back:  a,  genital 
orifice;  b,  intestine,  c,  oviducts; 
rf,  longitudinal  band;  e,  ovaries. 
(Heller.) 


1266 


DISEASES  DUE  TO  AXIMAL  PARASITES 


may  result  from  the  parasite  itself),  vomiting,  delirium  or  convulsions. 
The  extr.  spigelioe  fl.  (3i)  may  be  given  with  or  without  the  santonin. 
These  remedies  do  not  kill  the  parasite,  but  merely  render  it  uncom- 
fortable. 


II.  Oxyuris  Vermicularis  (Seat  Worm,  Pin  or  Thread  Worm). 


Fig.  94. 


^ 


Fig.  95. 


Children  are  more  often  affected  than  adults,  and  women  more  often 
than  men.  They  are  relatively  frequent  in  the  insane.  The  female  in 
length  measures  10  and  the  male  4  mm.     (See  Figs.  94,  95  and  96.) 

Ingested  ova  develop  in  the  small  intestine, 
where  the  worms  mature  and  cohabit; 
afterward  they  exist  chiefly  in  the  lower 
colon  and  rectum.  The  eggs  remain  in  the 
mother  until  the  worm  is  expelled,  though 
she  occasionally  "aborts"  in  the  bowel. 
Infection  occurs  in  those  who  are  the  most 
uncleanly,  as  in  children  and  the  insane. 
Infection  may  occur  from  water  and  green 
vegetables,  and  reinfection  is  not  uncommon 
from  scratching  the 
anus  during  sleep 
and  thus  crushing 
the  parasite;  Eich- 
horst  frequently 
found  ova  in  the 
minute  fsecal  parti- 
cles about  the  anus 
and  Zenker  demon- 
strated repeatedly 
their  presence 
under  the  finger 
nails.  As  the  par- 
asites migrate  at 
night,  the  symp- 
toms are  greatest 
at  that  time;  they 
may  be  found  on 
the  bed  sheet.  The 
anal  itching  and 
rectal  irritation  are 
often  excessive; 
periproctal  suppuration  may  be  excited.  If  any  vaginal  discharge 
moistens  the  perineum  (and  only  then),  they  can  wander  into  the 
vagina,  causing  irritation,  sexual  stimulation  or  masturbation.  Dis- 
turbance of  the  sleep  and  appetite,  nervous  symptoms  and  ansemia 
may  result.    Diarrhoea  is  due  to  large  numbers  of  parasites. 


Eggs  of  Ox jTiris  vermicularis: 
X  275 .    (After  Eichorst .) 

Fig.  96. 


Oxyuris  vermicularis,  magnified:  a, 
young  female;  b,  male;  c,  mature 
female,  full  of  eggs.    (Payne.) 


Oxyuris  vermicularis:   natural 
size.    (Eichorst.) 


TRICHINA   (TRICHINELLA)   SPIRALIS;   TRICHINOSIS        1267 

Treatment. — Santonin  may  be  given  in  obstinate  cases,  but  local 
measures  are  usually  sufficient,  as  high  enemata  containing  small 
proportions  of  carbolic  acid,  quassia,  and  turpentine.  They  should 
be  repeated  daily  for  two  weeks.  Itching  is  palliated  by  application 
of  "2"  per  cent,  carbolic  salve  to  or  within  the  anus. 


III.  Trichina  (Trichinella)  Spiralis;  Trichinosis. 

Though  Tiedemann  (1822),  Hilton  (1832)  and  Paget  (1835)  saw 
the  parasite,  Owen  (1835)  first  fully  described  it.  Leidy  saw  it  in  the 
hog  in  1847.  Zenker  (1855-60)  first  described  its  pathological  and 
clinical  bearings;   he  found  4  cases  in  136  autopsies. 

Swine  are  infected  in  a  manner  which  is  not  wholly  clear,  but  in- 
fection most  probably  results  from  eating  offal.  The  disease  is  rare 
in  some  countries,  as  France,  and  more  common  in  others,  as  Germany. 
The  hog  is  more  frequently  diseased  in  America  than  in  Germany  (a 
ratio  of  1  to  17  [or  48]  in  the  former  and  but  1  to  18,000  in  the  latter). 
From  the  clinical  and  etiological  standpoint,  the  (a)  muscular  or 
larval  stage  in  hogs  should  be  considered  first.  The  small  encapsulated, 
"hair-like"  (trichina)  worm  lies  in  the  abdominal,  diaphragmatic, 
psoas,  laryngeal  and  other  muscles.  They  live  for  a  long  while,  even 
twenty  to  twenty-five  years,  without  apparently  causing  any  symptoms ; 
calcification  rarely  occurs  in  swine.  Man  is  infected  by  eating  smoked, 
"cured"  or  insufficiently  cooked  pork;  animals  may  be  accidentally 
or  experimentally  inoculated,  especially  the  rat,  guinea-pig,  rabbit, 
less  often  the  cat,  and  rarely  the  dog.  In  much  of  the  literature  relating 
to  its  alleged  presence  in  fish  or  worms,  the  trichina  has  been  confused 
with  other  parasites.  (6)  The  adult  or  intestinal  stage  in  man  is  the 
next  phase.  When  it  is  eaten  by  man,  the  small  capsules  (larval  form  in 
swine)  are  digested  and  the  worms  liberated;  in  the  small  intestine 
they  mature  (the  females  measure  3  to  4  mm.,  and  the  males  are  half  as 
long)  and  the  females  are  fecundated  in  two  to  three  days.  The  female 
trichinae  produce  one  to  two  thousand  embryos  at  once  or^ossibly  in 
succession,  which  stage  requires  another  week  (from  fecundation  of 
the  female  to  birth  of  the  embryos).  At  the  end  of  the  second  week  the 
embryos  commence  to  migrate;  they  enter  the  lymph  vessels  and 
then  the  veins,  by  which  they  reach  the  voluntary  muscles;  some 
writers,  as  Graham,  maintain  that  there  is  a  primary  direct  entrance 
into  the  venous  system.  They  lodge  between  the  muscle  fibers,  enter 
them  and  attain  (c)  the  mature  larval  form,  which  is  identical  with  the 
larval  stage  (a)  in  hogs,  and  differing  only  in  that  man  is  their  host. 
They  measure  0.5  to  1  mm.  in  length.  As  a  result  of  tissue  reaction 
against  the  foreign  bodies,  a  capsule  develops  in  about  six  weeks,  which 
surrounds  one  or  more  parasites.  The  capsules  are  at  first  trans- 
parent, but  grow  more  opaque  and,  after  months,  calcify  and  later  the 
trichinae  calcify  also. 


1268  DISEASES  DUE  TO  ANIMAL  PARASITES 

Frequency. — Though  trichinae  are  apparently  about  40  times  as 
frequent  in  American  as  in  German  swine,  the  disease  is  more  common 
in  North  Germany  where  raw  sausage,  Westphahan  ham  and  smoked 
ham  are  freely  eaten.  Frankel  denies  that  German  trichinosis  results 
from  American  pork,  Williams  of  Buffalo,  in  505  autopsies,  found 
trichinosis  in  5  per  cent.  Miiller  of  Dresden  found  it  in  0.98  per 
cent,  of  1,939  postmortem  examinations.  Other  statistics  usually 
show  lower  figures  than  Miiller's,  and  like  the  above,  are  taken  from 
accidental  postmortem  findings.  The  disease  occurs  sporadically 
or  epidemically.  Perhaps  a  thousand  cases  have  occurred  in  America. 
In  Germany  the  epidemic  at  Hedersleben  numbered  337,  and  that  at 
Emersleben  250  cases. 

Symptoms  may  be  absent  or  slight,  particularly  in  sporadic  cases, 
and  with  moderately  severe  infection,  as  evidenced  by  accidental 
autopsy  finding  of  encapsulated  parasites. 

In  clear  cases  the  symptoms  are  divisible  into  two  stages;  (a)  the 
preliminary  or  g astro-intestinal  stage,  which  begins  in  two  to  three 
days  after  eating  the  diseased  meat;  the  symptoms  are  not  constant 
either  in  sporadic  or  severe  epidemic  cases ;  they  are  anorexia,  nausea, 
vomiting,  colic  and  sometimes  diarrhoea,  which  may  resemble  the 
evacuations  of  cholera,  (b)  The  invasion  symptoms  begin  in  one  or 
two  weeks,  and  correspond  to  the  parasitic  migration,  (i)  Fever  is 
usual,  but  its  onset  seldom  begins  with  rigors.  It  results  from  the 
parasites  and  probably  from  some  toxin  which  they  elaborate;  it  may 
rise  to  102,  104  or  106°,  and  its  course  is  remittent  and  intermittent. 
Symptoms  which  are  attendant  on  any  fever  may  be  present,  as  head- 
ache, febrile  urine,  or  quickened  pulse.  In  severe  cases,  as  in  Zenker's, 
typhoid  may  be  suggested  by  delirium,  epistaxis,  dry  tongue,  status 
typhosus,  Ehrlich's  diazo  reaction  of  the  urine  (in  80  per  cent.), 
bronchitis,  albuminuria  and  kindred  toxsemic  symptoms.  In  two 
cases  typhoid  and  trichinosis  co-existed  (McCrae).  (ii)  Acute  diffiise 
myositis  is  alw^ays  most  suggestive.  Its  intensity  varies  from  mild 
forms  of  "muscular  rheumatism"  to  the  most  severe  and  characteristic 
involvement;  there  is  pain,  tenderness,  swelling,  flexion  to  relieve 
muscular  tension,  and  oedema  in  the  face  and  other  locations.  The 
worms  most  curiously  select  only  the  striated  muscles,  so  that  the 
oedema  which  is  observed  in  the  abdomen  and  thighs,  for  example, 
never  invades  the  scrotum  or  vulva.  The  eyelids  are  often  aft'ected 
greatly  and  early.  Invasion  of  the  eye  muscles  causes  pain  on  moving 
the  eyes;  pain  during  mastication,  phonation  and  deglutition  mark 
penetration  of  the  masseteric,  laryngeal  and  pharyngeal  muscles  by  the 
parasite;  dyspnoea  results  from  involvement  of  the  diaphragm  and 
intercostal  muscles.  The  tendon  reflexes  may  disappear,  (c)  The 
blood  presents  two  striking  features:  first,  the  leukocytosis  (15,000  to 
30,000)  and  second,  the  eosinophilia  (T.  R.  Brown);  the  eosinophiles 
normally  constitute  0.3  to  4  per  cent,  of  the  leukocytes;  their  number 
rises  as  high  as  50  or  68  per  cent,  and  though  they  increase  in  the  other 
parasitic  diseases,  this  rise  is  most  peculiar  if  not  absolutely  patho- 


ANKYLOSTOMA   (UNCINARIA)  1269 

gnomonic.  The  eosinophilia  is  greatest  at  the  time  when  the  trichinae 
enter  the  muscles.  (See  Plate  XIV,  Fig.  5.)  (d)  Profuse  sweats,  poly- 
uria, paresthesia,  urticaria  and  anaemia  are  inconstant  manifestations. 

Diagnosis. — This  is  based  on  (a)  the  possibility  of  infection,  as  by 
eating  poorly  cooked  pork,  (b)  the  discovery  of  trichinae  in  the  uneaten 
portions  of  suspected  meat,  (c)  the  detection  by  removal  of  small 
slivers  of  the  biceps  or  pectorals  for  microscopic  examination,  especially 
the  parts  near  the  muscular  insertion,  (d)  the  myositis  with  oedema  or 
muscular  rheumatism,  (e)  signs  of  particular  muscular  insufficiency, 
as  of  the  ocular  or  diaphragmatic  muscles  and  (/)  leukocytosis  with 
eosinophilia. 

Prognosis. — This  depends  on  the  number  of  parasites  ingested. 
Choleraic  and  typhoidal  symptoms,  dyspnoea  and  pneumonia  are  most 
ominous.  In  moderately  severe  early  diarrhoea  it  is  favorable. 
Children  die  less  often  than  adults.  Convalescence  is  prompt  or  tardy 
as  the  infection  is  light  or  severe.  According  to  Stiles,  the  German 
mortality  averages  5.6  per  cent.  In  the  epidemic  at  Weimar  there 
were  no  fatalities  in  108  cases.  In  the  epidemic  at  Hedersleben  30 
per  cent.  died.  Instances  have  occurred  when  as  many  as  70  per  cent, 
of  those  who  were  attacked  have  died. 

Treatment. — (a)  Prevention  comprises  the  feeding  of  hogs  with 
clean  food,  government  inspection  of  meat,  and  thorough  cooking. 
(b)  In  the  'preliminary  stage,  active  and  repeated  purgation  should  be 
given,  for  moderate  and  early  spontaneous  diarrhoea  is  prognostically 
favorable;  calomel  should  be  followed  by  salts  and  castor  oil;  male 
fern,  santonin  {v.  s.),  thymol  gr.  v,  t.  i.  d.,  benzene  tt^  ii  to  v,  t.  i.  d. 
and  oil  of  turpentine  ttt^  v  to  x  are  recommended ;  glycerine  is  now 
regarded  as  useless,  (c)  In  the  stage  of  muscular  invasion,  the  fever 
is  treated  as  in  other  infections,  the  myositis  by  local  applications  of 
ice  and  by  narcotics,  and  the  general  nutrition  by  food  and  stimulants. 

IV.  Ankylostoma  (Uncinaria). 

The  uncinaria  duodenalis  (ankylostoma  duodenale)  exists  in  two 
forms,  that  of  the  old  and  that  of  the  new  world.  Ankylostomiasis 
was  first  well  described  by  Piso  (1648)  in  Brazil,  and  the  parasite  was 
recognized  in  Milan  by  Dubini  (1838).  It  occurs  chiefly  in  the  tropics 
and  sub-tropics ;  according  to  Thornton,  it  is  the  most  dangerous  of  all 
tropical  diseases.  In  Egyptian  chlorosis  it  was  found  by  Griesinger, 
and  is  said  to  be  present  in  nearly  every  autopsy  made  there.  It  is 
epidemic  in  Italy  ("brick-layers'"  anaemia).  In  India  it  is  found  in 
even  80  per  cent,  of  the  healthy  coolies  and  in  300  autopsies  in  Assam 
it  was  present  299  times.  Thirty  per  cent,  of  Porto  Rican  deaths 
result  from  uncinariasis,  and  Ashford  and  King  state  that  90  per  cent, 
of  the  rural  and  50  per  cent,  of  the  urban  population  have  the  disease; 
during  six  months  in  1905,  18,865  cases  were  treated  in  Porto  Rico 
of  which  33  per  cent.  died.    It  prevails  in  our  southern  states.    Capps 


1270 


DISEASES  DUE  TO  AXIMAL  PARASITES 


ill  1903  reported  one  case,  and  collected  50  other  American  cases. 
More  than  twenty  years  ago,  Belfield  recognized  the  parasite  in  cats. 
In  the  Westphalian  mines,  Tenholt  himself  treated  over  4,000  cases. 
It  was  the  cause  of  the  "tunnel  anaemia,"  which  was  observed  in 
building  the  St.  Gothard  tunnel.  It  is  disseminated  by  Italian  and 
Polish  workmen.  Infection  occurs  from  ingestion  of  the  larvae  and 
not  of  the  ova.  Infection  comes  from  the  food,  drinking  water  and 
Fig.  97.  earth  which  are  infected  by  dejections  from  persons 

suffering  with  the  disease.  Loos  has  proven  that  it 
may  enter  by  the  skin, producing  the  "ground  itch" 
which  is  common  in  the  Southern  States.  The 
exact  role  of  the  uncinaria  in  clay  eaters  is  not  yet 
determined;  the  parasite  certainly  exists  in  some 
cases,  though  it  is  claimed  that  the  dirt  eaters  in- 
stinctively eat  clay  to  remove  the  parasite.  The 
male  is  8  to  10  and  the  female  10  to  18  mm.  in 
length;  the  mouth  has  hooks  by  which  it  adheres 
to  the  mucosa  of  the  duodenum.  (See  figs.  97,  98, 
and  99.)  The  ova  measure  30  to  60  micromilli- 
meters;  they  are  oval,  are  covered  with  a  trans- 
lucent shell  and  differ  from  oxyuris  ova  which  are 
flat.  They  show  1  to  6  yolk  segments  and  may 
number  over  four  millions.  The  larvae  develop  in 
moist  earth,  whence  they  infect  the  water  or  the 
fingers  or  enter  through  the  skin, 

Sjnnptoms. — Symptoms  may  be  absent,  or  of  a 
mildly  dyspeptic  character.  In  pronounced  infec- 
tions (a)  an  anaemia  develops  which  is  first  of  the 
secondary  type  and  later  of  the  progressive  pernic- 
ious type ;  anaemia  results  not  only  from  sucking 
of  blood  by  the  parasites,  but  from  haemolysis  due 
to  some  toxin  which  they  elaborate  (in  their  sali- 
vary glands);  normoblasts  are  much  more  common 
than  megaloblasts,  poikilocytosis  is  less  marked 
than  in  the  usual  pernicious  type,  and  the  eosinoph- 
iles  are  increased,  and  sometimes  reach  30  per  cent, 
of  the  total  number  of  leukocytes.  (6)  Gastro- 
intestinal symptoms  are  usual,  as  ink-like  patches 
on  the  tongue,  diarrhoea  and  colic;  in  Herrick's  Panama  case  (re- 
ported by  Capps)  which  the  author  saw  in  the  County  Hospital, 
there  was  great  nausea,  pain  and  exquisite  abdominal  tenderness; 
the  stools  contained  blood,  eosinophile  cells,  Charcot-Leyden  crystals 
and  ova.  Stiles  suggests  a  ready  test  for  blood,  by  which  parts  of  the 
stool  are  placed  upon  blotting  paper;  after  an  hour  or  so  a  rusty 
stain  develops  about  the  stool.  Gastro-intestinal  catarrh  and  small 
ecchymoses  are  found  at  autopsy,  (c)  Nutrition  suffers;  as  in  per- 
nicious anaemia,  oedema  develops.  Clay  eaters  are  emaciated  and 
apathetic ;    debility  is  frequent.    In  young  children  puberty  is  retarded ; 


Uncinaria  duodenalis, 
magnified:  a,  female; 
b,  male.    (Bristow.) 


ANKYLOSTOMA   (UNCINARIA) 


1271 


development  is  poor  and  the  abdomen  is  greatly  distended.  Cardiac 
atrophy  and  dilatation  are  common.  The  prognosis  is  grave,  though 
less  serious  in  the  New  World  than  in  the  Old  World  type. 


Fig.  98. 


Above;  to  the  left,  three  ova  of  Uncinaria  Americana  in  different  stages  of  segmentation,  from 
66/jt  to  68  /t  in  long  diameter;  to  the  right,  three  ova  of  Uncinaria  Americana  in  varying  stages  of 
segmentation,  long  diameter  from  58  fJ-  to  62  fJ.. 

Middle:  to  the  left,  the  head  of  Uncinaria  Americana  (dorsal  view),  exhibiting  the  smaller  size 
of  the  head  and  more  tapering  anterior  extremity  of  the  worm  in  comparison  witu  U.  duodenalis, 
and  its  buccal  armature  consisting  of  lips;  to  the  right,  the  head  of  Uncinaria!  duodenalis  (dorsal 
view),  drawn  to  same  scale,  showing  its  greater  size  and  the  hook  armature  of  the  buccal  border. 

Below:  to  the  left  the  caudal  border  of  male  Uncinaria  Americana  (dorsal  view,  dorsal  lobe  of 
bursa  thrown  forward),  showing  comparative  size  of  the  worm  in  relation  to  that  of  U.  duodenalis 
partly  divided  dor.sal  lobe  and  suggestion  of  a  ventral  lobe,  the  dorsal  ray  divided  nearly  to  base, 
each  of  its  divisions  having  a  bipartite  tip,  showing  also  the  tip  of  tail  within  bursa,  the  long  barbed 
sexual  spicules,  and  the  arrangement  of  the  rays  of  the  bursa;  to  the  right,  caudal  bursa  of  male 
U.  duodenalis,  showing  Larger  size  of  bursa,  entire  dorsal  lobe,  absence  of  ventral  lobe,  division  of 
dorsal  ray  limited  to  distal  third  and  tripartite  tips  of  each  division,  with  other  features  in  genera 
.similar  to  U.  Americana.      (Smith.) 


1272 


DISEASES  DUE  TO  ANIMAL  PARASITES 


Treatment. — 1.  Prevention. — Drinking  water  should  be  boiled^ 
and  the  hands  should  be  cleansed  before  eating.  The  stools  should 
be  received  in  water-tight  closets  and  disinfected;  careless  defecation 
in  mines  has  caused  wide  dissemination  of  the  disease.  Mines  should 
be  disinfected  with  the  milk  of  lime. 


Fig.  99. 


Uncinaria  duodenalis,  with  eggs.    (After  Blickhan.) 

2.  Medication. —  Thymol  is  the  most  efficacious  remedy.  After  a 
light  diet,  q  ss  should  be  given,  and  this  should  be  followed  by  an 
equal  dose  in  two  hours,  and  by  a  saline  purge  two  hours  afterward. 
As  toxic  symptoms  (nervous  excitation,  or  smoky  urine)  may  develop, 
no  solvents  of  thymol  should  be  given,  as  alcohol,  chloroform,  ether  or 
castor  oil.  This  treatment  should  be  repeated  once  a  week,  as  long  as 
ova  or  Charcot-Leyden  crystals  appear  in  the  stools.  The  most 
severe  cases  do  not  respond  to  any  treatment.  Male  fern  is  considered 
the  best  remedy  by  Tenholt,  and  other  Westphalian  writers. 

V.  Filaria. 


Demarquai  (1863)  first  found  the  embryos  of  the  filaria;  Wiicherer 
(1866)  found  them  in  the  urine,  and  Lewis  (1872)  in  the  blood. 

Filaria  Nocturna. — Its  distribution  is  largely  tropical  and  sub- 
tropical. It  occurs  in  10  to  50  per  cent,  of  the  inhabitants  of  the  Samoan 
Islands,  and  in  32  per  cent,  of  those  of  the  Friendly  Islands.  In  the 
United  States  it  has  been  found  in  the  South,  and  also  in  New  York, 
Illinois  and  Pennsylvania,  (a)  Infection  of  man  occurs  by  mosquito 
bites  or  possibly  by  water  which  the  mosquito  contaminates  with  its 
eggs.  In  .the  mosquito,  the  embryos  change  to  the  young  adult  form. 
(6)  The  next  stage  is  the  presence  of  adult  filaria  in  the  lymph 
channels,  where  they  cause  lymph  stasis  and  lymphangitis.  The 
female  filaria  measures  155  x  0.7  mm.  and  the  male  83  x  0.4  mm. 
(c)  The  embryos  enter  the  blood  current  from  their  birth  place,  the 
lymph  channels;  they  are  very  numerous,  measure  ^  inch  in  length, 
and  have  the  same  diameter  as  a  red  blood  cell.  Under  a  low  power 
lens  their  active  movements  are  easily  seen.  They  appear  in  the  blood 
only  at  night,  usually  near  midnight,  and  during  the  day  retire  to 
internal  organs  as  the  lungs  but  if  the  patient  sleeps  by  day,  they 
appear  in  the  day  time  only. 

Symptoms  are  absent  in  the  majority  of  cases  of  human  and  animal 
infection,  and  are  due  to  the  parent  worm,  not  to  the  embryos,  (a) 
Chyluria  or  hsematochyluria  is  due  to  plugging  by  the  worm  of  the 


DRACUNCULUS  (FILARIA)  MEDINENSIS  1273 

lymphatic  vessels  in  the  peritoneum,  pelvis,  vesical  and  perirenal 
tissues.  Lymph  stasis,  ectasia  and  lymphangitis  result,  with  inter- 
mittent rupture  into  some  part  of  the  urinary  tract,  and  the  passage  of 
milky  chylous  urine,  containing  molecular  albumin  and  fat.  The 
amount  of  the  urine  varies;  it  may  be  normal,  or  increased.  There  is 
usually  also  some  blood.  If  the  blood  clots,  vesical  disturbance  results. 
The  embryos  are  often  found  in  the  blood  and  sometimes  in  the  urine; 
there  is  also  a  non-filarial  chyluria  (page  806).  The  affection  may  last 
for  years  without  impairment  of  health.  The  very  rare  rupture  into  the 
peritoneum  causes  chylous  ascites,  (b)  The  lymph  scrotum  is  due  to 
lymphatic  obstruction  by  the  adult  worm.  The  scrotum  may  weigh 
50  to  200  pounds.  Rupture  into  the  tunica  vaginalis  causes  chylocele. 
The  labia  may  be  similarly  involved.  The  embryos  are  often  missing 
from  the  blood,  being  apparently  confined  to  the  local  involvement  by 
the  lymphangitic  thickening,  whence  the  difficulty  in  stating  the 
relative  percentage  of  parasitic  and  non-parasitic  cases  of  lymph 
scrotum  and  elephantiasis,  (c)  Elephantiasis  usually  develops  in  the 
legs,  scrotum  (v.  s.)  and  labia,  less  often  in  the  arms,  breasts  or  trunk. 
In  forms  (b)  and  (c),  there  occur  intermittent  exacerbations  with  fever 
and  nervous  disturbance,  which  end  with  critical  sweats. 

Other  Forms  of  Filaria. — The  exact  status  of  the  filaria  diurna  is 
not  known ;  /.  perstans,  which  causes  pustular  eruptions  (craw-craw) ; 
/.  loa  (the  adult  stage  of  filaria  perstans)  which  inhabits  the  conjunc- 
tiva;   /.  labialis;    and  /.  oris,  and  bronchialis,  are  other  forms. 

Treatment. — (a)  For  prevention,  mosquito  bites  and  infected  water 
should  be  avoided.  (6)  No  parasiticide  is  known,  (c)  Chyluria  is 
treated  expectantly;  a  dry  and  fat-free  diet  is  recommended  but  it  is 
difficult  to  understand  how"  it  can  influence  lymph  stasis,  (d)  Lymph 
scrotum  and  elephantiasis  may  necessitate  castration,  amputation  or 
less  radical  measures  to  eradicate  the  obstructing  parasite. 


VI.    Dracunculus  (Filaria)  Medinensis. 

This  is  found  on  the  West  African  coast,  the  Gold  Coast,  in  Abyssinia 
and  South  Egypt;  on  the  Caspian  Sea  and  Persian  Gulf;  in  the  East 
Indies,  parts  of  India,  and  South  America.  Guinea-worm  disease 
(drachontiasis)  has  developed  in  a  person  who  had  always  lived  in 
Philadelphia.  Man  is  infected  by  a  small  water  flea  (cyclops)  which 
contaminates  the  water  with  the  larvae  (embryos).  These  embryos, 
measuring  0.6  mm.,  enter  the  stomach,  bowel  and  probably  the 
mesentery,  where  they  copulate;  the  male,  of  which  little  is  known, 
is  either  discharged  from  the  bowel  or  dies  in  the  mesentery.  The 
female  is  cylindrical  in  form,  measures  50  to  80  x  2  mm.,  has  a  tri- 
angular mouth,  eight  papillae  and  a  blunt  tail;  its  uterus  occupies 
almost  its  entire  length.  The  female  which  is  usually  solitary,  wanders 
downward  in  the  subcutaneous  and  intermuscular  tissues  to  the 
thighs,  legs  and  in  66  per  cent,  of  cases  reaches  the  feet  where,  near 


1274 


DISEASES  DUE  TO  ANIMAL  PARASITES 


its  head,  vesicles,  abscesses  and  ulcers  develop.  Its  downward  course 
occupies  a  year,  during  which  it  may  be  felt  subcutaneously.  When 
the  skin  breaks  the  parasite  discharges  her  embryos  and  then  leaves 
the  body,  to  die. 

Treatment. — Treatment  by  excision,  or  by  1  to  1,000  bichloride 
injections,  seems  most  rational.  If  the  worm  is  ruptured  in  efforts  to 
extract  it,  high  temperature,  alarming  nervous  symptoms  and  sepsis  are 
said  to  result  from  migration  of  the  embryos  which  are  liberated  in 
the  tissues. 


VII.    The  Trichocephalus  Dispar  or  Whip  Worm. 

This  is  a  nemotode,  which  is  found  most  often  in  Southern  Italy  and 
France  and  but  seldom  in  this  country;  one  case  occurred  in  the  County 
Hospital  service.  It  is  also  called  trichuris  trichura.  It  requires  no 
intermediate  host,  enters  with  the  food  and  drink,  and  is  found  in  the 
caecum  and  large  gut.  The  male  is  slightly  shorter  than  the  female 
which  is  4  to  5  cm.  in  length.  The  anterior  portion  of  the  worm  is 
thin;  the  posterior  two-fifths  is  thick,  in  the  male  round  and  in  the 
female  pointed.  It  bores  into  the  mucosa  and  is  nourished  by  the 
blood  and  not  by  the  alimentary  contents.  The  eggs  measure  0.05 
mm.,  are  oval  and  are  marked  by  a  button-like  projection.    It  causes 


Fig.  100. 


Fig.  101. 


Eggs  of  Trichuris  trichura:  X  275. 
(After  Eichorst.) 


Trichuris  trichura,  male  and  female:  natural 
size.    (Eichorst.) 


few  symptoms;  occasionally  there  is  severe  abdominal  pain.  Three 
fatal  cases  are  recorded.  Male  fern  and  thymol  internally  and  benzene 
5i  to  Oij  of  water  as  an  enema  are  recommended.  (See  figs.  100 
and  101.) 

VIII.    The  Strongyloides  Intestinalis. 


This  includes  a  number  of  nematodes,  as  the  anguillula  intestinal 
or  stercorals ,  rhabdonema,  etc.    They  are  found  in  the  endemic  diar 
rhoea  which   occurs   in   Cochin    China.     Strong   reports   cases   from 
Manila,  and  W.  F.  Thayer  reported  the  first  case  in  America.    A  few 
parasites  cause  no  symptoms.     Thymol  is  almost  specific. 


DISEASES  CAUSED  BY    TREMATODES   (DISTOMIASIS)      1275 


(C).  DISEASES   CAUSED  BY  TREMATODES   (DISTOMIASIS). 

1.  Bilharzia  disease  (endemic  hsematuria)  is  due  to  the  blood  fluke 
(Cystosoma  hsematobium).  Billiarz  described  the  disease  in  1851.  It 
is  an  African  affection;  it  has  prevailed  for  many  centuries  in  Egypt, 
where  Bilharz  considered  that  half  of  the  lower  classes  were  affected. 
It  is  equally  frequent  in  Uganda.  Importation  has  occurred  into 
India,  the  Mediterranean  Islands,  and  America.  Only  six  cases  have 
occurred  in  the  United  States   (Gunn,  1906). 

Children  are  more  predisposed  than  adults  to  infection,  which 
occurs  through  the  drinking  water  or  possibly  through  the  skin.  The 
embryos  enter  the  stomach,  penetrate  the  alimentary  mucosa,  and 
mature  in  the  veins  of  the  pelvis,  spleen,  mesentery,  liver,  kidney  and 
bladder.  The  male  worm  measures  4  to  15  x  0.6  mm.,  the  female 
15  to  20  X  0 . 3  mm.  The  male  is  rolled  up  like  a  leaf,  forming  a  groove 
in  which  the  female  lies  during  copulation.  Many  ova  are  found  in 
the  urine;  they  are  oval,  carry  a  spine,  and  contain  a  ciliated  embryo. 
They  die  in  the  urine  in  a  day  but  live  for  some  time  in  water,  where 
their  life  history  is  still  imperfectly  understood. 

HoBmaturia  is  the  most  common,  and  often  the  only  symptom;  it 
may  be  macro-  or  microscopic  and  passes  chiefly  at  the  end  of  urination; 
its  examination  shows  many  ova  and  eosinophiles.  Cystitis  occurs  in 
severe  infection.  Stones  are  not  uncommon,  particularly  in  cases  in 
Canton,  China.  Suppuration  may  develop  fistulse.  These  clinical 
symptoms  result  from  massive  accumulation  of  ova  in  the  submucosa, 
which  leads  to  papillomatous  hyperplasia,  hemorrhage,  suppuration, 
necrosis,  salt  deposits  (calculi),  and  rarely  to  malignant  degeneration. 
Similar  changes  in  the  rectum  cause  pile-like  papillomata,  dysenteric 
evacuations  and  tenesmus.  As  complications,  pyelitis,  prostatitis  and 
changes  in  the  uterus,  seminal  vesicles  and  renal  pelvis,  resembling 
those  in  the  bladder,  may  develop.  The  eosinophiles  are  increased  to 
10  to  50  per  cent. 

Treatment.^ — Change  of  climate  is  advisable  in  order  to  avoid 
infection.  The  parasites  usually  die,  though  slowly,  and  as  no  local 
application  or  systemic  remedies  modify  their  life  history,  treatment 
must  be  expectant. 

2.  Lung  flukes  cause  the  endemic  hoemoptysis  which  is  observed 
chiefly  in  North  China,  Corea,  Japan  and  Formosa.  The  parasite  is 
named  Distoma  pulmonale  (Paragonius  Westermanni);  it  measures 
10  x  6  mm,  and  is  found  largely  in  the  lungs,  but  sometimes  in  the 
brain  and  skin.  In  young  males  a  chronic  cough  develops  with  bloody 
or  prune-juice  sputum,  in  which  are  found  blood,  dark  brown  ova, 
eosinophile  cells  and  Charcot-Leyden  crystals.  The  hemorrhages, 
which  are  sometimes  profuse,  result  from  small  infarcts  of  ova  in  the 
subpleural  lung  tissue.  The  course  is  usually  favorable,  though 
chronic,  and  is  not  influenced  by  treatment. 


1276  DISEASES   CAUSED   BY   ANIMAL  PARASITES 

3.  Liver  flukes  (Fasciola  hepatica,  Opisthorchis  siensis)  enter  like 
the  above  forms  through  contaminated  water.  The  fluke  is  found  in 
the  upper  small  intestine,  and  the  bilary  or  pancreatic  duct.  It  is 
found  in  Japan,  and  certain  provinces  show  a  mortality  of  20  to  72 
per  cent.  (Balz  and  Inouye).  The  liver  is  enlarged  and  tender; 
icterus  results  from  biliary  stasis,  for  the  parasites  lie  in  the  walls  of  the 
biliary  duct  and  gall-bladder;  diarrhoea  develops,  and  the  dejections 
contain  ova  and  blood;  anaemia,  ascites,  anasarca,  adynamia,  and 
emaciation  develop  and  death  invariably  results.  There  is  no  treat- 
ment beyond  the  symptomatic  support  of  the  heart.  Prophylaxis  is 
valuable;  avoidance  of  drinking  or  of  swimming  in  canal  water,  and 
thorough  cooking  of  fish  and  mussels,  has  stamped  out  the  plague  in 
one  Japanese  province  (Inouye). 


(D).     DISEASES   CAUSED  BY  PROTOZOA. 

I.  Malaria  and  Amcebic  Dysentery  (v.  Acute  Infections). 

II.  The  Trypanosoma. — This  is  a  protozoon  found  by  Gruby  (1843) 
in  frogs,  Doflein  (1845)  in  rats,  and  later  in  many  other  animals, 
and  in  man  (Nepvue,  1890-98).  There  are  many  species.  It  is  leech- 
shaped;  its  body  is  granular,  measures  13  to  25,  by  2  to  4pL,  and  contains 
a  nucleus  and  micronucleus  (centrosome) ;  on  one  side  and  attached 
to  an  "undulating  membrane"  is  a  solitary  flagellum  by  which  the 
parasite  moves.  In  cool  and  moist  hanging-drop  perparations  they 
may  live  for  a  month  and  a  half.  Novy  and  McNeal  cultivated  the 
T.  Lewisi  and  Brucei  on  agar  and  defibrinated  blood.  Infection  is 
carried  by  the  tsetse-fly,  flea,  louse,  mosquito  and  ticks.  In  man  the 
two  clinical  forms  (v.  i.)  of  trypanosomiasis  are  conveyed  by  the 
tsetse-fly  (Glossina  palpaHs)  or  possibly  by  bites  from  infected  rats. 
Animals  may  be  infected  during  coitus,  by  subcutaneous  inoculation, 
or  by  the  stomach. 

1.  Trypanosoma  fever  was  first  described  by  Nepveu.  The  atrium 
may  be  present  as  an  inflamed  bite,  or  the  history  of  a  bite  may  be 
obtained.  Parasites  in  the  blood  may  cause  no  symptoms;  they  occur 
in  the  plasma  and  not  in  the  corpuscles ;  some  anaemia  is  present  and 
the  large  lymphocytes  are  increased  in  number  (up  to  20  per  cent.), 
but  the  eosinophiles  show  no  increase.  Fever  is  irregular,  subcontin- 
uous  or  remittent;  it  does  not  react  to  quinine;  it  lasts  from  three 
days  to  three  weeks.  An  erythematous  eruption  is  almost  constant. 
(Edema,  particularly  of  the  lower  lids,  weak  and  rapid  pulse,  pros- 
tration, splenic  tumor  and  enlargement  of  the  lymph  glands  which  con- 
tain the  parasite,  usually  occur.  In  treatment,  arsenic  is  apparently 
most  helpful,  while  quinine  is  without  effect.  Careful  feeding  and 
cardiac  stimulation  are  indicated.  The  patient,  as  is  the  case  in  yellow 
fever,  should  be  so  screened  that  flies  can  neither  convey  fresh  infection 
to  him  nor  bite  him,  and  thus  infect  others. 


DISEASES  CAUSED  BY  PROTOZOA  1277 

2.  Sleeping  sickness  or  African  lethargy,  which  is  endemic  in  Cen- 
tral Africa,  is  due  to  localization  of  the  same  trypanosoma  parasite 
in  the  nervo^us  system,  causing  a  diffuse  meningo-encephalomyelitis 
(Mott).  Negroes  are  chiefly  affected  but^^Caucasians  may  contract  the 
disease. 

The  incubation  is  long,  and  may  possibly  cover  years.  Incipient 
symptoms  are  those  of  the  trypanosoma  fever  {v.s.)  or  less  often  there 
are  preliminary  psychical  phenomena,  as  epileptiform  convulsions, 
melancholia  or  mania.  Somnolence  develops,  from  which  at  first  the 
patient  can  be  aroused,  but  which  later  develops  into  profound  lethargy. 
The  parasite  is  found  in  the  blood  (in  92  per  cent.,  Bruce)  and  in  60 
per  cent,  of  cases  in  the  cerebrospinal  fluid  when  withdrawn  by  lum- 
bar puncture  (Castellani),  or  in  100  per  cent.  (Bruce).  Malnutrition, 
decubitus,  and  sometimes  secondary  infections  develop,  and  after  the 
convulsions  deepen  into  coma,  the  patient  dies.  The  course  lasts 
from  months  to  several  years.  Treatment  is  unavailing.  More  than  a 
quarter  of  a  million  people  died  in  Uganda  in  the  last  few  years  from 
this  affection. 


INDEX. 


Abdominal  pain,  causes  of,  668 
in  pneumonia,  141 
in  typhoid  fever,  32 
Aboulia,  hysterical,  1186 
Abortion  in  typhoid  fever,  38 
Abscess  of  brain,  1013 

differentiation   of,   from   brain 
tumor,  1008 
cold,  311 
extradural,  differentiation  of,    from 

brain  abscess,  1007 
of  liver,  707 

amoebic,  708 

dysentery,  230 
cholangitic,  708 
differentiation  of,  from  cancer, 
713,  724 
from  pleurisy,  559 
from  portal  cirrhosis,  724 
pylephlebitic,  707 
septic,  707 
solitary,  708 
tropical,  708 
in  typhoid  fever,  31 
of  lung,  526 

differentiation    of,    from    gan- 
grene, 530 
pneumonic,  149 
in  typhoid  fever,  36 
perinephric,  812 
of  spleen,  883 
subphrenic,  756 

differentiation    of,    from   pleu- 
risy, 559 
from  pneumothorax,  566 
of  thymus  gland,  897 
Acetonuria,  diabetic,  909,  918 

test  for,  909 
Achylia  gastrica,  609,  644 
etiology  of,  609 
pathology  of,  609 
prognosis  of,  610 
symptoms  of,  609 
treatment  of,  610 
Achlorhydria  in  gastric  cancer,  633 
"Acid-fast"  bacilli,  304 
Acidosis,  diabetic,  908,  910,  912,  918,  918 
Acoria,  648 
Acrodynia,  207 


Acromegaly,  898 
course  of,  899 
diagnosis  of,  900 
differentiation  of,  900 
etiology  of,  898 
prognosis  of,  899 
symptoms  of,  898 
treatment  of,  901 
Acroparsesthesia,  1235 
Actinomycosis,  256 
diagnosis  of,  259 
etiology  of,  256 
forms  of,  257 
incubation  in,  257 
of  liver,  258 
parapleuritis,  554 
symptoms  of,  259 
treatment  of,  260 
Adams-Stokes  syndrome,  443,  457 
Addison's  anaemia.     See  Pernicious  An- 
semia 
disease,  877 

course  of,  880 
diagnosis  of,  880 
differentiation  of,  from  argyria, 
880 
from  icterus,  880 
from  other  pigmentations, 

880 
from  pellagra,  880 
etiology  of,  877 
symptoms  of,  878 
treatment,  881 
Adenia,  860 
Adenitis,  bronchial,  339 

cervical,  338 
Adenoids,  587 
Adiamorrhysis,  962 
Adipose  ascites,  765,  766 
Adiposis  dolorosa,  938 

pathology  of,  938 
symptoms  of,  938 
treatment  of,  939 
Adiposity,  936 

Adrenal  glands,  diseases  of,  877 
Adrenals,  syphilis  of,  277 
^goi^hony,  145 
Aerophagia,  645 
African  lethargy,  1277 
Agraphia,  948,  952 
Ague-cake,  in  malaria,  119 

1279 


1280 


INDEX 


Ainhum,  1237 
Albumin  in  urine,  799 
Albuminuria,  799 
albumose,  801 
Bence-Jones,  801 
diabetic,  908 
diagnosis  of,  802 
diphtheritic,  168 
etiology  of,  800 
genuine,  799 
globulin,  801 
in  malaria,  120 
mucin,  801 
in  nephritis,  769 
nucleo-albumin,  801 
peptone,  801 
in  pneumonia,  147 
prognosis  of,  802 
renal,  799 
rheumatic,  192 
scarlatinal,  89 
spurious,  799 
syphilitic,  276 
tests  for,  acetic  acid,  801 
boiling,  800 
ferrocyanide,  801 
Jolles',  801 
'nitric  acid,  801 
Spiegler's,  801 
in  tuberculosis,  336 
in  typhoid  fever,  37 
in  yellow  fever,  217 
Albumose,  tests  for,  801 
Alcohol,  coma  from,  975 
Alcoholic  cirrhosis  of  liver,  695 
Alcoholism,  acute,  diagnosis  of,  1241 
symptoms  of,  1241 
treatment  of,  1242 
chronic,  prognosis  of,  1243 
symptoms  of,  1242 
treatment  of,  1243 
delirium  tremens,  1244 
differentiation  of,  1026 
Alexia,  946,  947,  949,  950 
Alimentary  tract,  tuberculosis  of,  346 
Alkalies.     See  Ulcer  of    Stomach,   also 

Hyperchlorhydria. 
Alkaptonuria,  808 
Allantiasis,  1251 
Allocheiria,  tabetic,  1117 
Amaurosis,  1149  i 

with  idiocy,  1137 
Amblyopia,  1149 
Ammonisemia,  811 
Ammonium,  in  urine,  908 
Amoeba  dysenterise,  227 
Amoebic  dysentery,  227 

complications  of,  229 
issues  of,  229 
pathology  of,  229 
symptoms  of,  228 
treatment  of,  231 
Amyloid  degeneration  of  kidneys,  793 
of  spleen,  882 
in  tuberculosis,  336 


Amyloid  kidney,  differentiation  of,  from 
nephritis,  796,  797 
liver,  differentiation  of  from  cancer, 
713,  724 
from  portal  cirrhosis,  701, 
724 
Anaemia,  aplastic  846 
of  brain,  961 
in  cirrhosis  of  liver,  699 
classification  of,  831 
in  heart  disease,  418 
infantum,  pseudoleuksemica,  863 
lienalis,  860 
lymphatica,  860 
in  nephritis,  770 
pernicious,  839 
course  of,  844 
diagnosis  of,  844 
differentiation   of,    from    bone 
tumors,  845 
from   carcinoma  of  stom- 
ach, 845 
from  chlorosis,  845 
from  parasitic  anaemia,  845 
from    secondary  anaemia, 
845 
etiology  of,  839 
prognosis  of,  844 
symptoms  of,  blood,  839,  840 
circulation,  841 
digestion,  842 
hsemolymph  glands,  842 
metabolism,  841 
nervous,  843 
sexual,  843 
skin,  841 
subjective,  841 
treatment  of,  846 
pseudopernicious,  of  children,  863 
secondary,  post-hemorrhagic,  acute, 
847 
etiology  of,  847 
symptoms  of,  847 
prognosis  of,  848 
treatment  of,  848 
clu-onic,  etiology  of,  849 
differentiation  of,  845 
symptoms  of,  849 
treatment  of,  850 
of  spinal  cord,  1083 
splenic,  864,  883 

splenica  infettiva  dei  bambini,  863 
tuberculous,  311,  323 
Anaesthesia,  dissociated,  1110 
Anarthria,  948,  959 
Anasarca  in  nephritis,  770 
Aneurysm,  abdominal,  481 
diagnosis  of,  481 
prognosis  of,  482 
signs  of,  481 
symptoms  of,  481 
treatment  of,  482 
of  aorta,  470 
of  brain,  989 
coeliac,  482 


INDEX 


1281 


Aneurysm,  gastric,  482 
of  heart,  446 
hepatic,  482 
intracranial,  989 

diagnosis  of,  990 
etiology  of,  989 
pathologj^  of,  990 
symptoms  of,  990 
treatment  of,  990 
mesenteric,  482 
miliary  in  cerebral  hemorrhage,  965, 

966 
renal,  482 
splenic,  482 
syphilitic,  278,  285 
thoracic,  470 

death  mechanism  of,  479 
diagnosis  of,  478 
differentiation  of,  479 
etiology  of,  470 
pathology  of,  471 
physical  signs  of,  473 

heart  changes,  475 
respiratory  changes, 

476 
sympathetic,  478 
vascular  changes,  475 
prognosis  of,  479 
sym^Dtoms  of,  472 
treatment  of,  480 
Angina  abdominalis,  460,  469 
cruris,  460,  468 
erysipelatous,  106 
in  influenza,  178 
Ludovici,  580 
pectoris,  458 

diagnosis  of,  460 
differentiation  of,  461 
etiology  of,  458 
pathology  of,  458 
prognosis  of,  461 
symptoms  of,  459 
treatment  of,  461 
phlegmonosa,  583 
syphilitic,  270 
in  tyjjhoid  fever,  30 
ulceromembranosa,  583 
Vincent's,  583 
Angioneurotic  crisis,   differentiation    of, 
from  gall-stones,  733 
hsematuria,  802 
oedema,  1236 
Angiosclerosis,  463 
Anguillula  intestinalis,  1274 
Ankylosis,  rheumatic,  193 
Ankylostoma  duodenale,  1269 
Anorexia,  647 

in  tuberculosis,  335 
Anosmia,  1146 
Anthracosis  of  lungs,  522 
Anthrax,  239 

bacteriology  of,  239 

differentiation     of,     from     typhoid 

fever,  42 
etiology  of,  239 
external,  240 
81 


Anthrax,  external,  diagnosis  of,  241 
differentiation  of,  241 
prognosis  of,  241 
site  of,  240 
symptoms  of,  240 
treatment  of,  242 
internal,  242 

intestinal,  242 

diagnosis  of,  243 
symptoms  of,  242 
respiratory,  243 

symptoms  of,  243 
treatment  of,  244 
septicaemia,  244 
Antitoxin,  in  diphtheria,  172 

in  tetanus,  251 
Anuria,  renal  colic  causing,  819 

in  yellow  fever,  217 
Aorta,  aneurysm  of,  470 
arteriosclerosis  of,  468 
atheroma  of,  468 
dilatation  of,  intermittent,  482 
embolism  of,  483 
inflammation  of,  483 
rupture  of,  483 
syphilis  of,  278 
thrombosis  of,  484 
tuberculosis  of,  356 
Aortic  insufficiency,  401 
etiology  of,  401 
mechanism  of,  402 
physical  signs  of,  402 

auscultation,  404 
inspection,  402 
palpation,  403 
percussion,  403 
treatment  of,  423 
stenosis,  405 

diagnosis  of,  407 
differentiation  of,  407,  412 
etiology  of,  405 
mechanism  of,  406 
physical  signs  of,  406 

auscultation,  406 
inspection,  406 
palpation,  406 
percussion,  406 
symptoms  of,  406 
treatment  of,  423 
Aortitis,  acute,  483 
sjrphilitic,  278 
Aphasia,  amnestic,  950,  952 
auditory,  949,  952 
in  cerebral  embolism,  983,  988 
hemorrhage,  971,  988 
thrombosis,  986,  988 
conduction,  952 
differentiation  of,  952 
localization,  947,  948,  952 
motor,  948,  952 
sensory,  949,  952 
visual,  950,  952 
Aphthse  epizootics,  375 
Aphthous  fever,  375 
stomatitis,  575 
Aplastic  antemia,  846 


1282 


INDEX 


Apneumatosis  of  lungs,  524 
Apoplectiform    attacks    in    paretic    de- 
mentia, 1024 
bulbar  paralysis,  1033 
seizures,  in  multiple  sclerosis,  1106 
Apoplexy,  965 
cardiac,  449 
differentiation  of,  988 
fulminating,  969 
habitus,  965 
ingravescent,  969 
Appendicitis,  664 

actinomycotic,  258 
in  aged,  668 
bacteriology  of,  664 
in  children,  668 
complications  of,  abscess,  667 
chronic  changes,  668 
necrosis,  666 
peritonitis,  667 
ulceration,  666 
diagnosis  of,  668 
differentiation  of,  668 
from  gall-stones,  733 
from  pneumonia,  141 
etiology  of,  664 
larvata,  668 
pathology  of,  665,  666 
prognosis  of,  668 
symptoms  of,  665 
early,  665 
late,  666 
remote,  668 
treatment  of,  669 
tuberculous,  349 
typhoid,  32 
Appendix  vermiformis,  cancer  of,  678 
foreign  bodies  in,  664 
inflammation  of,  664 
typhoid  ulcers  of,  31,  32 
Appetite,  disturbance  of  sense  of,  647 
Aprosexia,  587 
Argyll-Robertson  pupil,  1118 

in  paretic  dementia,  1024 
Argyria,  differentiation  of,   from   Addi- 
son's disease,  880 
Arrhythmia,  457 
Arsenical  poisoning,  1251 
Arterial  tension,   in   contracted   kidney, 

781 
Arteries,  diseases  of,  463 

syphilitic  endarteritis  of,  277 
Arteritis,  483 

pneumococcic,  148 
rheumatic,  196 
in  typhoid  fever,  25 
Arteriocapillary  fibrosis,  463 
Arteriosclerosis,  463 
diagnosis  of,  466 
differentiation    of,    from    syphilitic 

endarteritis,  285 
etiology  of,  463 
pathogenesis  of,  464 
pathology  of,  464 
prognosis  of,  469 
symptoms  of,  466 


Arteriosclerosis,  treatment  of,  470 

tuberculous,  311 
Artery  of  hemorrhage,  965 
Articular  rheumatism,  acute,  190 
Arthritis  deformans,  926 
diagnosis  of,  929 
differentiation  of,  929 

from    articular   infections, 

930 
from  chronic  fibrous  rheu- 
matism, 930 
from  gout,  929 
from  haemophilic  arthritis, 

930 
from    syphilitic    arthritis, 

930 
from  syringomyelic  joints, 

930 
from  tabetic  arthropathies, 

930 
from  tuberculous  arthritis, 
929 
etiology  of,  926 
pathology  of,  927 
treatment  of,  930 
types  of,  927 

diffuse,  acute,  927 

chronic,  927 
Heberden's  nodes,  929 
juvenile,  929 
monarticular,  928 
partial,  928 
vertebral,  928 
divitum,  921 
pauperum,  921 
pneumococcic,  149 
rheumatic,  192 
in  typhoid  fever,  29 
Arthropathies,  syringomyelic,  1111 

tabetic,  1119 
Ascaris  lumbricoides,  1264 
Ascites,  adipose,  765,  766 
in  cancer  of  liver,  712 
chyliform,  766 
chylous,  765 
in  cirrhosis  of  liver,  697 
diagnosis  of,  760 

differentiation     of,     from     hepatic 
cirrhosis,  764 
from  perihepatitis,  764 
from  peritoneal  cancer,  763,  764 
from    serous    peritonitis,    761, 

762,  763 
from    tuberculous     peritonitis, 
761,  762,  763 
etiology  of,  759 
in  heart  disease,  421 
in  pericarditis  adhesiva,  387 
symptoms  of,  759 
treatment  of,  765 
Aspergillus,  pseudotuberculosis,  307,  332 
Associated  movements  in  apoplexy,  974 
Association,  centres  for,  947 
Astasia-abasia,  hysterical,  1188 
Asthma,  bronchial,  506 

diagnosis  of,  508 


INDEX 


1283 


Asthma,  differentiation  of,  508 
etiology  of,  506 
pathogenesis  of,  507 
prognosis  of,  509 
symptoms  of,  507 
treatment  of  paroxysm,  509 
of  tendency,  510 
cardiac,  509 
Millar's,  897 
thymic,  897 

periodic,     differentiation    of,     from 
whooping-congh,  185 
Asthenia  in  tuberculosis,  335 
Asthenic  bulbar  paralysis,  1032 
Ataxia,  cerebellar,  960 
cortical,  946 
crus  lesion  causing,  957 
Friedreich's,  1135 
hereditary,  1135 
cerebellar,  1137 
diagnosis  of,  1137 
etiology  of,  1135 
pathology  of,  1136 
prognosis  of,  1137 
symptoms  of,  1136 
treatment  of,  1137 
pons  lesions  causing,  958 
in  tabes,  1116 
Atelectasis  of  lungs,  acquired,  525 

congenital,  524 
Atheroma,  463 

of  aorta,  468 
Athetosis,  in  cerebral  infantile  paralysis, 
998 
posthemiplegic,  974,  975 
Atony  of  stomach,  610 
Atrophia  hepatis  fusca,  692 
Atrophic  cirrhosis  of  liver,  695 
Atrophy  of  brain,  1028 
of  heart,  441 
hemifacial,  1157 
of  liver,  acute  yellow,  692 
progressive  spinal,  1128 
of  stomach,  609 
of  testicles  in  mumps,  189 
Aura,  epileptic,  1202 
Autumnal  fever,  19 


B 


Babinski's  sign,  972 
Baccelli's  sign  in  pleurisy,  549 

in  pneumonia,  145 
Bacilluria,  treatment  of,  55 

in  typhoid  fever,  37 
Bacillus  aerogenes  encapsulatus,  390 
in  pneumothorax,  563 

anthracis,  239 

botulinus,  1251 

diphtheriiB,  159 

dysenteriae,  225 

Klebs-Loeffler,  159 

leprae,  304 

mallei,  244 

Oppler-Boas,  634,  635 


Bacillus  tetani,  247 
tuberculosis,  304 
typhosus,  17 
Bacterisemia,  septic  affections,  131 
Balne's  cough,  588 
Bamberger's  sign  in  pericarditis,  383 
Banting's  cure,  937 

Banti's  disease,  differentiation  of,  from 
portal   cirrhosis  of  liver, 

702 
from  pseudoleuksemia,  864 
Barlow's  disease,  872 

diagnosis  of,  873 
etiology  of,  872 
prognosis  of,  873 
symptoms  of,  872 
treatment  of,  873 
Basedow's  disease,  888 
Baths  in  typhoid  fever,  49 
Baume's  law,  295 
Becker's  sign,  890 
Bednar's  plaques,  574 
Bedsores  in  typhoid  fever,  24 
causes  of,  55 
treatment  of,  55 
Bence- Jones'  albumose,  801 
Beriberi,  236 

diagnosis  of,  238 
distribution  of,  236 
etiology  of,  236 
prognosis  of,  238 
symptoms  of,  237 
treatment  of,  238 
types  of,  238 
Beta-oxybutyric  acid,  908,  910 
Biernacki's  sign,  1117 
Bile,  flow  of,  651 

Bile-ducts,    obliteration   of,    congenital, 
741 
tumors  of,  742 
Bile-vessels,  diseases  of,  725 
Bilharzia  disease,  1275 
Biliary  cirrhosis  of  liver,  695,  704 

differentiation  of,   from 
portal,  705,  724 
colic,  730,  733 
Bilious  typhoid,  61 
Bilirubin,  test  for,  in  stools,  653 
Biot's  breathing,  1047 
Black  death,  219,  223 
smallpox,  71 

water  fever,  118,  121,  125 
Bladder,  tuberculosis  of,  352 
"Bleeders,"  874 
Blood,  diseases  of,  831 
in  pneumonia,  145 
pressure  in  typhoid  fever,  24 
typhoid,  bacilli  in,  27 
in  urine,  802 
Bloodvessels,  syphilis  of,  277 

tuberculosis  of,  356 
Bones,  syphilis  of,  292 

tuberculosis  of,  357 
Bothriocephalus  latus,  1261 
Botulism,  1251 
Boulimia,  648 


1284 


INDEX 


Bowels,  intussusception  of,  670 
strangulation  of,  671 
stricture  of,  673 

diagnosis  of,  675 

symptoms  of,  673 

treatment  of,  676 

in  typhoid  fever,  hemorrhage  from, 

33 

perforation  of,  34 

treatment  of,  53 
Brachial  neuritis,  1178 
Brachycardia,  456 
Bradycardia,  456 
etiology  of,  456 
prognosis  of,  457 
treatment  of,  457 
Brain,  abscess  of,  1013 

diagnosis  of,  1017 
differentiation  of,  1017 

from    extradural    abscess, 

1017 
from  otitis,  1017 
from     serous     meningitis, 

1017 
from     sinus      thrombosis, 

1017 
from  suppurative  meningi- 
tis, 1018 
from  tumor,  1008 
etiology  of,  1013 
pathology  of,  1013 
prognosis  of,  1019 
symptoms  of,  1015 
treatment  of,  1019 
actinomycosis  of,  259 
arteriosclerosis  of,  468 
atrophy  of,  1028 
cancer  of,  1001 
circulatory  diseases  of,  961 
anaemia,  961 
aneurysms,  989 
congestion,  962 
embolism,  979 
hemorrhage,  965 
hypersemia,  962 
oedema,  964 

thrombosis  (arterial),  985 
cysts  of,  1001 
degeneration  of,  1027 

lacunar,  987 
diffuse  lobar  sclerosis  of,  997,  1028 
diseases  of,  941 

differentiation  of,  from  serous 
meningitis,  1055 
glioma  of,  1000 
gumma  of,  1000 
hemorrhage  of,  449 
in  syphilis,  285 
hypertrophy  of,  1028 
inflammation  of,  1010 
lesions  of,  in  diphtheria,  167 
localization  of,  941 
sarcoma  of,  1000 
"softening"  of,  979,  985,  1020 
chronic,  1027 
syphilitic,  284 


Brain,  syphilis  of,  281 

differentiation  of,  from  paretic 
dementia,  1025 
from  tabes  dorsalis,  1122 
tuberculosis  of,  346,  999 
tumors  of,  999 

classification  of,  999 
course  of,  1009 
diagnosis  of,  1007 
differentiation  of,  1007,  1008 
from  brain  abscess,  1008 
from    chronic    meningitis, 

1009 
from     multiple     sclerosis, 

1009 
from  uraemia,  1007 
etiology  of,  999 
localization  of,  1001,  1003 
pathology  of,  999 
prognosis  of,  1009 
symptoms  of,  1001 
treatment  of,  1009 
Brand  bath  in  typhoid  fever,  49,  50 
Breasts,  chancre  of,  294 
gimama  of,  294 
syphilis  of,  294 
Breathing,  metamorphosing,  326 
Bremer's  test  of  diabetic  blood,  912 
Bright's  disease,  chronic,  774 
Briquet's  syndrome,  1190 
Broadbent's  sign,  388 
Broca's  convolution,  948 
Brodie's  joints,  1200 
Bromatotoxismus,  1251 
Bromism,  differentiation  of,  1026 
Bronchi,  dilatation  of,  502 
diseases  of,  495 
inflammation  of,  495 
foreign  bodies  in,  505 
stenosis  of,  504 
stones  in,  506 
syphilis  of,  280 
Bronchial  adenitis,  339 
astlama,  506 
breathing  in  pleurisy,  549 

in  pnemnonia,  145 
casts  in  pneumonia,  142 
glands,  antlTracosis  of,  523 

tuberculosis  of,  339 
stenosis,  505 

diagnosis  of,  505 
etiology  of,  505 
symptoms  of,  505 
treatment  of,  506 
ulcers,  syphilitic,  280 
Bronchiectasis,  502 

complications  of,  503 

diagnosis  of,  503 

differentiation  of,  from  gangrene  of 

lung,  530 
pathology  of,  502 
lahysical  signs  of,  503 
symptoms  of,  502 
treatment  of,  504 
Bronchitis,  acute,  495 

etiology  of,  495 


INDEX 


1285 


Bronchitis,  acute, symptoms  of,  496 
treatment  of,  497 
capillary,  518 
chronic,  498 

diagnosis  of,  499 
etiology  of,  498 
pathology  of,  498 
prognosis  of,  499 
symptoms  of,  498 
treatment  of,  499 
differentiation   of,    from   influenza, 

181 
fibrinous,  500 

diagnosis  of,  501 
etiology  of,  500 
prognosis  of,  501 
symptoms  of,  501 
treatment  of,  501 
in  heart  disease,  419 
in  influenza,  178 
mucinosa,  501 
pseudomembranacea,  501 
putrid,  499 

differentiation    of,    from    gan- 
grene of  lung,  530 
syphilitic,  280 
tuberculous,  311,  333 
in  typhoid  fever,  35 
in  whooping-cough,  184 
Bronchophony,  145 
Bronchopneumonia,  515 
bacteriology  of,  516 
diagnosis  of,  518 

differentiation  of,  from  lobar  pneu- 
monia, 519 
from  tuberculosis,  519 
diphtheritic,  168 
etiology  of,  515 
in  influenza,  179 
issues  of,  518  ' 

measles  as  cause  of,  99 
pathology  of,  516 
physical  findings  of,  516 
prognosis  of,  518,  519 
symptoms  of,  516 
treatment  of,  prophylactic,  519 

symptomatic,  519 
types  of,  special,  capillary,  518 
disseminated,  518 
generalized,  518 
in  whooping-cough,  184 
Bronchorrhcea,  498 
Brown-Sequard's  paralysis,  1086 
prognosis  of,  1088 
symptoms  of,  1086 
Bryson's  sign,  890 
Bruit  d'  arain  in  pneumothorax,  564 
de  diable,  833 
de  pot  fel6,  326 
Bubonic  plague,  219 
Bulbar  paralysis,  apoplectiform,  1033 
asthenic,  1032 
chronic,  1029 

diagnosis  of,  1031 
etiology  of,  1029 
pathology  of,  1029 


Bulbar  paralysis,  chronic,  prognosis  of, 
1032 
symptoms  of,  1030 
treatment  of,  1032 
complicated,     by     progressive 
muscular  atrophy,  1031 
syringomyelia,  1111 
Bundle  of  His,  457 
Burr  bath  in  typhoid  fever,  49,  50 


Cat's  tongue,  scarlatinal,  88 
Cachexia  in  cancer  of  liver,  712 
lienalis,  860 
lymphatica,  860 
scorbutic,  870 
strumipriva,  895 
thyreopriva,  895 
Cachexie  pachyder?nique,  894 
Caecum,  tuberculosis  of,  349 
Caisson  paralysis,  1085 

etiology  of,  1085 
pathology  of,  1085 
prognosis  of,  1085 
treatment  of,  1086 
Calcium  calculus,  818 

chloride,  in  hemorrhages,  875 
Calculus,  calcium,  818 
cystin,  818 
of  lung,  320 
oxalate,  818 
of  pancreas,  747 
phosphatic,  818 
renal,  817 

in  gall-stones,  733 
of  ureter,  822 
uric  acid,  817 
xanthin,  818 
Cancer  of  appendix  vermiformis,    678 
of  brain,  1001 
of  gall-bladder,  741 

diffei'entiation     of,      from 
gall-stones,  734,  735 
of  intestines,  677 
of  liver,  711 

differentiation  of,  from  biliary 
cirrhosis,  706,  724 
from  portal  cirrhosis,  701, 
702,  724 
primary,  711 
of  oesophagus,  595 
of  pancreas,  differentiation  of,  from 

gall-stones,  750 
of  peritoneum,  758 
of  rectum,  677,  679 
renal,  822 
of  stomach,  629 
of  thyroid  gland,  887 
of  vertebra;,  1075 
Cancrum  oris,  576 
Capsular  cirrhosis  of  liver,  695 
Caput  Medusa;,  698 
Carbohydrates,  physiology  of,  903 
Carbuncle  in  plague,  221,  222 


1286 


INDEX 


Carbuncle,    simple,     differentiation    of, 

from  anthrax,  241 
Cardiac  apoplexy,  449 
asthma,  509 

insufficiency  of  stomach,  646 
spasm,  644 
Cardialgia,  647 
Cardiogmus,  451 
Cardiomegaly,  899 
Cardiopalmus,  451 
Cardiospasm,  oesophagus,  593 
Caries  of  vertebrae,  1071 
Carphologia  in  typhoid  fever,  28 
Casts  in  pneumonia,  bronchial,  142 
fibrin,  142 
urinary,  769 

origin  of,  776 
significance  of,  776 
Catarrhal  diphtheria,  163 

stomatitis,  573 
Catarrhus  sestivus,  486 
Cauda  equina,  lesions  of,  1065 
Cellulitis,    differentiation   of,   from   ery- 
sipelas, 107 
Centrum  ovale,  localizing  symptoms,  951 
Cerebellar,  ataxia,  960 
causes  of,  960 
differentiation  of,  960 
vertigo,  960 
Cerebellum,  localizing  symptoms  of,  959 
Cerebral  embolism,  979 

diagnosis  of,  984 
differentiation  of,  from  cerebral 
hemorrhage,  988 
thrombosis,  988 
etiology  of,  979 
location  of,  982 
basilar,  984 
cerebral,  anterior,  983 

posterior,  983 
internal  carotid,  983 
Sylvian  artery,  982 
vertebral,  984 
pathology  of,  980 
prognosis  of,  984 
symptoms  of,  981 
treatment,  984 
hemorrhage,  965 
cerebellar,  977 
cortical,  976 
crus,  977 
diagnosis  of,  449 
of  coma,  975 
of  hemiplegia,  976 
of  location,  976 
differentiation,    from    cerebral 
embolism,  988 
from  cerebral  thrombosis, 
988 
etiology  of,  965 
locations  of,  966 
medulla,  977 
pathology  of,  965 
13ons,  977 
jDrognosis  of,  977 
symptoms  of,  968,  975,  988 


Cerebral     hemorrhage,      treatment     of 
chronic  stage,  979 
of  insult,  978 
prophylaxis,  978 
of  reaction,  979 
ventricular,  976 
localization,  941 

centrum  ovale,  951 
cerebellum,  959 
cerebral  peduncle,  956 
corpora  quadrigemina,  955 
corpus  striatum,  954 
crus,  956 

frontal  cortex,  947 
internal  capsule,  951 
motor  cortex,  941 
occipital  cortex,  946 
optic  thalamus,  954 
parietal  cortex,  946 
pons,  957 

temporal  cortex,  947 
nerves,  syphilis  of,  282 
paralysis,  infantile,  994 

diplegic  form,  996 
hemiplegic  form,  995 
pneumonia,  152 
rheumatism,  194,  199 
thrombosis,  985 

diagnosis  of,  987 
differentiation  of,  from  cerebral 
embolism,  988 
hemorrhage,  988 
from  lacunar  degeneration, 
987 
etiology  of,  985 
localization  of,  basilar,  987 
cerebral  anterior,  987 

posterior,  987 
Sylvian  artery,  986 
•-vertebral,  987 
pathology  of,  985 
prognosis  of,  989 
symptoms  of,  985 
treatment  of,  989 
Cerebrasthenia,  1194 
Cerebritis,  1010 
Cerebrospinal  fever,  175 

meningitis,  epidemic,  1045 
Cervical  adenitis,  338 
Cervix,  syphilis  of,  291 
Chalicosis  of  lungs,  523 
Chancre.     See  Syphilis 
Chancroid,  266 
Charcot-Leyden  crystals,  508 
Charcot's  disease,  1126,  1119 
Cheese  poisoning,  1252 
Chiasm,  optic,  1147 
Chicken-breast,  588 

rhachitic,  933 
Chickenpox,  81 

complications  of,  83 
diagnosis  of,  83 
differentiation  of,  83 
from  eczema,  83 
from  miliaria,  83 
from  pemphigus,  83 


INDEX 


1287 


Chickenpox,     differentiation    of,     from 
smallpox,  74 
from  syphilis,  83 
etiology  of,-81 
sequels  of,  83 
symptoms  of,  81 
Chills,  in  typhoid  fever,  21,  24 
Chlorides,  absence  of,  in  pneumonic  urine, 

146 
Chloroma,  858 
Chlorosis,  831 

complications  of,  834 
course  of,  835 
diagnosis  of,  835 

differentiation   of,    from   pernicious 
anaemia,  845 
from  secondary  anaemia,  845 
etiology  of,  831 
prognosis  of,  835 
symptoms  of,  832 
treatment  of,  836 
dietetic,  838 
iron,  836 
prophylactic,  836 
specific,  836 
Choked  disk,  in  brain  tumor,  1002,  1007, 

1008 
Cholaemia,  693,  699,  727 
Cholangitis,  catarrhal,  739,  741 
differentiation  of,  734,  735 

from  gall-stones,  734,  735 
suppurative,  739 
Cholecystitis,  738 

differentiation  of,  from  cancer,  734, 
735 
from  gall-stones,  734,  735 
etiology  of,  738 
following  typhoid  fever,  31 
prognosis  of,  739 
symptoms  of,  739 
treatment  of,  739 
Cholelithiasis.     See  Gall-stones,  728 
Cholera,  Asiatic,  207 

bacteriology  of,  207 
comma  bacillus,  207 
complications  of,  210 
diagnosis  of,  211 
dissemination  of,  207 
predisposition  to,  208 
prognosis  of,  212 
symptoms  of,  209 
treatment  of,  212 
infantum,  659 
nephritis,  771 
nostras,  211 
Cholerine,  211 

Chondrodystrophia  foetalis,  894 
Chondroma  of  thyroid  gland,  887 
Chorea,  acute,  1211 

course  of,  1214 
diagnosis  of,  1214 
etiology  of,  1211 
pathology  of,  1211 
prognosis  of,  1214 
symptoms  of,  1212 
treatment  of,  1216 


Chorea,  acute,  types  of,  1214 

in  cerebral  infantile  paralysis,  998 

chronic,  1215 

electric,  1216 

endocarditis  from,  397 

habit,  1215 

Huntindon's,  1215 

posthemiplegic,  974,  975 

rheumatic,  192,  199 
Choreiform  affections,  1210 
Choroidal  tubercles,  316,  1051 
Choroiditis,  syphilitic,  288 
Chyle  in  urine,  806 

vessels,  disease  of,  691,  765 
Chyliform  ascites,  766 

pleurisy,  553 
Chylothorax,  568 
Chylous  ascites,  765 
Chyluria,  806 

parasitic,  1272 
Chvostek's  sign,  1219 
Cirrhosis  of  liver,  695 

in  heart  disease,  421 
tuberculous,  311 

ventriculi,  609 
Cirsomphalos,  698 
Cladothrix  asteroides,  259 
Claudication  intermittente,  468 
Coccygodynia,  1232 
Colectasia,  682 
Colic,  biliary,  730 

lead,   differentiation  of,   from  gall- 
stones, 733 

mucous,  differentiation  of,  from  gall- 
stones, 733 

renal,  819,  821 

differentiation    of,    from    gall- 
stones, 733 
Colica  mucosa,  654 

etiology  of,  654 
symptoms  of,  654 
treatment  of,  654 

pictonum,  1247 
Colitis,  membranacea,  654 

mucosa,  654 
Collapse  in  pneumonia,  146 

in  typhoid  fever,  21,  25,  47 
Collar  of  brawn  in  scarlatina,  90 
Colles'  law,  295 

Colon   bacillus.     See    Septic   Affections, 
130, 133 

dilatation  of,  682 

prolapse  of,  680,  681 
Coloptosis,  680 
Coma,  alcoholic,  975 

apoplectic,  975,  988 

cardiac,  975,  976 

diabetic,  910,  918,  976 

epileptic,  1203 

opium,  975 

in  pernicious  malaria,  124 

urjeniic,  976 

vigil  in  typhoid  fever,  28 
Comma  bacillus,  207 
Common  bile-duct,  gall-stones  in,  differ- 
entiation of,  750 


1288 


INDEX 


Concato's  disease,  758 
;Concretio  pericardii,  387 
Concussion  of  spinal  cord,  1088 
Congenital  heart  disease,  430 

tuberculosis,  309 
Congestion  of  brain,  982 
of  kidney,  791 
of  liver,  arterial,  720 

passive,  721 
of  lungs,  acute,  534 
passive,  534 
Conjugate  deviation,  958 
in  apoplexy,  970 
Conjunctiva,  syphilis  of,  287 
Constipation,  685 

in  colica  mucosa,  treatment  of,  655 
etiology  of,  685 
symptoms  of,  685 
treatment  of,  cathartics,  688 
diet,  686 
enemata,  688 
exercise,  687 
rnassage,  687 
posture,  687 
in  typhoid  fever,  treatment  of,  52 
Constitutio  lymphatica,  886 
Constitutional  diseases,  903 
Consumption,  318 
Contracted  kidney,  775,  778,  784 
Contractures,  in  apoplexy,  973 

hysterical,  1188 
-Conus  meduUaris,  lesions  of,  1064 
stenosis,  405,  446 
in  syphilis,  277 
Convulsions  in  brain  tumor,  1002,  1007 
in  cerebral  embolism,  983,  988 
hemorrhage,  970 
thrombosis,  987,  988 
epileptic,  1203 
infantile,  1209 

etiology  of,  1209 
symptoms  of,  1210 
treatment  of,  1210 
Jacksonian,  1004,  1007 
in  typhoid  fever,  28 
in  whooping-cough,  184 
Coprostasis,  obstructing  bowel,  674 
Cor  bovinum,  402,  439 

villosum,  378 
Cornea,  syphilis  of,  287 
Coronary  disease,  arteritis,  447,  450 

atheroma,  447,  450 
Corpora  oryzoidea,  357 

quadrigemina,  localizing  symptoms, 
955 
Corpulence,  936 
Corpus   striatum,   localizing  symptoms, 

954 
Corrigan's  disease,  401 
Corset  liver,  720 

Cortex,  cerebral,  localization,  941 
Coryza,  485 

differentiation    of,    from    influenza, 

181 
syphilitic,  297 
in  typhoid  fever,  35 


Costa  fluctuans  decima,  680 

Courvoisier's  law,  732 

Cracked  pot  resonance,  in  pneumonia, 

144 
Craniotabes,  rhachitic,  932,  934 
Cranium  progenium,  900 
Crepitant  rale,  145 

diseases  where  present,  145        i 
in  pneumonia,  145 
Cretinism,  893 

diagnosis  of,  894 
etiology  of,  893 
symptoms  of,  893 
Crie  hydrencephalique,  1046 
Croup,  differentiation  of,  from  whooping- 
cough,  185 
diphtheritic,  165 
false,  491 

differentiation  of,  from  whoop- 
ing-cough, 185 
Croupous  enteritis,  655 
Crus,  localizing  symptoms,  956 
Cryoscopy,  780 

Crystals,  Charcot-Leyden,  508 
Culex  fasciata,  213 
Cyanosis  in  heart  disease,  419 
tuberculous,  315 
with  polycythaemia,  885 
with  splenomegaly,  885 
Cyclaster  scarlatinalis,  84 
Cycloplegia,  1150 
Cylinduria  in  pneumonia,  147 
Cynanche  gangrceneuse,  580 
Cystic  duct,  in  gall-stones, 731 

kidney,  etiology  of,  826. 
Cysticercus,  of  brain,  1001 

cellulosae,  1259 
Cystin  calculus,  818 

Cystitis,   differentiation  of,  from  pyeli- 
tis, 811 
in  typhoid  fever,  37 
Cystosoma,  hsematobium,  1275 
Cysts  of  brain,  1001 
of  liver,  714 

echinococcus,  714,  716 
multilocular,  716 
unilocular,  714 
hydatid,  differentiation  of,  from 

portal  cirrhosis,  724 
non-parasitic,  715 
of  pancreas,  748 
of  spleen,  883 
of  thymus  gland,  897 
of  thyroid  gland,  887 
Cytodiagnosis,  551 

in  lumbar  puncture,  1053 
Cytorytes  vaccinise,  77 
variolae,  64 


Damoiseau's  curve  in  pleurisv,  546 
Dandy-fever,  205 
Deafness,  1164 

cortical,  947,  948 


INDEX 


128.9 


Degeneratio  renum  polycystica,  826 
Degeneration  of  brain,  1027 
lacunar,  987 
of  kidnej's,  amyloid,  793 

cystic,  826 
of  pyramidal  tracts,  967 
of  spinal  cord,  ascending;,  1064 

descending,  1060,  1061 
of  spleen,  amyloid,  882 
of  suprarenal  glands,  881 
Delirium  cordis,  458 

in  fevers,  treatment  of,  54,  80 
tremens,  diagnosis  of,  1244 
etiology  of,  1244 
prognosis  of,  1244 
symptoms  of,  1244 
treatment  of,  1245 
Dementia  paralytica,  1020 
diagnosis  of,  1025 
differentiation  of,  from  alcohol- 
ism, 1026 
from  brain  sclerosis,  1025 

tumor,  1026 
from  bromism,  1026 
from  mania,  1026 
from     multiple     sclerosis, 

1025 
from  neurasthenia,  1026 
from  pachymeningitis, 

1026 
from  plumbism,  1026 
from  senile  dementia,  1025 
from  syiDhilis,  1025 
etiology  of,  1020 
pathogenesis  of,  1020 
pathology  of,  1020 
prognosis  of,  1026 
symptoms  of,  general,  1021 
treatment  of,  1027 
paretic,  1020 
senile,  1026 
Dengue,  205 

complications  of,  206 
diagnosis  of,  206 
differentiation  of,  207 
from  acrodynia,  207 
from  influenza,  207 
etiology  of,  205 
prognosis  of,  206 
sequels  of,  206 
symptoms  of,  205 
treatment  of,  207 
Dermatitis,      differentiation     of,      from 

erysipelas,  107 
Dermatomyositis,  1238 
Dercum's  disease,  938 
Dextrocardia,  432 
Diablie  bronze,  702,  913 
Diabetes,  coma  from,  976 
decipiens,  908 
in  gall-stones,  733 
insipidus,  919 

cerebral  syphilis,  282 
diagnosis  of,  920 
etiology  of,  919 
prognosis  of,  920 


Diabetes  insipidus,  symptoms  of,  919 
treatment  of,  920 
mellitus,  903 

cerebral  syphilis,  282 
complications  of,  910 
amaurosis,  911 
arteries,  912 
blood,  912 
coma,  910 
cystitis,  913 
dyspnoea,  910 
heart,  912 
gangrene,  914 

of  lungs,  912 
genital,  913 
infectious,  914 
intestines,  913 
liver,  913 
mental,  910 
neuralgia,  911 
neuritis,  911 
pregnancy,  913 
renal,  913 
retinitis,  911 
skin,  914 
stomach,  913 
tuberculosis  of  lungs,  912 
course  of,  914 
diagnosis  of,  915 
etiology  of,  904 
physiology  of,  903 
prognosis  of,  914 
symptoms  of,  glycosuria,  906 
tests  for,  906 
polydipsia,  910 
polyphagia,  910 
urine,  acetone,  909 
albuminuria,  908 
ammonium,  908 
beta-oxybutyric  acid, 

908 
constituents,  908 
diacetic  acid,  909 
pneumaturia,  910 
quantity,  906 
sugar,  906 
treatment  of,  complications,  918 
diet,  915 
general,  915,  917 
special,  916 
phosphatic,  807 
tuberculous,  311 
Diacetone,  diabetic,  909 
Diiimorrhysis,  961 

Diaphragmatic  hernia,  differentiation  of, 
from  pneumothorax,  566 
pleurisv,  553 
Diarrhoea,  648,  649,  684 
in  cholera  Asiatica,  209 
etiology  of,  684,  689 
infantile,  658 

cholera  infantum,  659 
chronic  dyspepsia,  661 
etiology,  65S 
fermental,  659 
ileocolitis,  660 


1290 


INDEX 


Diarrhoea,  infantile,  treatment  of  acute 
colitis,  663 
dyspepsia,  662 
enteritis,  663 
of  cholera  infantum,  663 
of  chronic  dyspepsia,  663 
dietetic,  661 
modified  feeding,  662 
in  pnemnonia,  146 
treatment  of,  684 
in  typhoid  fever,  treatment  of,  52 
Diazo  reaction,  in  malaria,  120 
in  measles,  99 
in  pneumonia,  147 
scarlatinal,  89 
in  tuberculosis,  336 
in  typhoid  fever,  37 
Dicrotic  pulse  in  typhoid  fever,  24 
Dietl's  crisis,  798 
Dietrich's  heart  stenosis,  405,  446 
Dilatation  of  aorta,  intermittent,  482 
of  bronchi,  502 
of  heart,  434 

differentiation    of,    from    peri- 
carditis, 385 
in  typhoid  fever,  25 
of  mesenteric  vessels,  691 
of  oesophagus,  593 
of  stomach,  acute,  610 
chronic,  611 
Diphtheria,  159 

bacteriology  of,  159 
complications  of,  166 
alimentary,  169 
glands,  169 
heart,  168 
nephritis,  168 
paralysis,  166 
respiratory,  168 
skin,  169 
course  of,  170 
diagnosis  of,  169 
differentiation  of,  170 

from  scarlatina,  87,  92 
from  tonsillitis,  585 
from  Vincent's  angina,  170 
dissemination  of,  161 
etiology  of,  159 

bacillus  diphtherise,  159 
Mebs-Loeffler  bacillus,  159 
localizations  of,  special,  164 
ear,  166 
eye,  166 
genitalia,  166 
larynx,  165 
nose,  164 
skin,  166 
prognosis  of,  170 
sequelse  of,  166 
symptoms  of,  162 

classifications  of,  162 
special,  164 
treatment  of,  171 
general,  174 
local,  171 
prophylactic,  171 


Diphtheria,  treatment  of,    serotherapy, 
172 
symptomatic,  174 
types  of,  162 

catarrhal,  163 
chronic,  163 
general  infection,  163 
latent,  163 
pharyngitic,  163 
septic,  164 
simple,  163 
tonsillitic,  163 
Diphtheritic  croup,  165 
enteritis,  655 
ophthalmia,  166 
otitis,  166 
vulvovaginitis,  166 
Diphtheroid,  159 
Diplegia,  in  cerebral  infantile  paralysis, 

996 
Diplococcus  intracellularis  meningitidis, 

1043,  1045 
Diplopia,  1152 
Dipsomania,  1241 
Disinfection,  by  formaldehyde,  79 
Dislocation  of  kidney,  795 

of  spine,  1070 
Disseminated  encephalomyelitis,  1095 

sclerosis,  1103 
Distoma  of  kidney,  829 
of  lung,  541 
pulmonale,  1275 
Distomiasis,  1275 
Dittrich's  mycotic  plugs,  499 
Diver's  paralysis,  1085 
Drachontiasis,  1273 
Dracunculus  medinensis,  1273 
Dropsy,  cardiac,  422,  427 
Drug  eruptions,  differentiation  of,  from 
measles,  101 
rashes,     differentiation     of,     from 
scarlatina,  92 
Drlisenfieber,  371 
Dubini's  disease,  1216 
Duct,  common,  in  gall-stones,  731 

cystic,  in  gall-stones,  731 
Ductless  glands,  diseases  of,  877 
Ductus  Botalli,  patency,  431 
Duke's  disease,  103 
Dunbar's  serum,  487 
Duodenal  ulcer,    complications   of,   657 
etiology  of,  655 
diagnosis  of,  657 
differentiation  of,   from   round 

ulcer,  624 
issues  of,  657 
symptoms  of,  656 
treatment  of,  657 
Duroziez's  murmur,  405 
Dysacusis,  1164 
Dysarthria,  948,  958,  959 
Dysbasia  intermittens,  468 
Dysentery,  224 

classification  of,  225 
amoebic,  227 

complications  of,  229 


INDEX 


1291 


Dysentery,  amcBbic,  issues  of,  229 
liver  abscess  in,  708 
pathology  of,  229 
symptoms  of,  228 
treatment  of,  231 
indeterminate  types,  230 
catarrhal,  230 
croupous,  231 
gangrenous,  231 
parasitic,  231 
Shiga's  bacillary,  225 

complications  of,  227 
diagnosis  of,  227 
pathology  of,  226 
prognosis  of,  227 
symptoms  of,  226 
treatment  of,  231 
Dyspepsia,  acute,  598 

in  children,  acute,  659 

chronic,  661 
intestinal,  648 
nervosa,  648 
Dysphagia  in  tuberculosis,  333 
Dyspnoea  in  heart  disease,  420 

Kussmaul's,  in  diabetes,  910 
tuberculous,  315 


Ear,  syphilis  of,  290 

tuberculosis  of,  354 
Ebstein's  cure,  937 
Echinococcus  disease,  1262 

of    liver,    differentiation    of,    from 
abscess,  724 
from  biliary  cirrhosis,  706, 
724 
multilocular,  716 
unilocular,  714 
of  lungs,  540 
renal,  828 

of  thyroid  gland,  887 
Eclampsia  in  contracted  kidney,  782 

in  kidney  of  pregnancy,  771 
Eczema,  differentiation  of,  from  chicken- 
pox,  83 
from  erysipelas,  107 
of  tongue,  577 
Ehrlich's  diazo  reaction,  37 
Emaciation  in  tuberculosis,  334 
Embolism  of  aorta,  483 
of  brain,  979 
cerebral,  979 
of  kidneys,  792 
of  lungs,  535 

in  typhoid  fever,  36 
of  mesentery,  691 
of  spinal  cord,  1083 
of  spleen,  882 

in  valvular  heart  disease,  422 
Emphysema  of  lungs,  510 
Empyema,  551 

necessitatis,  552 
pulsans,  552 
pneumococcic,  147,  552 


Empyema,  streptococcic,  551 

in  typhoid  fever,  36 
Encephalitis,  1011 

acute  hemorrhagic,  1011 

ophthalmoplegic,  1011 
etiology  of,  1010 
in  influenza,  177 
pathology  of,  1011 
poliencephalitis,  1012 
inferior,  1012 
superior,  1012 
poliencephalomyelitis,  1012 
prognosis  of,  1012 
suppurative,  1013 
syphilitic,  285 
treatment  of,  1013 
Encephalomalacia,  atheromatous,  985 
embolic,  979 
syphilitic,  284 
Encephalomyelitis,  disseminated,  1095 
Encephalopathia,  saturnina,  1250 
Endarteritis  deformans,  463 

syphilitic,  285 
Endiamorrhysis,  962 
Endocarditis,  392 
acute,  392 

benign,  397 

diagnosis  of,  399 
etiology  of,  397 
localization  of,  398 
pathology  of,  397 
prognosis  of,  399 
symptoms  of,  398 
treatment  of,  399 
malignant,  392 

diagnosis  of,  396 
etiology  of,  392 
pathology  of,  392 
prognosis  of,  397 
symptoms  of,  394,  395 
treatment  of,  397 
types  of,  394 

bacteriological,  396 
septic,  395 
typhoidal,  394 
visceral,  395 
verrucose,  397 
chorea,  relations  of,  1211,  1213 
chronic,  400 

etiology  of,  400 
pathology  of,  400 
symptoms  of,  401 
differentiation  of,  from  pericarditic 
rub,  384 
from  typhoid  fever,  44,  45 
rheumatic,  194 
scarlatinal,  88 
syphilitic,  277 
tuberculous,  334,  356 
in  tyijhoid  fever,  25 
ulcerative,  pneumococcic,  148 
Endocardium,  diseases  of,  392 
Endothelioma  of  spleen,  883 
Enemata,  nutrient,  625 
English  sweats,  372 
Enstrongylus  of  kidney,  829 


1292 


INDEX 


Enteralgia,  690 
Enteritis,  actinomycotic,  258 
acute,  649 
diagnosis  of,  650 
etiology  of,  649 
pathology  of,  649 
symptoms  of,  649 
treatment  of,  650 
chronic,  651 

pathology  of,  651 
prognosis  of,  653 
symptoms  of,  652 
treatment  of,  653 
croupous,  655 

differentiation     of,     from     typhoid 
fever,  43 
.  diphtheritic,  655 
mucous,  654 
phlegmonous,  655 
Enterocolitis  in  children,  660 
Enterodynia,  690. 
Enterokinase,  651 
Enteroliths,  674 
Enteroptosis,  680 
etiology  of,  600 
symptoms  of,  681 
treatment  of,  681 
Enterospasm,  689 
Enterostenosis,  673 
Ephemeral  fever,  371 
Epidemic  cerebrospinal  meningitis,  1045 
Epididymitis  in  mumps,  189 
Epilepsy,  1201 

in  cerebral  infantile  paralysis,  995, 

998 
convulsions  in  cerebral  syphilis,  284 
course  of,  1207 
diagnosis  of,  1205 
differentiation  of,  1205,  1206 
etiology  of,  1201 
Jacksonian,  944,  945,  1004,  1007 
differentiation  of,  1205 

from  organic  disease,  1007 
pathology  of,  1202 
prognosis  of,  1207 
symptoms  of,  1202 
treatment  of,  1207 
tyiDes  of,  1204 
Epileptiform  attacks  in  paretic  demen- 
tia, 1024 
Epistaxis,  etiology  of,  488 
in  influenza,  178 
treatment  of,  489 
in  typhoid  fever,  35 
Erb-Goldflam  syndrome,  1032 
Erb's  sign,  1219 
Ergotism,  1253 
Eructations,  gastric,  644 
Erysipelas,  103 

bacteriology  of,  104 
complications  of,  105 
alimentary,  106 
circulatory,  106 
genito-urinary,  106 
nervous,  105 
respiratory,  106 


Erysipelas,  complications  of,  septic,  107 
course  of,  105 
as  curative  agent,  109 
diagnosis  of,  107 
differentiation  of,  107 
from  angina,  107 
from  cellulitis,  107 
i  from  dermatitis,  107 

from  eczema,  107 
from  erysipeloid,  107 
from  erythema,  107 
from  lymphangitis,  107 
from  malignant  pustule,  107 
from  jjhlegmon,  107 
'         etiology  of,  104 

streptococcus  erysipelatos,  104 
of  larynx,  106 
of  lungs,  106 
of  pharynx,  106,  107 
prognosis  of,  108 
recurrence  of,  108 
symptoms  of,  104 
chill,  104 
eruption,  104 
fever,  105 
incubation,  104 
treatment  of,  108 
general,  109 
local,  108 
mechanical,  108 
medicinal,  109 
prophylaxis,  108 
serotherapy,  109 
varieties  of,  108 
Erysipeloid,  107 

differentiation  of,    from    erysipe- 
las, 107 
Erythema,  differentiation  of,  from  ery- 
sipelas, 107 
rheumatic,  192,  196 
visceral  crises  in,  867 
Erythromelalgia,  1235 
Exophthalmos,  goitrous,  889 
Extradural    abscess,    differentiation    of, 

from  brain  abscess,  1017 
Exudates,  character  of  fluid,  761,  762 
Eye,  syphihs  of,  287 


Facial  hemiatrophy,  1157 

hemihypertrophy,  1158 

paralysis,  1158 
Facies  cholerica,  209 
Faeces,  functional  examination  of,  652 
Fallopian  tubes,  syphilis  of,  292 

tuberculosis  of,  353 
Famine  fever,  55,  61 
Farcy,  245 

Fasciola  hepatica,  1276 
Fat  necrosis,  pancreatic,  743 

in  urine,  806 
Fatty  heart,  442 

liver,  717 


IXDEX 


1293 


Fatty  liver,    differentiation  of,  from  ab- 
scess, 724 
from  portal  cirrhosis,  701,  724 
Febricula,  371 
Febris  recurreiis,  61 
Fehleissen's   streptococcus    erysipelatos, 

103 
Felons,  syringomyelic,  1111 
Fever-cake,  in  malaria,  119 
Fibrin  casts  in  pneumonia,  142 
Filaria  medinensis,  1273 

nocturna,  1272 
Fish  poisoning,  1252 
Fissures  of  lungs,  interlobar,  555 
Fistula  in  ano,  350 
Fistulse  in  gall-stones,  733 
Flint's  murmur,    404,  412 
Floating  liver,  719 

spleen,  884 
Fcetor  ex  ore,  differentiation  of,  530 
Folie  cardiaque,  458 
Food  poisoning,  1251 
Foot  and  mouth  disease,  375 
Forced  movements,  960 

postures,  960 
Formaldehyde  as  disinfectant,  79 
Forscheimer's  spots,  102 
Fourth  disease.  Duke's,  103 
Fracture  of  spine,  1068 
Frantzel's  rules,  in  valvular  disease,  409 
Friction  rub,  pericarditic,  381,  382 

pleuritic,  545,  548 
Friedlander's  bacillus,  137 
Friedreich's  ataxia,  1135 
change  of  note,  326 
tones,  405 
Fumigation,  formaldehyde,  79 
Funnel  breast,  588 


Galactotoxismus,  1252 
Gall-bladder,    cancer    of,    complications 
of,  742 
differentiation  of,  742 
from    gall-stones, 
734,  735 
etiology  of,  741 
pathology  of,  741 
symptoms  of,  741 
diseases  of,  725 

differential  table,  735 
in  gall-stones,  731 
inflammation  of,  738 
sarcoma  of,  741 
tumors  of,  741 

differentiation    of,    from 
gastric  cancer,  636 
stones,  728 

chemistry  of,  729 
complications     of,     ampulla 
.     Vateri,  732 
common  duct,  731 
cystic  duct,  731 
diabetes,  733 


Gall-stones,    complications   of,    fistulse, 
733 
gall-bladder,  731 
intestinal  obstruction,  732 
renal  calculus,  733 
diagnosis  of,  733,  734,  735 
differentiation   of,    from   acute 
pancreatitis,  745 
from   angioneurotic   crisis, 

733 
from  appendicitis,  733 
from  cancer  of  gall-bladder,. 

734,  735 
from   cancer  of  pancreas, 

750 
from  cholangitis,  734,735 
from  cholecystitis,  734,  735 
from  gastralgia,  733 
from  gastric  ulcer,  657,  733 
from  lead  colic,  733 
from  mucous  colic,   733 
from  renal  colic,  733 
from  round  ulcer  of  stom- 
ach, 624 
from  syiDhilis,  733 
of  liver,  275 
from  tabes,  733 
etiology  of,  728 
following  tyi^hoid  fever,  31 
frequency  of,  728,  729 
intestinal   obstruction    from, 

674,  676 
prognosis  of,  736 
properties  of,  729 
symptoms  of,  730 
treatment  of,  colic,  736 
medicinal,  736 
prevention,  736 
surgical,  736 
varieties  of,  729 
Gangrene,  diabetic,  914,  918 
of  lung,  528 

pneumonic,  149 
in  tuberculosis,  333 
in  typhoid  fever,  36 
spontaneous  symmetrical,  1235 
in  typhoid  fever,  24 
Gangrenous  stomatitis,  576 
Gastralgia,  647 

differentiation  of,  626 
from  gall-stones,  733 
Gastrectasia,  610 
Gastric  fever,  371 

ulcer,    complications   of,   duodenal, 
655,  656,  657 
differentiation    of,    from    duo- 
denal ulcer,  657 
from  gall-stones,  733 
Gastritis,  acute  diplitheritic,  601 
parasitic,  601 
phlegmonous,  600 
simple,  diagnosis  of,  599 
etiology  of,  598 
symptoms  of,  598 
treatment  of,  599 
toxic,  600 


1294 


INDEX 


Gastritis,  atrophic,  631,  633 
chronic,  diagnosis  of,  606 
etiology  of,  601 
pathology  of,  601 
symptoms  of,  602 
treatment  of,  diet,  606 
lavage,  607 
medicinal,  608 
preventitive,  606 
differentiation  of,  from  cancer,  626 
from  gastralgia,  626 
from  gastria  ulcer,  626 
from  hyperchlorhydria,  626 
from  typhoid  fever,  43 
pneumococcic,  149 
stenosing,  611 
■Gastrodynia,  647 
Gastro-enterostomy  in  gastric  cancer,  637 

in  gastric  ulcer,  629 
Gastroptosis,  680.     See  Enteroptosis. 
Gastrorrhagia,  637 
Gastrosuccorrhoea,  diagnosis  of,  643 
etiology  of,  642 
prognosis  of,  643 
symptoms  of,  642 
treatment  of,  643 
Gelatin  injections,  tetanus  from,  248 
Genitalia,  syphilis  of,  290 
Genito-urinary  tract,  tuberculosis  of,  350 
Genu  valgum,  rhachitic,  936 
Gerhardt's  change  of  note,  326 
German  measles,  102 

diagnosis  of,  103 
differentiation  of,  103 

from  Duke's  disease,  103 
from  measles,  100 
from  scarlatina,  100 
etiology  of,  102 
prognosis  of,  103 
symptoms  of,  102 

constitutional,  103 
eruption,  102 
incubation,  102 
prodromes,  102 
stages,  102 
treatment  of,  103 
Gersuny's  sign,  686 
Gigantism,  900 
Gingivitis,  scorbutic,  870 
Glanders,  244 

course  of,  245 

diagnosis  of,  247 

differentiation  of,  from  anthrax,  241 

from  smallpox,  76 
etiology  of,  244 
pathology  of,  245 
symptoms  of,  245 
farcy,  245 
,  acute,  245 
chronic,  246 
glanders,  246 
acute,  246 
chronic,  246 
treatment  of,  247 
Glandular  fever,  371 
•  Glioma  of  brain,  1000 


Glissonian  cirrhosis  of  liver,  695 
Globulin,  tests  for,  801 
Globus^  hystericus,  1187 
Glomerulo-nephritis,  scarlatinal,  89 
Glossitis,  acute,  578 

dessicans,  578 
Glottis,  cedema  of,  493 

in  typhoid  fever,  35 
spasm  of,  diagnosis  of,  185 

differentiation  of,  from  whoop- 
ing-cough, 185 
Glycosuria,  903,  906 
syphilitic,  277 
tests  for,  Fehling's,  906 
fermentation,  906 
phenylhydrazin,  907 
Goitre,  886 

exophthalmic,  888,  890 
acute,  891 
course  of,  891 
diagnosis  of,  891 
etiology  of,  888 
forme  fruste,  891 
prognosis,  891 
symptoms  of,  889 
accessory,  890 
cardinal,  889 
constitutional,  891 
tachycardia,  889 
treatment  of,  electrical,  892 
general,  891 
medicinal,  892 
organotherapy,  892 
thyroidectomy,  892 
Gonococcus.    See  Septic  Affections,130, 
133 
localizations,  260,  261 
Gonorrhoeal  infection,  260 
arthritis,  261 

classification,  262 
course,  262 
pathology,  262 
symptoms,  261 
treatment,  262 
variations,  262 
gonococcus,  260 
in  blood,  260 
in  brain  and  cord,  261 
in  endocarditis,  261 
in  joints,  260 
in  liver,  260 
in  myocardium,  260 
in  pleura,  260 
in  skin,  260 
in  vessels,  261 
,  regional,  260 
septicopyaemia,  260 
Gout,  920 

complications  of,  923 
diagnosis  of,  924 
etiology  of,  920 
pathology  of,  922 
prognosis  of,  924 
symptoms  of,  acute,  921 

chronic,  922 
treatment  of,  acute,  924 


INDEX 


1295 


Gout,  treatment  of,  acute,  alkalies,  925 

colchicum,  924 

diet,  925 

salicylates,  924 
chronic,  926 
Grafe's,  von,  sign,  890 
Grain  poisoning,  1253 
Graphospasmus,  1221 
Graves'  disease,  888 
Greene's  sign  in  pleurisy,  545 
Grindelia,  509,  510 
Grippe.    See  Influenza,  175 
Grocco's  sign  in  pleurisy,  547 
Guinea- worm  disease,  1273 
Gumma.    See  Syphilis. 
Gums,  tuberculosis  of,  346 
Gutta  cadens,  566 


H 


Habitus  enteroptoticus,  680 
Hsematemesis,  diagnosis  of,  629,  636 

differentiation  of,  hsemoptysis,  538 

etiology  of,  637 

in  gastric  cancer,  634,  632,  626 
ulcer,  620,  626 

in  portal  cirrhosis,  699 

symptoms  of,  638 

syphilitic,  272 

treatment  of,  628 

in  typhoid  fever,  30 
Hsematomyelia,  1083 
Haematoporphyrinuria,  809 
Haematorrhachis,  1077 
Hematuria,  802 

angioneurotic,  802 

diagnosis  of,  803 

endemic,  1275 

etiology  of,  802 

renal  colic  causing,  819,  821 
tumor  causing,  823 

symptoms  of,  803 

treatment  of,  804 
Hajmochromatosis,  702 

etiology,  746 
Heemoglobinuria,  804 

epidemic,  804,  869 

etiology  of,  804 

in  malaria,  125 

nephritis  in,  771 

paroxysmal,  804 

symptoms  of,  804 

syphilitic,  276 

treatment  of,  805 
Hsemopericardium,  391 

differentiation  of,  from  pericarditis, 
385 
Haemophilia,  873 

diagnosis  of,  875 

etiology  of,  874 

prognosis  of,  875 

renal,  874 

symptoms  of,  874 

treatment  of,  875 
Ha^moptoe,  537 


Haemoptysis,  320 

bronchiectasis  causing,  503 
cause  of  tuberculosis,  321 
endemic,  1275 
forms  of,  320,  321 
frequency  of,  320 
in  heart  disease,  419 
of  lungs,  537 

result  of  tuberculosis,  320 
symptoms  of,  321 
in  tuberculosis,  320 
Haemorrhoids,  683 
Haemothorax,  568 
"Half-moon"  space,  547 
Hanford's  tender  toes  in  typhoid  fever,  29 
Hanot's  disease,  704 
Hay  fever,  486 

etiology  of,  486 
symptoms  of,  486 
treatment  of,  487 
Haygarth's  nodosities,  928 
Head,  actinomycosis  of,  257 
Headache,  in  brain  tumor,  1002,  1007, 
1008 
difTerentiation  of,  1228 
fevers,  treatment  of,  54,  80 
in  malaria,  121 
migraine,  1227 
sick,  1226,  1228 
in  typhoid  fever,  27 
Head's  maximal  points,  1230,  1232 
Hearing,  centre  for,  947 
Heart.    See  also  Myocardium 
aneurysm  of,  446 
arteriosclerosis  of,  468 
atrophy  of,  441 
block,  457 
dilatation  of,  434 

diagnosis  of,  436 
differentiation  of,  436 

from     encapsulated    pleu- 
risy, 437 
from   mediastinal   obesity, 

437 
from  pericarditis,  385 
from    pulmonary    consoli- 
dation, 436 
etiology  of,  434 
pathology  of,  434 
prognosis  of,  437 
signs  of  auricular  dilatation,  436 
of  left  ventricle  dilatation, 

435 
of    right    ventricle    dilata- 
tion, 436 
symptoms  of,  435 
treatment  of,  437 
in  typlioid  fever,  25 
disease  colls,  420 
congenital,  430 

aortic  atresia,  432 
dextrocardia,  432 
interauricular  defects,  430 
interventricular  defects, 

431 
patent  ductus  Botalli,  431 


1296 


INDEX 


Heart    disease,    congenital,     persistent 
isthmus  aortse,  431 
prognosis  of,  433 
pulmonary  stenosis,  430 
symptoms  of,  general,  433 
transposition     of     vessels, 

432 
treatment  of,  433  ; 

tricuspid  stenosis,  432 
vahnilar  anomalies,  432 
valvular  combined  lesions,  417 
diagnosis  of,  417 
prognosis  of,  418 
course  of,  422 
prognosis  of,  422 
signs   of.      See   Individual 

Lesions, 
symptoms  of,  418 
cardiac,  418 
constitutional,  418 
embolism,  422 
gastro-intestinal,  420 
joint,  422 
kidney,  421 
liver,  421 
nervous,  419 
cedema,  422 
respiratory,  419 
spleen,  421 
treatment  of,  423 

compensated    lesions, 

423 
digitalis,  425 
exercise,  424 
hygiene,  423 
Oertel  method,  425 
purgative,  425 
rest,  424 

Schott  method,  425 
sjTnptomatic,  427 
uncompensated     les- 
ions, 424 
venesection,  425 
fatty,  442 

Adams-Stokes  syndrome  of,  443 
diagnosis  of,  443 
etiology  of,  442 
pathology  of,  442 
prognosis  of,  443 
signs  of,  443 
symptoms  of,  443 
treatment  of,  444 
hypertrophy  of,  438 
diagnosis  of,  441 
etiology  of,  439 
in  interstitial  nephritis,   780 
pathology  of,  438 
prognosis  of,  441 
signs    of   left   ventricle    hj-jDer- 
trophy,  440 
of    right    ventricle    hjiDer- 
trophy,  440 
symptoms  of,  440 
treatment  of,  441 
intermittence  of,  458 
irritable,  439 


Heart  murmurs,  ansemic  diastolic,  405 
systolic,  409,  414 
functional,  833 
diastolic,  405 
neuroses  of,  451 
operations  on,  450 
palx^itation  of,  451 
diagnosis  of,  453 
etiology  of,  452 
prognosis  of,  453 
signs  of,  452 
symptoms  of,  452 
treatment  of,  453 
pang,  458 

retraction  of  apex  of,  388 
rupture  of,  446,  450 
diagnosis  of,  450 
etiology  of,  450 
pathology  of,  450 
symptoms  of,  450 
treatment  of,  450 
sj-jjhilis  of,  277 
thrombosis  of,  451 
tuberculosis  of,  356 
Heat  exhaustion,  1254 
Heberden's  nodes,  929 
Hemianesthesia,  hysterical,  1184 
lesions  in,  crus,  957 

internal  capsule,  953 
optic  thalamus,  955 
pons,  958 
Hemianopsia,  946,  952,  954,  1147,  1148 
Hemiatrophy,  facial,  1157 
Hemicrania,  1226 
Hemifacial  atrophy,  1157 

hj'pertrophy,  1158 
Hemih^qjertrophv,  facial,  1158 
Hemiopia,  946,  952,  954 
Hemiplegia,  in  aged,  987 
alternating,  956,  957 
in  apoplexj%  970,  972,  976,  988 
cerebral,  953 

embolism,  983,  988 
infantile  paralysis,  994 
thrombosis,  986,  988 
collateral,  971 
cortical,  943 
double,  958 
etiology  of,  976 
hysterical,  1187 
internal  capsule  lesion  in,  953 
in  pachjTiieningitis,  1039 
in  pneumonia,  147 
spinal,  1086 
uremic,  782 
Hemorrhage    from    bo-\vels,    in    t3T)hoid 
fever,  33 
of  brain,  449,  965 

in  syphilis,  285 
in  cirrhosis  of  liver,  699 
mediastinal,  571 
of  mesentery,  691 
of  new-born,  s^'23llilitic,  297 
occult,  620,  638 
of  oesophagus,  597 
from  pancreas,  747 


lYDEX 


1297 


Hemorrhage  of  spinal  cord,  1083 
of  tlijaiius  gland,  897 
in  tuberculosis,  316 
in  whooping-cough,  184 
in  yellow  fever,  217 
Hemorrhagic  diseases,  866 

classification  of,  866 
haemophilia,  873 
infantile  scurvj^,  872 
of  new-born,  869 
purpura,  866 
scurvy,  870 
encephalitis,  acute,  1011 
erosions  of  stomach,  624 
pachymeningitis,  1040 
pleurisy,  553 
Henoch's  purpura,  868 
Hepar  adiposum,  717 
migrans,  719 
mobile,  719 
Hepatargia,  699,  693,  727 
Hepatic  fever,  intermittent,  732 
insufficiency,  727 
vein  cirrhosis  of  liver,  695 
vessels,  diseases  of,  723 
Hernia,  diaphragmatic,  672 

differentiation  of,  from  pneumo- 
thorax, 566 
external,  671 
internal,  671 
of  linea  alba,  624 
Herpes  in  malaria,  119 
in  pneumonia,  146 
in  tuberculosis,  317 
in  typhoid  fever,  24 
zoster,  1232 
Herpetic  fever,  371 
Hiccough,  1175 
Hippocratic  fingers,  336 

succussion,  566 
Hirschsprung's  disease,  682 
His'  bundle,  457 
Hodgkin's  disease,  860 
Horse-shoe  kidney,  795 
Hour-glass  stomach,  616 
Hunger,  disturbance  of,  sense  of,  647 
Huntingdon's  chorea,  1215 
Hutchinson's  mask,  1117 
teeth,  297 
triad,  287 
Hydatids,  1262 

cysts.     See  Liver,  Cysts  of. 
Hydrarthrosis,  intermittens,  1237 
Hydrencephalic  state,  660 
Hydrencephaloid,  962 
Hydrobilirubin,  test  for,  in  stools,  653 
Hydrocephalus,  acute,  1034 
chronic,  acquired,  1036 

diagnosis  of,  1036 
etiology  of,  1036 
symptoms  of,  1036 
treatment  of,  1037 
congenital,  1034 

course  of,  1036 
etiology  of,  1034 
pathology  of,  1035 

82 


Hydrocephalus,      chronic,       congenital. 

symptoms  of,  1035 
Hydrochinon  in  urine,  809 
Hydrochloric  acid,  action  of,  607 

tests  for,  in  stomach,  603,  604 
Hydromyelus,  1109 
Hydronephrosis,  814 

diagnosis  of,  815 

differentiation      of,       from      cystic 
kidney,  828 
from  ovarian  tumor,  816 
from  pyonephrosis,  815 

prognosis  of,  816 

symptoms  of,  814 

treatment  of,  816 
Hydropericardium,  391 

differentiation     of,     from     pericar- 
ditis, 384 
Hydroperitoneum,  759 
Hydrophobia,  252 

course  of,  254 

diagnosis  of,  255 

differentiation  of,  255 

etiology  of,  253 

incubation  in,  253 

pathology  of,  254 

prognosis  of,  254,  255 

stages  of,  253 

symptoms  of,  253 

treatment  o*,  255 
inoculation,  255 
late,  256 

l^rimary  wound,  255 
proi^hylactic,  255 
Hydrops  articulorum  intermittens,  1237 

pericardii,  391 

renum  cysticus,  826 
Hydrorrhachis  interna,  1109 
Hydrotherapy,  in  pneumonia,  158 

in  tyi^hoid  fever,  49 
Hydrothorax,  567 

diagnosis  of,  568 

differentiation  of,  from  pleurisy,  558 

etiology  of,  567 

symptoms  of,  568 
Hyperaciditas  hydrochlorica,  640 
Hyperacusis,  1164 
Hyperaemia  of  brain,  962 

of  .spinal  cord,  1083 
Hypersesthesia  of  stomach,  646 
Hyperchlorhydria,  diagnosis  of,  641 

differentiation  of,  626,  641 

etiology  of,  640 

in  gastric  ulcer,  621 

prognosis  of,  641 

symptoms  of,  640 

treatment  of,  627,  641 
Hyperdiiimorrhysis,  962 
Hyperkinesis  cordis,  451 

gastric,  644 
Hypernephroma,  825 
Hyperorexia,  648 
Hyperosmia,  1146 
Hyperostosis  cranii,  900 
Hypersecretion,  578 

gastric,  642 


1298 


INDEX 


Hypertrophy  of  brain,  1028 
of  heart,  438 

arteriosclerotic,  467 
hemifacial,  1158 
of  lungs,  514 
of  pylorus,  636 
of  thymus  gland,  897 
of  thyroid  gland,  886,  888 
Hypochlorhydria,  644 
Hypochondriasis,  1197 
Hypodermatoclysis,  212 
Hypophysis,  diseases  of,  898 
Hyposecretion,  gastric,  644 
Hypostasis  of  lungs,  534 

in  typhoid  fever,  36 
Hysteria,  1184 

angina  pectoris,  461 
course  of,  1191 
diagnosis  of,  1191 

differentiation     of,      from     hydro- 
phobia, 255 
from  multiple  sclerosis,  1108 
from  myelitis,  1094 
from  serous  meningitis,  1055 
from  tetanus,  250 
from  whooping-cough,  185 
etiology  of,  1184 
ileus  in,  675 
prognosis  of,  1191 
stigmata,  1184 

hemiansesthesia,  1184 
sensory,  1184 
symptoms  of,  1184 
treatment  of,  1191 
Icing  liver,  758 
Icterus,  725 

acute  catarrhal,  etiology  of,  739 
prognosis  of,  740 
symptoms  of,  740 
treatment  of,  740 
febrile,  372 
in  cancer  of  liver,  712 
in  cirrhosis  of  liver,  700 
diagnosis  of,  728 

dififerentiation  of,  from  biliary  cir- 
rhosis of  liver,  706 
epidemic,  373 
etiology  of,  725 
gravis,  694 
hsematogenous,  725 
in  heart  disease,  421 
neonatorum,  725 
pneumonic,  149 
prognosis  of,  728 
symptoms  of,  726 
syphilitic,  275 
treatment  of,  728,  740 
in  typhoid  fever,  30 
urobilin,  725,  726 
Ichthyosis  of  tongue,  577 
Ichthyotoxismus,  1252 
Idiocy,  amaurotic  family,  1137 
Ileocolitis  in  children,  acute,  660 

dysenteric,  660 
Ileus,  dynamic,  675 
hysterical,  675 


Incoordination.     See  Ataxia 
Indicanuria,  808 
Indurative  pneumonia,  520 
Infantile  convulsions,  1209 
diarrhoea,  658 
paralysis,  cerebral,  994 

diplegic  form,  996 
hemiplegic  form,  995 
Infantilism,  894 
Infarcts  of  kidney,  792,  818 

of  lungs,  535 
Inflammation  of  brain,  1010 
of  bronchi,  495 
of  meninges,  1041 
of  mesentery,  690 
of  pancreas,  acute,  743 

chronic,  746 
of  spinal  cord,  1089 
of  thyroid  gland,  887 
Influenza,  175 

bacteriology  of,  176 
diagnosis  of,  181 
differentiation  of,  181 
from  bronchitis,  181 
from  coryza,  181 
from  dengue,  207 
from  measles,  101,  181 
from  meningitis,  181 
from  miliary  tuberculosis,  181 
from  typhoid  fever,  181 
etiology  of,  176 
prognosis  of,  181 
symptoms  of,  176 
alimentary,  180 
circulatory,  180 
classification  of,  176 
duration  of,  176 
fever,  177 
genito-urinary,  180 
joint,  180 
muscle,  180 
nervous,  177 
respiratory,  178 
skin,  180 
types  of,  176 
treatment  of,  181 

catarrhal  symptoms,  182 
convalescence,  182 
heart  symptoms,  182 
nervous  symptoms,  182 
varieties  of,  175 
Infusions,  saline,  158 
Insane,  paralysis  of,  1020 
Insolation,  1254 
Insular  sclerosis,  1103 
Interlobar  pleurisy,  554 
Intermittent  limping,  468 
Internal  capsule,    localizing    symptoms, 

951 
Interstitial  nephritis,  chronic,  777 
Intestinal  dyspepsia,  648 
obstruction,  670 
stenosis,  complications  of,  611 
Intestines,  amyloidosis  of,  272 
anthrax  of,  242 
arteriosclerosis  of,  469 


INDEX 


1299 


Intestines,  cancer  of,  670 

complications  of,  679 
diagnosis  of,  679 
differentiation  of,  679 
etiology  of,  677 
pathology  of,  677 
symptoms  of,  678 
treatment  of,  679 
diseases  of,  648 

foreign  bodies  in,  forms  of,  674 
hemorrhage  of,  682 
diagnosis  of,  683 
etiology  of,  682 
symptoms  of,  682 
treatment  of,  683 
obstruction  of,  diagnosis  of,  675 

differentiation   of,    from  acute 

pancreatitis,  745 
foreign  bodies,  674 
gall-stones  causing,  732 
intussusception,  670 
invagination,  670 
knots,  672 
strangulation,  671 
stricture,  673 
treatment  of,  medical,  676 

surgical,  677 
tumors,  674 
twists,  672 
volvulus,  672 
syphilis  of,  272 
typhoid  fever,  hemorrhage  from,  33 

perforation  of,  34 
tuberculosis  of,  347,  349 
tumors  of,  benign,  680 
cancer  of,  677 
sarcoma  of,  680 
ulceration  of,  655,  657 
syphilitic,  272 
in  tuberculosis,  335 
urgemic,  783 
Intoxications,  1241 
Intracranial  aneurysm,  989 
Intubation  in  diphtheria,  175 
Intussusception  of  bowel,  670 
etiology  of,  670 
issues  of,  671 
pathology  of,  670 
varieties  of,  670 
Iridoplegia,  1151 
Iritis,  syphilitic,  288 
Ischialgia,  1181 
Isthmus  aortse,  persistent,  431 
Itching,  treatment  of,  740 


Jaboulay's  sign,  in  hour-glass  stomach, 

617 
Jacksonian  convulsions,  1004,  1007 
epilepsy,  causes  of,  944 

characteristics  of,  945 
differentiation  of,  1205 
-Jaundice.    See  Icterus,  725 
acute  catarrhal,  739 


Jaundice,  acute  febrile,  372 

epidemic,  373 
Joffroy's  sign,  890 
Joints,  rheumatic,  192 

syphilis  of,  293 

tuberculosis  of,  357 
Jungle  fever,  125 

pernicious  malaria,  125 
Justus  test,  in  syphilis,  268 


K 


ICahler's  disease,  801 

Kakke,  236 

Keratitis,  syphilitic,  287 

Keratosis  of  tongue,  577 

Kernig's  sign,  1054 

Kidney,  anomalies  of,  794,  799 

Kidneys,  absent,  794 

amyloid  degeneration  of,  793 

differentiation  from   acute 
nephritis,  796,  797 
from  chronic  nephritis, 

796,  797 
from    congested    kid- 
ney, 796,  797 
etiology  of,  793 
pathology  of,  793 
symptoms  of,  793 
syphilitic,  276 
anomalies  of  secretion,  799 

of  structure,  794 
arteriosclerosis  of,  468 
ascending  infection  of,  778 
calculus  of,  817 
cancer  of.    See  Renal  Cancer 
congestion  of,  passive,  791 
diagnosis  of,  792 
differentiation  of,  796,  797 
etiology  of,  791 
pathology  of,  791 
symiDtoms  of,  792 
contracted,  arteriosclerotic,  778,  784 
embolic,  778 
primary,  778 
secondary,  775 
cystic,  826 

diagnosis  of,  828 
etiology  of,  826 
pathogenesis  of,  827 
pathology  of,  827 
symptoms  of,  827 
treatment  of,  828 
degeneration  of,  cystic,  826 
diseases  of,  767 
dislocation  of,  acquired,  795 

congenital,  795 
distoma  of,  829 
echinococcus  of.    See  Renal  Echino- 

coccus 
embolism  of,  792 
enstrongylus  of,  829 
floating,  795 
horse-shoe,  795 
infarction  of,  792 


1300 


INDEX 


Kidneys,  infarction  of,  pigment,  818 
uric,  818 
large,  red,  775 

variegated,  775 
white,  774 
malformations  of,  794 
movable,  795 

complications  of,  798 
diagnosis  of,  799 
etiology  of,  795 
prognosis  of,  799 
symptoms  of,  795 
treatment  of,  799 
of  pregnancy,  eclampsia  in,  771 
rudimentary,  794 
sarcoma  of,  825 
stone  of,  817 
supernumerary,  794 
syphilis  of,  277 
tuberculosis  of,  351 
Klebs-Loeffler  bacillus,  159 
Kopftetanus,  250 
Koplik's  spots,  97 
Kreatotoxismus,  1251 
Kussmaul's  breathing,  910 
Kyphosis,  rhachitic,  933 


Labioglossopharyxgeal     paralysis, 

1029 
Lactosuria,  905 
Lachrymal  glands,   symmetrical  hj^Der- 

trophy  of,  580 
Lactic  acid  in  gastric  cancer,  633 
etiology  of,  634 
tests  for,  634 
in  infantile  dyspepsia,  663 
Lacunar  degenerations  of  brain,  987 
Laennec's  cirrhosis  of  liver,  695 
La  Grippe,  175.     See  Influenza 
Landry's  paralysis,  1102 
etiology  of,  1102 
pathology  of,  1102 
prognosis  of,  1103 
symptoms  of,  1103 
Langerhans'  islands,  746,  904 

insufficiency,  904 
Laryngeal  gumma,  279 
perichondritis,  279 

in  typhoid  fever,  35 
.stenosis,  279 

ulcers,  in  typhoid  fever,  35 
Laryngismus  stridulus,  1169 
Laryngitis,  acute  catarrhal,  489 
diagnosis  of,  490 
etiology  of,  489 
syniptoms  of,  490 
treatment  of,  490 
in  children,  491 
fibrinous,  491 
nodose,  491 
submucous,  491 
suppurative,  491 
chronic  catarrhal,  492 


Laryngitis,   chronic   catarrhal,    etiology 
of,  492 
symptoms  of,  492 
treatment  of,  492 
hypertrophic,  492 
pachydermia,  492 
tuberosa,  492 
diphtheritic,  165 
in  influenza,  178 
rlieumatic,  192,  197 
stridiilous,  491 
syphilitic,  279 
Larynx,  diseases  of,  489 

differentiation  of,  from  whoop- 
ing-cough, 185 
erysipelas  of,  106 
oedema  of,  493 

paralysis  of.  1168,  1169,  1170 
perichondritis  of,  493 
symptoms  of,  494 
treatment  of,  494 
syphilis  of,  279 
tuberculosis  of,  354 
tumors  of,  494 
ulcerations  of,  494 
Lasegue's  sign,  193,  1182 
Lathyrism,  1254 

Lead  colic,  differentiation  of,  from  gall- 
stones, 733 
poisoning,  acute,  1248 
chronic,  1248 
Leontiasis  cssea,  900 
Leprosy,  366 

bacteriology  of,  367 
course  of,  370 
diagnosis  of,  370 

differentiation     of,     from     syringo- 
myelia, 1112 
i      •    distribution  of,  366 

pathology  of,  368 
'  prognosis  of,  370 

sjTQiptoms  of,  368 
i  treatment  of,  370 

I  Leptomeningitis,  1041 
I  chronic,  1056 

spinal,  1078 
I  Leukjemia.  850 
j  classification  of,  850 

]  lymphatic,  acute,  850 

diagnosis  of,  852 
symptoms  of,  851 
chronic,  852 
I  course  of,  853 

1  diagnosis  of,  854 

I  etiology  of,  852 

I  symptoms,  852 

myeloid,  854,  857 

complications  of,  857 
i  diagnosis  of,  857 

differentiation  of,  858 
prognosis  of,  859 
symptoms  of,  854 
treatment  of,  859 
Leukansemia,  858 
Leukocytha?mia,  850 
Leukocytosis  in  pneumonia,   146 


INDEX 


1301 


Leukopenia  in  typhoid  fever,  26 
Leukoplakia,  syphilitic,  271 

of  tongue,  577 
Leyden-Curschmann  spirals,  508 
Lichen  scrofulosorum,  358 
Lien  mobile,  884 
Lientery,  650 

Life  assurance,  syphilis  and,  295 
Lingual  tonsil,  587 
Lips,  tuberculosis  of,  346 
Lipuria,  806 
Lithiasis,  747 

diagnosis  of,  747 
symptoms  of,  747 
Lithuria,  807 

Litten's    diaphragmatic    sign    in    pneu- 
monia, 143 
sign  in  tuberculosis,  324 
Little's  disease,  997 
Liver,  abscess  of,  707 
amoebic,  708 

diagnosis  of,  710 
differentiation  of,  710,  724 
from  gall-stones,  710 
from  sepsis,  44 
from    subphrenic    ab- 
scess, 710 
from  typhoid  fever,  44 
pathology  of,  708 
symptoms  of,  hepatic,  709 
icterus,  710 
rupture,  710 
septic,  709 
treatment  of,  711 
cholangitic,  708 

differentiation  of,  from  cancer, 
713,  724 
from  cirrhosis,  724 
from  echinococcus,  724 
from  fatty  liver,  724 
from  pleurisy,  559 
from  stasis,  724 
from  syphilis,  724 
from  tumors,  724 
etiology  of,  707 
pylephlebitic,  707 
septic,  707 
solitary,  708 
tropical,  70S 
in  typhoid  fever,  31 
varieties  of,  707 
actinomycosis  of,  258 
amyloid,  275,  717 
diagnosis,  718 

differentiation  of,  from  cancer, 
713,  724 
from  portal  cirrhosis,  701, 
724 
etiology  of,  717 
laathology  of,  718 
symjjtoms  of,  718 
anomalies  of,  719 
atrophy  of,  acute  yellow,  692 
course  of,  694 
diagnosis  of,  694,  724 
differentiation  of,  694 


Liver,  atrophy  of,  acute  yellow,  etiology 
of,  692 
symptoms  of,  693 
treatment  of,  695 
cancer  of,  711 

diagnosis  of,  713 
differentiation  of,  713,  724 
from  abscess,  713,  724 
from  amyloid,  713,  724 
from  biliary  cirrhosis,  706, 

724 
from  corset  liver,  713 
from  hydatid,   713,   724 
from  portal  cirrhosis,  701, 

702,  724 
from  renal  tumors,  714 
from  stasis,  713,  724 
from  syphilis,  275,  713,  724 
primary,  711 
secondary,  711 
symptoms  of,  ascites,  712 
cachexia,  712 
icterus,  712 
liver,  712 
treatment,  714 
cirrhosis  of,  273,  695 
alcoholic,  695 
atrophic,  695 
biliary,  695,  704 

diagnosis  of,  705 
differentiation  of,  705,  724 
from  cancer,  706,  724 
from  echinococcus, 

706,  724 
from  icterus,  706 
from  portal  cirrhosis, 
705,  724 
etiology  of,  704 
symptoms  of,  704 
digestive,  705 
icterus,  704 
liver,  704,  705,  706 
nutrition,  705 
spleen,  705 
urine,  705 
treatment  of,  706 
capsular,  695 
cardio  tuberculosa,  336 
Glissonian,  695 
Hanot's,  695,  704 
hepatic  vein,  695 
in  heart  disease,  421 
Laennec's,  695 
malarial,  120 
mixed,  695 
•  pigmentary,  702 

differentiation   of,   from 
portal,  702 
portal,  695 

classification  of,  695 
complication  of,  699 
cardiac,  700 
febrile,  700 
hspmatemesis,  699 
hemorrhages,  699 


1302 


INDEX 


Liver,  portal  cirrhosis,  complication  of, 
icterus,  700 
nephritis,  700 
peritonitis,  700 
pulmonary,  700 
course  of,  701 
diagnosis  of,  701 
differentiation  of,  701,  724 
from  abscess,  724 
from  amyloid,  701,  724 
from  Banti's  disease, 

702 
from  biliary  cirrhosis, 

705,  724 
from  cancer,  701,  702. 

724 
from  chronic  peritoni- 
tis, 702,  764 
from  fatty,  701,  724 
from     hydatid     cyst, 

724 
from  icterus,  701,  724 
from        perihepatitis, 

702,  764 
from  pigmentary  cirr- 
hosis, 702 
from    pseudocirrhosis 

pericarditica,  702 
from   pylethrombosis, 

702 
from  stasis,  701,  702, 

724 
from     syphilis,     701, 
702,  724 
etiology  of,  696 
pathology  of,  696,  705 
prognosis  of,  701 
symptoms  of,  697 
clinical,  697 
general,  699 
liver,  697 
treatment  of,  medical,  703 
surgical,  703 
tuberculous,  311 
congestion  of,  arterial,  720 
passive,  421,  721 

differentiation  of,  722,  724 
etiology  of,  721 
pathology  of,  721 
symptoms  of,  721 
corset,  720 
cysts  of,  echinococcus,  714 

complications  of,  715 
diagnosis  of,  715 
differentiation  of,  715,  724 
multilocular,  716 
prognosis  of,  716 
rupture  of,  715 
symptoms  of,  714 
treatment  of,  716 
unilocular,  714 
hydatid,  differentiation  of,  from 

portal  cirrhosis,  724 
non-parasitic,  715 
diseases  of,  692 

differential  table  of,  724 


Liver,  enlargement  of,  differentiation  of, 
from  pleurisy,  559 
fatty,  717 

differentiation  of,  from  abscess, 
724 
from  portal  cirrhosis,  701, 
724 
etiology  of,  717 
pathology  of,  717 
symptoms  of,  717 
floating,  719 
flukes,  1276 
gmnma  of,  274 
large,  causes  of,  702 
lobulated,  274 

nut-meg,  in  heart  disease,  421 
perihepatitis,  •  273 
sarcoma  of,  711 
small,  causes  of,  701 
syphilis  of,  273 

differentiation  of,  from  abscess, 
724 
from  cancer,  713,  724 
from  portal  cirrhosis,  701, 
702,  724 
tuberculosis  of,  347,  336,  350 
tumors  of,   differentiation  of,  from 

abscess,  724 
wandering,  719 
Lock-jaw,  247 
Locomotor  ataxia,  1113 
LoefHer's  solution,  172 
Ludwig's  angina,  580 
Lues  venerea,  262 
Lumbago,  1239 
Lumbar  puncture,  1052 
Lumpy-jaw,  257 
Lungs,  abscess  of,  526 

bacteriology  of,  526 
diagnosis  of,  527 
differentiation  of,  527 

from  gangrene,  530 
etiology  of,  526 
pathology  of,  526 
pneumonic,  149 
prognosis  of,  527 
symptoms  of,  526 
treatment  of,  527 
in  typhoid  fever,  36 
actinomycosis  of,  259 
anthracosis  of,  522 
anthrax  of,  243 
arteriosclerosis  of,  469 
atelectasis  of,  524 
acquired,  525 

etiology  of,  525 
pathology  of,  525 
symptoms  of,  525 
treatment  of,  525 
congenital,  524 

etiology  of,  524 
pathology  of,  524 
symptoms  of,  524 
treatment  of,  524 
calculi  of,  320 


INDEX 


1303 


Lungs,    cavities    of,    differentiation   of, 
from  pleurisy,  559 
from  pneumothorax,  566 
signs  of,  326 
chalicosis  of,  523 
circulatory  affections  of,  534 
cirrhosis  of,  520 
congestion  of,  acute,  534 
passive,  534 

treatment  of,  535 
in  typhoid  fever,  36 
diseases  of,  510 
embolism  of,  535 

diagnosis  of,  536 
etiology  of,  535 
pathology  of,  535 
symptoms  of,  535 
in  typhoid  fever,  36 
emphysema  of,  510 
diagnosis  of,  513 
differentiation  of,  513 
etiology  of,  511 
interstitial,  513 
pathogenesis  of,  511 
pathology  of,  511 
prognosis  of,  514 
symptoms  of,  513 
treatment  of,  514 
erysipelas  of,  106 
fever,  136 
flukes,  1275 

gangrene  of,  bacteriology  of,  528 
complications  of,  530 
course  of,  530 
diagnosis  of,  530 
differentiation  of,  530 
etiology  of,  528 
pathology  of,  528 
physical  signs  of,  530 
pneumonic,  149 
prognosis  of,  530 
symptoms  of,  530 
treatment  of,  531 
in  tuberculosis,  333 
in  typhoid  fever,  36 
hfemoptysis,  537 

complications  of,  538 
course  of,  539 
diagnosis  of,  538 
etiology  of,  537 
prognosis  of,  539 
symptoms  of,  538 
treatment  of,  539 
hypertrophy  of,  514 

differentiation  of,  from  emphy 
sema,  514 
hypostasis  of,  534 
induration  of,  pneumonic,  149 
infarct  of,  535 

diagnosis  of,  536 
etiology  of,  535 
pathology  of,  535 
symptoms  of,  535 
interlobar  fissures  of,  555 
oedema  of,  536 

etiology  of,  536 


Lungs,  oedema  of,  in  heart  disease,  420 
pathology  of,  536 
in  rheumatism,  197 
symptoms  of,  536 
treatment  of,  537 
parasites  of,  540 
distoma,  541 
echinococcus,  540 

diagnosis  of,  541 
prognosis  of,  541 
symptoms  of,  540 
treatment  of,  541 
senile,  513 
siderosis  of,  523 
stones,  320,  506 
syphilis  of,  280 
tuberculosis  of,  318 
tumors  of,  531 
benign,  533 
cancer,  531 

etiology  of,  531 
symptoms  of,  532 

complications,  533 
compression,  532 
general,  532 
metastasis,  532 
physical  signs,  532 
sputum,  532 
differentiation   of,   from   pneu- 
monia, 153 
lymphosarcoma,  533 
sarcoma,  533 
Lupus,  358 

Lymph  glands,  tuberculosis  of,  337 
Lymphgemia,  acute,  850 

chronic,  852 
Lymphangitis,    differentiation   of,    from 

erysipelas,  107 
Lymphatism,  886 
Lymphoma,  malignant,  860 
Lymphosarcomatosis,  differentiation  of, 

864 
Lyssa,  252 
Lyssophobia,  255 


iVI 


Macule  tendinese,  379 
Maidism,  1253 
Maladie  de  Roger,  431 

de  Woillez,  534 
Malaria,  109 

cachexia  of,  122 
chronic,  122 
diagnosis  of,  125 
differentiation  of,  126 

from  other  febrile  diseases,  127 
from  sepsis,  126 
from  typhoid  fever,  44,  45 
etiology  of,  109 

Plasmodium,  110 

forms    of,     £Estivo-autum- 
nal,  112 
half-moons,  112 
quartan,  110 


1304 


IXDEX 


Malaria,  plasmodium  of.  forms  of,  tertian, 
111 
pernicious,  122 

etiology  of,  122 
forms  of.  124 
algid,  125 
alimentary,  125 
biliary,  125 
cerebral,  124 
comatose.  124 
convulsive.  125 
hsemoglobinuric.  125 
hemorrhagic.  125 
meningeal.  124 
typhoid,  123 
prognosis  of,  127 
relapses  of,  122 

relation  of,  to  other  diseases,  122 
spontaneous  recovery  from,  127 
symptoms  of,  115 
articular,  121 
blood,  118 
circulatory.  119 
digestive.  120 
fever,  115 

sestivo-autumnal.  117 
intermittent.  117 
quartan,  115 
tertian,  116 
genito-urinary,  120 
muscular,  121 
nervous,  121 
respiratory,  119 
skin,  119  ' 
special  senses,  121 
spleen.  118 
treatment  of.  127 

prophylaxic,  127 
sjDecific.  127 
symptomatic.  128 
Mai  perforant  du  pied,  1120 
Mallein.  245 
Malta  fever,  233 

complications  of,  234 
course  of,  235 
diagnosis  of,  235 
etiology  of.  233 
prognosis  of.  235 
symptoms  of,  234 
treatment  of.  235 
types  of.  235 
Mamma,  syphilis  of,  294 
tuberculosis  of.  353 
Mania  a  potu,  1244 
Marriage  after  syphilis,  299 
Mastitis,  syphilitic.  294 
Measles,  96 

clinical  course  of,  96 
diagnosis  of.  101 
differentiation  of.  100 

from  drug  eruptions,  101 
from  German  measles,  100 
from  influenza,  101.  181 
from  scarlatina,  100 
from  sepsis,  101 
from  smallpox.  67.  75 


Measles,   differentiation  of,  from  typhus 
fever.  60.  101 
from  variola,  101 
etiology  of,  96 

German.     See  German  Measles 
prognosis  of,  101 
stages  of,  96 
symptoms  of,  96 
cardiac,  99 
digestive,  99 
eruption,  97 
fever,  98 

general  course.  96 
genito-urinary.  99 
glandular.  99 
nervous.  99 
respiratory,  98 
splenic.  99 
treatment  of.  101 

of  complications,  102 
hygienic,  101 
prophylactic,  101 
Meat  poisoning,  1251 
Mediastinal  hemorrhage,  571 
pleurisy,  554 
tumors,  569 

diagnosis  of,  570 
symptoms  of,  569 
treatment  of,  571 
Mediastinitis,  acute,  571 

chronic,  571 
Mediastino-pericarditis,  387 
Mediastinum,  diseases  of,  569 
Megalogastria,  614 
Megalomania.  1022 
Melanaemia,  in  malaria.  118 
Melanoderma,  877,  879 
Melanoglossia,  578 
Melanotrichia  linguae,  578 
Melanuria,  713 
Melasma  suprarenale,  877 
Meniere's  disease,  diagnosis  of,  1166 
etiology  of,  1165 
symptoms  of,  1165 
treatment  of,  1166 
Meninges,  cerebral,  diseases  of.  1037 
hemorrhage  into,  1040 
inflammation  of,  1041 
spinal,  diseases  of,  1076 

hemorrhage,  1076 
hj'persemia,  1076 
leptomeningitis,  1077 
pachymeningitis,  1077 
tumors  of,  1079 

differentiation        of, 
from  syphilis.  283 
pathology,  1079 
symptoms  of,  1079 
tuberculosis  of,  346 
Meningismus,  1055 
Meningitis.  1041 

bacteriology  of,  1043 
chronic.  1056 

differentiation  of,  from  influenza, 
181 
from  typlnis  fever.  60 


INDEX 


1305 


Meningitis,  epidemic  cerebrospinal,  1045 
bacteriology  of,   1045 
clinical  forms  of,  1049 
complications  of,  1049 
etiology  of,  1045 
pathology  of,  1046 
prognosis  of,  1049 
sequelae  of,  1049 
symptoms  of,  1046 
treatment  of,  1055 
pneumococcic,  148 
etiology  of,  1042 
in  influenza,  178 
serous,  1052 

diagnosis  of,  1052 
differentiation  of,  1054,  1055 
from  brain  abscess,  1017 

disease,  1055 
from  hysteria,  1055 
from  labyrinthitis,  1055 
from  typhoid  fever,  1055 
symptoms  of,  1052 
suppurative,  1043 

diagnosis  of,  1052 
differentiation     of,     from     epi- 
demic, 1054 
from  brain  abscess,  1017, 

1018 
from  tuberculous,  1054 
pathology  of,  1043 
symptoms  of,  1044 
treatment  of,  1055 
syphilitic,  282 
tuberculous,  316,  1049 
diagnosis  of,  1052 
differentiation    of,     from     epi- 
demic, 1054 
from  suppurative,  1054 
from  syphilis,  283 
etiology  of,  1049 
pathology  of,  1050 
symptoms  of,  1051 
treatment  of,  1055 
in  typhoid  fever,  28 
Meningococcus  intracellularis,  1043,1045 
Meralgia  paraesthetica,  1179 
Merycismus,  646 

Mesenteric  glands,  suppuration     of,     in 
typhoid  fever,  32 
tuberculosis  of,  340 
vessels,  dilatation  of,  691 
embolism  of,  691 
periarteritis  of,  691 
Mesenteritis,  690,  764,  763 
Mesentery,  diseases  of,  690 
embolism  of,  691 
hemorrhage  of,  691 
inflammation  of,  690 
suppuration  of,  691 
tumors  of,  691 
Metabolism,  diseases  of,  903 
Metatarsalgia,  1232 
Meteorism  in  typhoid  fever,  32 
Micrococcus  catarrhalis,  496 

melitensis.  233 
Microgastria,  617 


Micromania,  1023 
Micromegaly,  899 
Migraine,  1226 

diagnosis  of,  1228 
etiology  of,  1226 
ophthalmoplegic,  1151 
prognosis  of,  1227 
symptoms  of,  1226 
treatment  of,  1228 
Mikiflicz's  disease,  580,  865 
Miliaria,  differentiation  of,  from  chicken- 
pox,  83 
in  pneumonia,  146 
in  typhoid  fever,  24 
Miliary  fever,  372 
tuberculosis,  313 

differentiation    of,    from    influ- 
enza, 181 
from  sepsis,  135 
from  typhoid  fever,  42,  44, 
45 
Milk  sickness,  374 

poisoning,  1252 
Millar's  asthma,  185,  897 
Mimetic  movements  of  expression,  954 
"Mind  blindness,"  946,  947 

centres  for,  947 
Mitral  insufficiency,  407 

diagnosis  of,  409,  412 
etiology,  407 
mechanism  of,  407 
physical  signs  of,  408 
stenosis,  410 

diagnosis  of,  411 
differentiation  of,  412,  449 
etiology  of,  410 
mechanism  of,  410 
physical  signs  of,  410 
prognosis  of,  412 
treatment  of,  423 
Mobius'  sign,  890 
Mogigraphia,  1221 
Moiler's  disease,  872 

Monoplegia,  in  cerebral  thrombosis,  986 
cortical,  943 

internal  capsule  lesion  in,  953 
Morbilli,  96 
Morbus  CEeruleus,  433 
coxae  senilis,  928 
maculosus  neonatoriun,  869 
Werlhofii,  868 
Morphinism,  1246 
Morphinomania,  1246 
Morvan's  disease,  1111 
Mosquito,  conveyance  of  malaria  by.  114 

yellow  fever,  213 
Motor  insufficiency  of  stomach,  610 

tracts,  1058,  1060,  1061 
Mountain  fever,  374 
Mouth,  diseases  of,  573 
syphilis  of,  270 
washes.  574,  575,  576 
Movable  kidney,  795 

.sijleen,  884 
Mucin,  tests  for.  801 


1306 


INDEX 


Mucous    colic,    differentiation    of,    from 

gall-stones,  733 
Mucus  casts,  of  bowel,  654 
Muguet,  575 
Multiule  neuritis,  1141 

sclerosis,  1103 
Mumps,  188 

complications  of,  189 
course  of,  189 
diagnosis  of,  190 
etiology  of,  188 
prognosis  of,  190 
sequels  of,  189 
symptoms  of,  188 
treatment  of,  190 
Muscles,  diseases  of,  1238 

sense,  in  cortex  lesions,  946 
syphilis  of,  293 
tuberculosis  of,  357 
in  typhoid  fever,  29 
Muscular  atrophy,  neuritic,  1131 
progressive  spinal,  1128 

diagnosis  of,  1130 
differentiation  of ,  1130 
etiology  of,  1128 
pathology  of,  1129 
prognosis  of,  1131 
symptoms  of,  1129 
treatment  of,  1131 
dystrophy,  1132 
"^^  diagnosis  of,  1134 

differentiation  of,  1135 
infantile  atrophic,  1133 
juvenile,  1134 
pseudohypertrophic,  1132 
treatment  of,  1135 
Myalgia,  1239 
capitis,  1239 
rheumatic,  197 
Myasthenia,  gastric,  612 
gravis,  1032 

differentiation,     from     polien- 

cephalitis,  1012 
pseudoparalytica,  1032 
Myasthenic  reaction,  1032 
Mycosis  intestinalis,  242 
Mycotic  plugs,  499 
Mydriasis,  syphilitic,  289 
Myelasthenia,  1194 
Myelitis,  acute,  1089 

course  of,  1093 
diagnosis  of,  1093 
differentiation    of,    from    hys- 
teria, 1094 
disseminated,  1095 
etiology  of,  1089 
localization  of,  1092 
pathology  of,  1090 
prognosis  of,  1093 
symptoms  of,  1090 
transverse,  1095 
treatment  of,  1094 
annular,  1090 
chronic,  1095 
compression,  1071 
cortical,  1090 


Myeloid  leukaemia,  857 

Myeloma,    multiple,    differentiation    of,. 

865 
Myelomalacia,  1083 
Myocarditis,  acute,  444 

circumscript,  445 
diagnosis  of,  445 
etiology  of,  444 
pathology  of,  444 
symptoms  of,  445 
treatment  of,  445 
chronic  fibrous,  446 

diagnosis  of,  448 
differentiation  of,  449 
etiology  of,  446 
pathogenesis  of,  447 
pathology  of,  446 
prognosis  of,  449 
symptoms  of,  448 
treatment  of,  449 
in  diphtheria,  168 
rheumatic,  196 
segmentary,  445 
syphilitic,  277 
in  typhoid  fever,  25 
Myocardium,  diseases  of,  434 
fragmentation,  445 
myofibrosis,  446,  447 
myolysis,  446 
myomalacia  cordis,  447 
parasites  of,  451 
segmentation,  445 
tuberculosis,  356 
tumors  of,  451 
Myoclonia,  1216 

Myofibrosis,  myocardii,  446,  447 
Myoidema,  335 
Myolysis  in  diphtheria,  168 

myocardial,  446 
Myomalacia,  cordis,  447 
Myopathies,  progressive,  1132 
Myositis,  1238 

ossificans,  1239 
rheumatic,  197 
syphilitic,  293 
Myotonia,  1222 

etiology  of,  1222 
symptoms  of,  1222 
treatment  of,  1222 
Mytilotoxismus,  1252 
Myxoedema,  893 
of  adults,  894 
differentiated,    from    exophthalmic 

goitre,  888 
operative,  895 
Myxoma  of  thyroid  gland,  887 


N 


Nasal  chancre,  278 

feeding  in  typhoid  fever,  51 

gumma,  278 
Nasopharynx,  tuberculosis  of,  354 
Nauheim  baths  in  heart  disease,  437 
Neck,  actinomycosis  of,  257 


INDEX 


1307 


Negri  bodies  in  hydrophobia,  254 
Nematodes,  diseases  caused  by,  1264 
Neoplasms  of  spleen,  883 
Nephritis,  acute,  767 
course  of,  772 
diagnosis  of,  770 
differentiation  of,  770,  796,  797 
from  amyloid  kidney,  796, 

797 
from  chronic,  796,  797 
from  congestion,  796,  797 
etiology  of,  767 
pathology  of,  768 
prognosis  of,  771 
symptoms  of,  albuminuria,  769 
ansemia,  770 
anasarca,  770 
casts,  769 
heart,  770 
hydrops,  770 
urine,  768 
treatment,  772 
types  of,  cholera,  771 

hsemoglobinuric,  771 
kidney  of  pregnancy,  771 
recurrent,  771 
chronic,  774 

interstitial,  777 

complications  of,  783 
diagnosis  of,  784 

of  cardiac  symptoms, 

784 
of  ursemia,  784 
of    urinary    findings, 
784 
differentiation     of,      from 
acute  nephritis,  796, 
797 
from  amyloid  kidney, 

796,  797 
from    chronic    paren- 
chymatous, 796, 797 
from    congested    kid- 
ney, 796, 797 
etiology  of,  778 
pathology  of,  778 
prognosis  of,  785 
symptoms  of,  779 

cardiovascular,  780 
digestive,  783 
hemorrhages,  783 
inflammations,  783 
oedema,  783 
retinitis,  781 
uraemia,  781 
urinaiy,  779 
treatment  of,  785 
parenchymatous,  774 

complications  of,  777 
death  in,  causes  of,  777 
diagnosis  of,  777 
differentiation      of,      from 
acute  nepliritis  796, 
797 
from  amyloid  kidney, 
796,  797 


Nephritis,  chronic,  parenchymatous,  dif- 
ferentiation of,  from 
congested     kidney, 
796,  797 
from  interstitial  neph- 
ritis, 796,  797 
etiology  of,  774 
pathology  of,  774 
prognosis  of,  777 
symptoms  of,  775 
ansemia,  776 
cardiovascular,  777 
oedema,  776 
urinary  of,  776 
treatment  of,  785 
treatment  of,  bleeding,  790 
climate,  786 
diet,  786 
diuretics,  788 
heart  stimulants,  790 
incisions,  789 
lumbar  puncture,  790 
oedema,  788 
rest,  785 
sweating,  788 
vasodilators,  790 
venesection,  790 
water,  788 
in  cirrhosis  of  liver,  700 
diphtheritic,  168 
in  ixialaria,  120 
in  pneumonia,  147 
suppurative,  809,  812 
scarlatinal,  89,  95 

treatment  of,  95 
syphilitic,  acute,  276 

chronic,  276 
tuberculous,  311 
typhoid,  37 
Nephrolithiasis,  817 
Nerves,  anterior  crural,  1179 
auditory,  paralysis  of,  1163 
brachial  plexus,  1178 
cerebral,  syphilis  of,  282,  289 
circumflex,  1176 
cranial,  diseases  of,  1146 
diseases  of,  1139 
eighth,  disease  of,  1163 
eleventh,  disease  of,  1172 
facial,  paralysis  of,  central,  1161 
peripheral,  1158 
spasm  of,  1163 
fifth,  paralysis  of,  1155 

spasm  of,  1157 
fourth,  diseases  of,  1149,  1151 
glossopharyngeal,  1166 
hypoglossal,  diseases  of,  1174 
lumbar  plexus,  1179 
median,  1177 
musculospiral,  1176 
ninth,  1166 
obturator,  1179 
olfactory,  1146 
optic,  1146 
peroneal,  1180 
phrenic,  1174 


1308 


IXDEX 


Nerves,  popliteal,  1180 

posterior  thoracic,  1176 

recurrent  laryngeal,  paralysis  of,  476 

spasm  of,  477 
sacral  plexus,   1180 
sciatic,  1180 

seventh,  diseases  of,  1158 
sixth,  diseases  of,  1149,  1151 
spinal  accessory,  paralysis  of,  1172 
spasm  of,  1172 

diseases  of,  1174 
superior  gluteal,  1180 
suprascapular,  1176 
syphilis  of,  282,  286,  289 
tenth,  1167 

third,  diseases  of,  1149,  1151 
twelfth,  diseases  of,  1174 
ulnar,  1177 
vagus,  1167 
Nervous  fever,  27 
diseases,  941 
vomiting,  645 
Neuralgia,  1229 
diabetic,  911 
etiology  of,  1229 
in  influenza,  178 
in  malaria,  121 
symptoms  of,  1230 
treatment  of,  1233 
in  tuberculosis,  334 
varieties  of,  cervicobrachial,  1232 

cervico-occipital,  1231 

intercostal,  1232 

lumbar,  1232 

phrenic,  1231 

sacral,  1232 

trifacial,  1230 

visceral,  1232 
Neurasthenia,  1193 
course  of,  1197 
diagnosis  of,  1197 
differentiation      of,      from     paretic 

dementia,  1026 
etiology  of,  1193 
prognosis  of,  1197 
symptoms  of,  1194 

cardiac,  452 
treatment  of,  1194 
types  of,  1194 
Neuritis,  1139 

brachial,  1178 

diabetic,  911 

diagnosis  of,  1141 

in  diphtheria,  167 

etiology  of,  1139 

in  influenza,  178 

lead  poisoning  causing,  1249 

multiple,  1141 

diagnosis  of,  1144 

differentiation  of,  1144 

etiology  of,  1142 

pathology  of,  1142 

prognosis  of,  1143 

symptoms  of,  1142 

treatment  of,  1145 
optic,  1147 


Neuritis,  pathology  of,  1139 

rheumatic,  199 

sciatic,  1181 

symptoms  of,  1139 

treatment  of,  1141 

in  tuberculosis,  334 

in  typhoid  fever,  29 
Neuroma,  1145 
Neurones,  1057 

motor,  1058 
Neuroses,  1184 

fatigue,  1221 

of  heart,  451 

occupation,  1221 

of  stomach,  639 

traumatic,  1199 

diagnosis  of,  1200 
etiology  of,  1199 
prognosis  of,  1201 
synaptoms  of,  1200 
treatment  of,  1201 

trophic,  1234 

in  typhoid  fever,  29 

vasomotor,  1234 
Nigrities  linguae,  578 
Nodes,  rheumatic,  196 
Noma  oris,  576 

in  typhoid  fever,  24 
Nose,  diseases  of,  485 

syphilis  of,  278 

tuberculosis  of,  354 
Nucleo-albumin,  tests  for,  801 
Nutmeg  liver  in  heart  disease,  421 
Nystagmus,  1154 

in  multiple  sclerosis,  1105 


Obesity,  936 

in  diabetes,  905 

etiology  of,  936 

symptoms  of,  936 

treatment  of,  937 
Ochronosis,  809 

Ocular  paralyses,  syphilitic,  289 
CEdema,  angioneurotic,  1236 

of  brain,  964 

cardiac,  422,  427 

of  glottis,  493 

in  typhoid  fever,  35 

hereditary,  1236 

of  larynx,  493 

of  lungs,  536 

in  heart  disease,  420 
in  rheumatism,  197 

in  whooping-cough,  184 
Oertel's  cure,  937 

treatment  of  heart  disease,   437 
(Esophagitis,  etiology  of,  589 

symptoms  of,  590 

treatment  of,  590 
CEsophagomalacia,  590 
CEsophagus,  cancer  of,  complications,  596 
diagnosis,  596 
etiology  of,  595 


INDEX 


1309 


CEsophagus,  cancer  of,  pathology,  595 
symptoms,  596 
treatment,  596 
dilatation  of,  etiology  of,  593 
symptoms  of,  593 
treatment  of,  594 
diseases  of,  589 
diverticulum,  594 
hemorrhage  of,  597 
measurements  of,  592 
necrosis  of,  590 
pulsion-diverticulum,  594 
rupture  of,  597 
perforation  of,  597 
sounding  of,  592,  593 
stenosis  of,  590 
stricture  of,  diagnosis,  591 
etiology  of,  591 
physical  signs  of,  591 
prognosis  of,  592 
symptoms,  591 
treatment  of,  592 
syphilis  of,  271 
traction-diverticulum,  595 
tuberculosis  of.  347 
tumors  of,  benign,  596 
tyi^hoid  ulceration  of,  31 
ulceration  of,  590 
varices  of,  699 
Oidium  albicans,  575 
Oligocardia,  456 
Oligochromgemia,  832 
Oligocythgemia,  832 
Oplitiialmia,  diphtheritic,  166 
Ophthalmoplegia,    progressiA'e    nuclear, 
1153 
syiDhilitic,  289 
Ophthalmoplegic  encephalitis,  acute,  1011 
Opisthorchis  siensis,  1276 
Opium,  coma  from,  975 
poisoning,  acute,  1245 
chronic,  1246 
Oppler-Boas  bacillus,  634,  635 
Optic  atrophy,  syphilitic,  289 
nerve,  1146 
neuritis,  syphilitic,  284 

in  typhoid  fever,  29 
thalamus,  localizing  symptoms,  954 
Orchitis,  in  mumps,  189 
syiDhilitic,  290 
in  typhoid  fever,  38 
Osteitis  deformans,  900 
Osteo-arthropathic  hypertrophiante,  503 

pneumonique,  900 
Osteo-arthropathy,  hypertrophic,  900 
Osteochondritis,  syphilitic,  297 
Osteomyelitis.  See  Septic  Affections,  133 

in  typhoid  fever,  29 
Otitis,  diphtheritic,  166 

media,  brain  abscess  from,  1014 

sinus  thrombosis  from,  991 
rheumatic,  192 
scarlatinal,  90,  94 
treatment  of,  94 
Ovarian    cyst,    differentiation   of,    from 
ascites,  760 


Ovarian  tumor,  differentiation  of,  fiom 

hydroneplirosis,  816 
Ovary,  syphilis  of,  292 
Oxalate  calculus,  818 
Oxaluria,  808 
Oxyuris  vermicularis,  1266 


Pachymeningitis,     cervical     hypertro- 
phic 1077 
diagnosis  of,  1078 
pathology  of,  1077 
symptoms  of,  1078 
treatment  of,  1078 
external,  1037 

hemorrhagic,  diagnosis  of,  1040 
differentiation  of,  1040 
etiology  of,  1038 
pathology  of,  1038 
prognosis  of,  1039 
symptoms  of,  1039 
treatment  of,  1040 
internal,  1037 
Paget's  disease,  900 
Pain,  centre  for,  947 
Palate,  tuberculosis  of,  347 
Palpitation  of  heart,  451 
Palsy,  shaking,  1223 
Pancreatic  cancer,  differentiation  of,  750 
symptoms,  749  r-.%-i 

Pancreas,  calculi  of,  747  l^*   ^ 

cancer  of,   differentiation  of,   from 

gall-stones,  750 
cysts  of,  748 

diagnosis  of,  748 
etiology  of,  748 
pathology  of,  748 
symptoms  of,  748 
treatment  of,  749 
diseases  of,  743 
hemorrhage  from,  747 
inflammation  of,  acute,  743 

chronic,  746 
syphilis  of,  273 
tumors  of,  749 
■  differentiation  of,  750 

j  from  cancer  of  stomach,  636 

j  symptoms  of,  749 

!  treatment  of,  751 

i  Pancreatitis,  acute,  diagnosis  of,  745 

differentiation,  745 
!  etiology  of,  743 

gall-stones  in,  732 
prognosis  of,  745 
symptoms,  743 
treatment  of,  745 
clironic,  etiology  of,  746 
gall-stones  in,  732 
patliology  of,  746 
j  prognosis  of,  746 

symptoms  of,  746 
1  treatment  of,  747 

Paracolon  infection,  43 
'  Paresie  analgesique  avec  panaris,  1111 


1310 


INDEX 


Paragonius  Westermanni,    1275 
Parkinson's  disease,  1223 
Paralysis.     See  Monoplegia,  Hemiplegia, 
Paraplegia 
agitans,  1223 

diagnosis  of,  1225 
differentiation  of,  from  multi- 
ple sclerosis,  1107 
etiology  of,  1223 
pathology  of,  1223 
prognosis  of,  1225 
symptoms  of,  1223 
treatment  of,  1225 
anterior  crural,  1179 
of  auditory  nerve,  1163 
Bell's,  1158 
brachial  plexus,  1178 
Brown-Sequard's,  1086 
bulbar,  apoplectiform,  1033 
asthenic,  1032 
chronic,  1029 
caisson,  1085 
circumflex,  1176 
combined,  of  arm  nerves,  1178 
compression,  spinal,  1071 
conjugate,  957 
cortical,  943 
diphtheritic,  166 
diver's,  1085 
facial,  1158  _ 

diagnosis  of,  1161 
etiology  of,  1158 
localization  of,  1161 
pathology  of,  1159 
prognosis  of,  1162 
symptoms  of,  1159 
in  tetanus,  250 
treatment  of,  1162 
of  fifth  nerve,  1155 
Gublers',  957 
hypoglossal,  1174 
infantile  cerebral,  994 
diplegic,  996 

diagnosis  of,  999 
etiology  of,  996 
pathology  of,  996 
symptoms  of,  997 
treatment  of,  999 
hemiplegic,  995 

diagnosis  of,  996 
etiology  of,  995 
symptoms  of,  995 
treatment  of,  999 
of  insane,  1020 
labioglossopharyngeal,  1029 
Landry's,  1102 
laryngeal,  1168 

I     recurrent,  1168,  1169 
lumbar  plexus,  1179 
in  malaria,  121 
median,  1177 
musculospiral,  1176 
obturator,  1179 
ocular,  1149 
oculomotor,  956,  959 
periodic  family,  1225 


Paralysis,  peroneal,  1180 

phrenic,  1174 

popliteal,  1180 

posterior  thoracic,  1176 

pseudobulbar,  1031,  1034 

pseudo-,  syphilitic,  873 

sciatic,  1180 

spinal  accessory,  1172 

superior  gluteal,  1180 

suprascapular,  1176 

of  sympathetic  nerves,  1154 

syphilitic,  284 

ulnar,  1177 

vagus,  1167 

of  vocal  cords,  1168 

Weber's,  956 
Paramyoclonus  mviltiplex,  1216 
Paramyotonia,  ataxic,  1223 

congenital,  1222 
Paranephritis,  812 
Paraplegia  ataxic,  1137 

in  cerebral  infantile  paralysis,  998 

hysterical,  1094,  1188 

spastic  spinal,  1124 
Parapleuritis,  554 
Parasecretion,  gastric,  642 
Parasites,  diseases  due  to  animal,  1257 

of  heart,  451 

of  lungs,  540 
Parasitic  stomatitis,  575 
Parathyroid  glands,  896 
Paratyphoid  fever,  19,  43 

differentiation  of,  from  typhoid 

fever,  43 
microorganisms  of,  43 
symptoms  of,  43 
Parenchymatous  nephritis,  chronic,  774 
Parorexia,  648 
Parosmia,  1146 
Parotitis,  acute,  579 

chronic,  580 

epidemic,  188 

post-operative,  190 

secondary,  190 

in  typhoid  fever,  30 
Paroxysmal  hsemoglobinuria,  804 
Parrot's  disease,  873 

ulcers,  575 
Pavor  nocturnus,  588 
Peliosis  rheumatica,  867 
Pellagra,  1253 

differentiation   of,    from    Addison's 
disease,  880 
Pelvis,  rhachitic,  933 
Pemphigus,     differentiation     of,     from 

chickenpox,  83 
Penis,  syphilis  of,  290 
Pentosuria,  915 

Pepsin,  test  for  in  stomach,  605 
Peptone,  tests  for,  801 
Perforation,  intestinal,  in  typhoid  fever, 
34 

of  oesophagus,  597 
Periarteritis  of  mesenteric  vessels,  691 

nodosa,  483 


INDEX 


1311 


Pericarditis,  377 
adhesive,  387 

diagnosis  of,  389 
prognosis  of,  389 
symptoms  of,  387 

cardiac  insufficiency,  387 
diastolic   collapse  of  veins 
388 
recoil,  388 
inspiratory    swelling    of 

veins,  389 
paradoxical  pulse,  388 
retraction  of  apex,  388 
,  of  chest  wall,  388 
treatment  of,  389 
differentiation  of,  from  pleurisy,  557 
effusive,  378 

course  of,  386 
diagnosis  of,  383 

character  of  exudate,  385 
dulness,  384 
friction  rub,  383 
pathology  of,  379 
physical  signs  of,  380 
prognosis  of,  386 
symptoms  of,  379 
treatment  of,  386 
etiology  of,  377 
externa,  379 
fibrinous,  378 

physical  findings  of,  378 
symptoms  of,  378 
pneumococcic,  148 
pseudocirrhosis  of  liver  in,  702 
rheumatic,  195 
scarlatinal,  88 
syphilitic,  277 
tuberculous,  334,  341 
in  typhoid  fever,  25 
Pericardium,  diseases  of,  377 

tuberculosis  of,  341 
Perichondritis,  laryngeal,    in    typhoid 
fever,  35 
of  larynx,  493 
Perihepatitis,  758 

differentiation  of,  from  ascites,  764 
from  cirrhosis  of  liver,  702,  764 
from  peritoneal  cancer,  764 
from    tuberculous     peritonitis, 
764 
Perinephric  abscess,  812 
diagnosis  of,  813 
etiology  of,  812 
symptoms  of,  813 
Perinephritis,  812 
Periostitis,  rheumatic,  197 
syphilitic,  292 
in  typhoid  fever,  29 
Peripheral  nerves,  diseases  of,  1139 
Peripleuritis,  554 
Perisplenitis,  883 
Peristaltic  unrest,  gastric,  644 
Peritoneum,  cancer  of,  758,  764 

differentiation  of,  from  ascites, 
764 
from  hepatic  cirrhosis,  764 


Peritoneum,  cancer  of,  differentiation  of, 
from    tuberculous    peri- 
tonitis, 764 
from  perihepatitis,  764 
diseases  of,  751 
tuberculosis  of,  341 
Peritonitis  in  cirrhosis  of  liver,  700 
diffuse,  acute,  751 

course  of,  753 
differentiation  of,  754 
diagnosis  of,  754 
etiology  of,  751 
perforative,  754 
pneumococcic,  754 
symptoms  of,  abdominal, 
752 
general,  753 
local,  752 
treatment  of,  755 
types  of,  753 
chronic,  755 

differentiation     of,      from 
portal  cirrhosis  of  liver, 
702,  764 
deforming,  755 
hemorrhagic,  chronic,  758 
localized,  756 

adhesive,  757 

perihepatitis,  758 
suppurative,  756 

pyopneumothorax,       sub- 

phrenicus,  756 
subphrenic  abscess,  756 
tuberculous,  336,  341 

differentiation  of,  from  ascites, 
762 
from  hepatic  cirrhosis,  762 
from  perihepatitis,  764 
from  peritoneal  cancer,  764 
typhoid  perforation,  causing,  34 
Peritonsillar  abscess,  586 
Perityplitis,  664 
Perles,  asthma,  508 
Pernicious  anaemia,  839 

differentiation    of,    from    gas- 
tric cancer,  634,  635 
Pertussis,  182.    See  Whooping-cough. 
Pest,  219 

Pesticeemia  in  plague,  220 
Petechise,  in  typhus  fever,  57 
Petit  mal,  1204 
Pharyngeal  tonsil,  587 
Pharyngitic  diphtheria,  163 
Pharyngitis,  acute,  581 
chronic,  582 
phlegmonous,  583 
ulcerative,  583 
Pharynx,  diseases  of,  581 
erysipelas  of,  106,  107 
tuberculosis  of,  347 
typhoid  ulcers  of,  31 
ulceration  of,  583 
Phenylhydrazin  test,  907 
Phlebitis,  pneumococcic,  148 
portal  vein,  722 
syphilitic,  278 


1312 


INDEX 


Phlegmon,      differentiation      of,      from 

erysipelas,  107 
Phlegmonous  enteritis,  655 
Phloridzin  test,  780 
Phosphate  calculus,  818 
Phosphates  in  urine,  807 
Phosphatic  calculus,  818 
Phosphaturia,  807 
Phosphorus  poisoning,  694 
Phthisis,  303,  318 
aneurysmal,  477 
fibroid,  520 
ventriculi,  609 
Pigeon-breast,  588 
Pigmentary  cirrhosis  of  liver,  702 
Pigmentation  of  oral  cavity  in  Addison's 

disease,  879 
Piles,  683 

Pityriasis,  tuberculous,  336 
Placenta,  syphilis  of,  291 
Plague,  219 

diagnosis  of,  223 
etiology  of,  219 
prognosis  of,  224 
symptoms  of,  220 
treatment  of,  224 
Plasmodium  malarise,  109 
Pleura,  diseases  of,  542 
tuberculosis  of,  341 
tumors  of,  569 
Pleurisy,  542 

bacteriology  of,  543 
course  of,  555 
cytodiagnosis  in,  551 
diagnosis  of,  557 
differentiation  of,  557 

from  abscess  of  liver,  559 

of  effusion,  558 

from  enlargement  of  liver,  559 

of  spleen,  559 
of  friction  rub,  557 
from  hydrothorax,  558 
from  lung  cavities,  559 
from  pericarditis,  557 
from  pneumonia,  153,  558 
from  pneumothorax,  565 
from  rales,  557 
from  subphrenic  abscess,  559 
empyema,  551 

necessitatis,  552 
Ijneumococcic,  552 
IJulsans,  552 
streptococcic,  551 
etiology  of,  542 
forms  of,  551 

in  children,  554 
chyliform,  553 
diaphragmatic,  553 
fibrinous,  551 
hemorrhagic,  553 
interlobar,  554 
mediastinal,  554 
parapleuritis,  554 
peripleuritis,  554 
purulent,  551 
putrid,  553 


Pleurisy,  forms  of,  serous,  551 
suppurative,  551 
in  influenza,  179 
issues  of,  556 
pneumococcic,  147 
physical  signs  of,  544 

auscultation,  548 
diagnostic  puncture,  549 
inspection,  544 
palpation,  545 
percussion,  546 
prognosis  of,  559 
rheumatic,  197 
symptoms  of,  550 
treatment  of,  560 

aspiration,  561 
in  tuberculosis,  333 
in  typhoid  fever,  36 
Pleuritic  friction,  545,  548 
Pleurodynia,  1239 
Pleuropericardial  friction,  '  diagnosis    of, 

384 
Pleuropneumonia,  136 
Plumbism,  1247 

differentiation  of.  1026 
Pneumatosis  peritonei,  754 
Pneumaturia,  910 
Pneumobacillus,  137 
Pneumococcsemia,  137 
Pneumococcic  pharyngitis,  581 
Pneumococcus.     See  Septic  Affections 

endocarditis,  396 
Pneumohsemia,  137,  146 
Pneumokoniosis,  522 
etiology  of,  522 
pathology  of,  522 
symptoms  of,  523 
treatment  of,  524 
Pneumomalacia,  529 
Pneumonia,  136 
aspiration,  515 
bacteriology  of,  136 

pneumobacillus,  137 
pneumococcus,  136 
central,  143,  152 
cerebral,  152 

clinical  types  and  variations  of,  149 
complications  of,  147 
abscess  of  lung.  149 
alimentary,  149 
arteritis,  148 
arthritis,  149 
empyema,  148 
endocarditis,  148 
gangrene  of  lung,  149 
gastritis,  149 
icterus,  149 

induration  of  lung,  149 
joint,  149 
lung,  149 
nervous,  148 
pericarditis,  148 
pleurisy,  147 
I  pulmonary,  149 

thrombophlebitis,  148 
crossed,  143 


INDEX 


1313 


Pneumonia,  death  mechanism  in,  147 
diagnosis  of,  151 

differentiation  of,  from  hing  tumor, 
153 

from  pleurisy,  152,  153 

from  tuberculous  pneumonia, 
153 

from  typhoid  fever,  42 
erysipelatous,  106 
etiology  of,  136 
frequency  of,  136 
hepatization  in,  gray,  143 

red,  143 
immunity  from,  137 
indurative,  520 

diagnosis  of,  522 

etiology  of,  520 

pathology  of,  521 

physical  findings  of,  521 

prognosis  of,  522 

symptoms  of,  521 

treatment  of,  522 
interstitial,  520 
Litten's  sign  in,  143 
lobar,  complications  of,   abscess  of 
lung,  520 
gangrene  of  lung,  528 
induration  of  lung,  520 

differentiation  of,    from  bron- 
chopneumonia, 519 
from    pleurisy    with    effu- 
sion, 558 
from     tuberculous     pneu- 
monia, 327 

in  influenza,  179 

in  typhoid  fever,  36 

in  whooping-cough,  184 
massive,  150,  152 
migratory,  150 
pathology  of,  142 
physical  signs  of,  143 
pleurogenous,  521 
prognosis  of,  153 
rheumatic,  197 
"schluck,"  515 
secondary,  515 
symptoms  of,  138 

chill,  139 

circulatory,  145 

digestive,  146 

fever,  139 

lymph  glands,  146 

nervous,  147 

respiratory,  141 

skin,  146 

urine,  146 
syphilitic  interstitial,  281 
total,  150,  152 
treatment  of,  154 

diet,  155 

hygienic,  155 

prophylactic,  154 

serotherapy,  155 

symptomatic,  155 
white,  syphilitic,  280 
Pneumonitis,  136^^ 
83 


Pneumopericardium,  390 
Pneumoperitoneum,  754 
Pneumorrhagia,  537 
Pneumothorax,  563 

diagnosis  of  type  of,  566 
differentiation  of,  566 

from  emphysema  of  lungs,  514 
etiology  of,  563 
pathology  of,  563 
physical  signs  of.  564 
prognosis  of,  567 
symptoms  of,  564 
treatment  of,  567 
in  tuberculosis,  333 
Podagra.    See  Gout 
Pododynia,  1232 
Poisoning,  arsenical,  1251 
cheese,  1252 
fish,  1252 
food,  1251 
grain,  1253 
lead,  acute,  1248 

chronic,  1248 

milk,  1252 

opium,  acute,  1245 

chronic,  1246 

potato,  1254 

Poliencephalitis,  inferior,  1012 

superior,  1012 
Poliencephalomyelitis,  1012 
Poliomyelitis,  acute,  in  adults,  1101 
of  children,  1095 

diagnosis  of,  1099 
differentiation  of,  1099 
from  cerebral  palsies 

996,  1100 
from  multiple  neuritis, 

1099 
from    muscular    atro 
phy, 1099 
from  myelitis,  1100 
etiology  of,  1096 
pathology  of,  1096 
prognosis  of,  1100 
symptoms  of,  acute  stage, 
1097 
chronic  stage,  1099 
degenerative    stage, 

1098 
localization,  1098 
treatment  of,  1100 
chronic,  1101 
subacute,  1101 
PoUakiuria,  779 
Polysesthesia,  tabetic,  1117 
Polyarthritis,  rheumatic,   192        , 
Polycardia,  454 

Polycythaemia,  with  splenic  tumor,  885 
Polyglobulism,  885 
Polymyositis,  1238 
Polyneuritis  endemica,  236 
Polyorrhomenitis,  341 
Polyphagia,  648 
Polysarcia  adiposa,  936 
Polyuria  in  cerebral  syphilis,  282 
diabetic,  907,  919 


1314 


INDEX 


Polyuria  in  malaria,  120 
in  tyi^hoid  fever,  37 
Pons,  localizing  symptoms,  957 
Porencephalia,  997 
Portal  cirrhosis  of  liver,  695 
vein  phlebitis,  722 
thrombosis,  722 
Posthemorrhagic  anaemia,  acute,  847 

chronic,  849 
Postmortem  tubercles,  358 
Potato  poisoning,  1254 
Pott's  disease,  1071 
Pox,  262 

Pregnancy,  effect  of  syphilis  on,  291 
kidney  of,  771 
tuberculosis  and,  336 
Prison  fever,  55,  61 
Profeta's  law,  296 
Prosopalgia,  1230 
Prosoplegia,  1158 
Prostate,  tuberculosis  of,  353 
Prostitution,  regulation  of,  298 
Pseudodiphtheria,  159 
Pseudohydrophobia,  255 

differentiation  of,   from   hydropho- 
bia, 255 
Pseudoleuksemia,  860 
allied  affection,  863 
course  of,  862 
diagnosis  of,  863 
differentiation  of,  863 

from  anaemia  infantum  pseudo- 

leukaemica,  863 
from  lymphosarcomatosis,  864 
from  multiple  myeloma,  865 
from     other     splenic     enlarge- 
ments, 864 
from  splenic  anaemia,  864 
from  tuberculous  adenitis,  863 
etiology  of,  860 
pathology  of,  861 
symptoms  of,  860 
blood,  861 
bone,  861 
fever,  862 
lymph  glands,  860 
skin,  862 
spleen,  861 
treatment  of,  865 
Pseudomeningitis,  1055 
Pseudoparalysis,  syf)hilitic,  873 
Pseudorheumatism,  201 
Pseudosclerosis  (multiple),  1108 
Pseudotetanus,  250 
Pseudotuberculosis,  307,  332 
aspergillus,  307,  332 
protozoan,  307 
streptothrix,  307,  332 
Psoriasis  of  tongue,  577 
Psychoses,  rheumatic,  199 
tuberculous,  311 
in  typhoid  fever,  28 
Ptosis,  1150 
Ptyalism,  578 

Puerperal  fever.     See  Septic  Affections, 
erysipelatous,  106,  108 


Puerperal  fever,  lymphangitis,  135 
peritonitis,  134 
sapraemia,  134 
scarlatiniform  rashes  in,  84 
thrombophlebitis,  134 
Pulmonary  artery,  sj^ohilis  of,  278 
distention  in  heart  disease,  420 
embolism,  in  typhoid  fever,  26 
gumma,  280 

hypostasis  in  tyjohoid  fever,  35 
infiltration,  syphilitic,  280 
insufficiency,  412 
etiology  of,  412 
mechanism  of,  413 
symptoms  of,  413 
stenosis,  413 

congenital,  430 
diagnosis  of,  414 
etiology  of,  413,  430 
mechanism  of,  413 
signs  of,  413 
Pulsating  pleural  effusions,  552 
Pulse,  alternans,  458 
bigeminus,  419 
collapsing,  403 
liver,  positive,  415,  416 
"pistol,"  403 
Quincke's  capillary,  402 
venous,  negative,  416 

positive,  415 
"water-hammer,"  403 
Pulsus  paradoxus,  388 
Pupil,  reflexes  of,  1067 

Wernicke's    hemianopsic    reaction, 
1149 
Purpura,  fulminans,  869 
hemorrhagica,  868 
diagnosis  of,  868 
etiology  of,  868 
prognosis  of,  869 
symptoms  of,  868 
treatment  of,  869 
Henoch's,  868 
renal,  802 
rheumatica,  867 

diagnosis  of,  867 
prognosis  of,  867 
symptoms  of,  867 
treatment  of,  868 
simplex,  866 
symptomatic,  866 
visceral  crises  in,  867 
Pus  in  urine,  805 
Pustule,  malignant,  240 

differentiation    of,    from    ery- 
sipelas, 107 
Pyaemia,  129 
Pyelitis,  809 

complications  of,  811 
diagnosis  of,  811 
differentiation  of,  811 
etiology  of,  809 
pathology  of,  810 
23rognosis  of,  811 
symptoms  of,  810 
treatment  of.  812 


INDEX 


1315 


Pyelitis,  in  typhoid  fever,  37 
Pyknocardia,  454 
Pylephlebitis,  722 

diagnosis  of,  723 

etiology  of,  722 

suppurative,  723 

symptoms  of,  723 

treatment  of,  723 
Pylethrombosis,  722 

differentiation     of,     from     cirrhosis 
of  liver,  702 
Pyloric  insufficiency,  646 

spasm,  644,  624 

stenosis,  611 
benign,  615 
Pylorus,  hypertrophy  of,  636 

insufficiency  of,  646 

spasm  of,  624,  643,  644 
Pyocyaneus.    See  Septic  Affections 
Pyramidal  tracts,  1059,  1060,  1061 
Pyuria,  805 

diagnosis  of,  805 

etiology  of,  805,  810 

renal  calculus  causing,  820 

symptoms  of,  805 

treatment  of,  806 


Q 


Quincke's  pulse,  402    • 

Quinine  in  malaria,  127 

administration  of,  128 
physiological  action  of,  128 


Rabic  tubercles  in  hydrophobia,  254 
Rabies,  252 

Rag-sorters'  disease,  243 
Rale  redux,  146 
Ray  fungus,  256 
Raynaud's  disease,  1235 
Reaction  of  degeneration,  1139 
Rectal  feeding,  625 
Rectum,  cancer  of,  677,  679 

syphilis  of,  272 
Recurrent  fever,  61 

convalescence  in,  64 

diagnosis  of,  63 

differential,  64 

etiology  of,  61 

prognosis  of,  64 

symptoms  of,  61 

treatment  of,  64 
Reichmann's  disease,  642 
Relapsing  fever,  61 
Ren  arcuatus,  795 
Renal  calculus,  817 

chemistry  of,  817 

complications  of,  820 

diagnosis  of,  820 

differentiation  of,  821 

etiology  of,  817 

in  gall-stones,  733 


Renal  calculus,  pathology  of,  817 
prognosis  of,  821 
symptoms  of,  819 
treatment  of,  medical,  821 
surgical,  822 
cancer,  822 

complications  of,  824 
diagnosis  of,  824 
differentiation    of,    from    liver 
tumor,  824 
from  splenic  tumor,  824 
from  ovarian  tumor,  824 
etiology  of,  822 
pathology  of,  822 
prognosis  of,  824 
symptoms  of,  823 
colic,  819 

differentiation    of,    from    gall- 
stones, 733 
echinococcus,  828 

complications  of,  829 
symptoms  of,  828 
treatment  of,  829 
sarcoma,  825 

tumors,     differentiation     of,     from 
cancer  of  liver,  714 
Rennet,  test  for,  605 
Rest  cure,  1198 
Retina,  arteriosclerosis  of,  469 
Retinitis,  1146 

albuminuric,  781 
diabetic,  911 
in  heart  disease,  419 
syphilitic,  288 
Retropharyngeal  abscess,  583 
Rhachitis,  931 

acute.    See  Barlow's  disease,  872 
tarda,  932 
Rheumatic  fever,  190 

purpura,  867 
Rheumatism,  acute  articxilar,  190 
diagnosis  of,  190,  200 

anomalous  forms,  201 
in  childhood,  200 
gonorrhoeal,  201 
pseudorheumatisnr, 

201 
scarlatinal,  201 
differentiation  of,  200,  202 
etiology  of,  191 
frequency  of,  190 
prognosis  of,  199,  201 
symptoms  of,  192 
arthritis,  192 
blood,  198 
bone,  197 
circulatory,  194 
digestive,  198 
eye,  199 
fever,  193,  195 
general,  192 
genito-urinarj^,  198 
muscle,  197 
nervous,  199 
prodromal,  192 


1316 


INDEX 


Rheumatism,  symptoms  of,  pseudorheu- 
matism,  201 
respiratory,  197 
skin,  196       i^  ^ 
treatment  of,  202 
diagnostic,  205 
atypical,  195,  201 
cerebral,  194,  199 
chronic,  926 
endocarditis  from,  397 
masked,  195 
muscular,  1239 
relations  of  chorea  to,  1211 
scarlatinal,  91,  94 
spinal,  199 
syphilitic,  293 
tuberculous,  357 
visceral,  194 
Rheumatoides,  201 
Rhiga's  disease,  574 
Rhinitis,  acute,  485 

etiology  of,  485 
symptoms  of,  485 
treatment  of,  486 
chronic,  487 

atrophic,  488 
hypertrophic,  487 
treatment  of,  488 
diphtheritic,  164 
fibrinous,  488 
syphilitic,  278 
Rhizomucor  parasiticus,  332 
Rickets,  931 

complications  of,  934 
course  of,  934 
diagnosis  of,  935 
differentiation  of,  935 

from   hydrocephalus,  1036 
etiology  of,  931 
pathology  of,  933 
prognosis  of,  934 
symptoms  of,  932 
treatment  of,  dietetic,  935 
hygienic,  935 
medicinal,  935 
orthopedic,  936 
Risus  sardonicus,  249 
Romberg's  sign,  1116 
Rose  cold,  486 
Roseola  in  meningitis,  23 
in  pneumonia,  23,  146 
in  tuberculosis,  23,  317 
in  typhoid  fever,  23 
in  typhus  fever,  52,  57 
Rose  spots  in  miliary  tuberculosis,  317 

in  typhoid  fever,  23 
Rotheln,  102 
Roth's  white  spots,  132 
Round  ulcer,  of  stomach,  617 
Rubeola,  96 

notha,  102 
Rudimentary  kidney,  794 
Rumination,  646 
Rupture  of  aorta,  483 
of  heart,  450 
of  oesophagus,  597 


Saddleback  nose,  279 
St.  Anthony's  fire,  103 
St.  Vitus  dance,  1210 
Saline  infusions,  158 
Salivation,  etiology  of,  578 
symptoms  of,  578 
treatment  of,  579 
Salivary  calculi,  580 

glands,  diseases  of,  578 

symmetrical    hypertrophy    of, 

580 
tuberculosis  of,  347 
Saprsemia,  129 
Sarcoma  of  brain,  1000 
of  liver,  711 
of  gall-bladder,  741 
of  intestines,  680 
renal,  825 
Saturnism,  1247 

Scarlatina,  differentiation  of,  from  small- 
pox, 67,  76 
from  measles,  100 
endocarditis  from,  397 
Scarlet  fever,  83 

diagnosis  of,  90 
differentiation  of,  91 

from  dermatitis  exfolians, 

92 
from  diphtheria,  87,  92 
from  erysipelas,  92 
from  German  measles,  92, 

100 
from  measles,  92,  100 
from  sepsis,  84,  91 
etiology  of,  83 
prognosis  of,  92 
sequels  of,  90 
symptoms  of,  85 
blood  in,  88  _ 
bones  and  joints,  91 
cardiac,  88 
digestive,  88 
eruption,  86 
fever,  85 
kidney,  89 

lymphatic  glands,   90 
respiratory,  88 
special  senses,  90 
stages,  85 
throat,  87 

diphtheria    differen- 
tiated, 87 
treatment  of,  92 
Schmidt's  abdominal  reflex,  in  pleurisy, 

553 
Schoch's,  formaldehyde  method,  79 
Schott's  treatment  of  heart  disease,  437 
Schroth  treatment  of  pleurisy,  560 
Sciatic  neuritis,  1181 
Sciatica,  1181 

diagnosis  of,  1182 
etiology  of,  1181 
pathology  of,  1181 
prognosis  of,  1182 


INDEX 


1317 


Sciatica,  symptoms  of,  1181 

X     treatment  of,  1183 
Sclerema  adiposum,  660 
Sclerodactylia,  1237 
Scleroderma,  1237 
Scleroedema,  660 
Sclerose  en  -plagues,  1103 
Sclerosis,  amytrophic  lateral,  1126 
diagnosis  of,  1128 
etiology  of,  1127 
pathology  of,  1127 
prognosis  of,  1128 
symptonfis  of,  1127 
treatment  of,  1128 
of  brain,  diffuse,  1028 

lobar,  997 
disseminated,  1103 
insular,  1103 
multiple,  1103 

apoplectiform  siezures  in,  1106 
course  of,  1107 
diagnosis  of,  1107 
differentiation  of,  1107 

from  brain  syphilis,    1108 
from  brain  tumor,  1009 
>  from  hysteria,  1008 

from  paralysis  agitans, 

1107 
from     paretic     dementia, 

1025 
from  pseudosclerosis,  1108 
from  syphilis  of  brain,  1108 
from  tabes,  dorsalis,  1122 
etiology  of,  1104 
pathology  of,  1104 
prognosis  of,  1107 
symptoms  of,  1104 
treatment  of,  1109 
nystagmus  in,  1105 
scorbutic,  871 
Scotoma,  1148 
Scorbutus,  870 
Scrofula,  337,  358 
Scrofuloderma,  358 
Scurvy,  870 

course  of,  871 
diagnosis  of,  872 
etiology  of,  870 

infantile,  872.    See  Barlow's  Disease 
prognosis  of,  871 
symptoms  of,  870 
treatment  of,  872 
Secondary  anaemia,  847 

post-hemorrhagic,   acute,  847 
chronic,  849 
Secretin,  651 

Secretion,  continuous  gastric,  642 
Semilunar  ganglia,  in  Addison's  disease, 
878 
space,  547 
Sensation,  cortical  representation,  945 
Sensory  crossway,  951 
Sepsis,  129 

differentiation  of,  from  malaria,  127 
from  measles,  101 
from  typhoid  fever,  44,  45 


Sepsis,  scarlatinal  rashes  in,  84,  91 
Septic  affections,  129 

colon  bacillus,  sepsis,  133 
diagnosis  of,  135 
differentiation  of,  135 

from  miliary  tuberculosis, 

135 
from  rheumatism,  135 
from  typhoid,  135 
endocarditis,  ulcerative,  133 
etiology  of,  130 
gonococcic  infection,  133 
groups  of,  129 
osteomyelitis,  133 
otogenous  sepsis,  133 
pathology  of,  130 
peritonitis,  134 
pneumococcic  infection,  133 
prognosis  of.  135 
puerperal  fever,  134 
pyocyaneus  infection,  133 
staphylococcic  infection,  132 
streptococcic  infection,  132 
symptoms  of,  130 
general,  130 
special,  132 
treatment,  135 
typhoid  infection,  133 
diphtheria,  164 
Septicaemia,  129 

in  plague,  220 
Septicopyagmia,  129 
gonorrhoeal,  260 
Serotherapy,  in  erysipelas,  109 

in  scarlatina,  95 
Serous  membranes,  tuberculosis  of,  341 
Serum  of  dethyroidated  animals,  892 
Seven-day  fever,  61 
Shaking  palsy,  1223 
Sheep-stools,  678 
Shiga's  bacillary  dysentery,  225 

complications  of,  227 
diagnosis  of,  227 
pathology  of,  226 
prognosis  of,  227 
symptoms  of,  226 
treatment  of,  231 
Ship  fever,  55 
Sialodochitis  fibrinosa,  580 
Sialolithiasis,  580 

pancreatica,  747 
Sialorrhoea,  578 
Siderosis  of  lungs,  523 
Singultus,  1175 
Sinus  thrombosis,  991 

of  cavernous  sinus,  993 
diagnosis  of,  992 
differentiation,    from    brain 

abscess,  1017 
etiology  of,  991 
of  lateral  sinus,  993 
pathology  of,  991 
prognosis  of,  994 
of  superior  longitudinal  sinus, 

992 
symjJtoms  of,  992 


1318 


INDEX 


Sinus  thrombosis,  treatment  of,  994 
Sitotoxismus,  1253 
Situs  viscerum  inversus,  432,  719 
Skin,  bronzing  of,  877,  879 
care  of,  in  scarlatina,  93 
diphtheria  of,  166 
tuberculosis  of,  323,  358 
Skoda's  note  in  pleurisy,  547 

resonance  in  pneumonia,  144 
Sleeping  sickness,  1277 
Slow  pulse  in  typhoid  fever,  24 
Smallpox,  64 
black,  71 

complications  and  sequelse  of,  72 
cutaneous,  73 
digestive,  73 
genito-urinary,  73 
locomotor,  73 
nervous,  72 
respiratory,  72 
special  senses,  73 
vascular,  72 
diagnosis  of,  74 

differentiation  of,  from  chickenpox, 
74 
from  drug  rashes,  76 
from  glanders,  76 
from  measles,  75 
from  scarlatina,  76 
from  syphilis,  76 
from  typhus  fever,  59 
etiology  of,  64 
prognosis  of,  76 
symptoms  of,  66 

purpura  variolosa,  71 
variola  confluens,  70 

pustulosa      hemorrhagica, 

11 
discreta,  66 
varioloid,  72 
treatment  of,  77 

prophylactic,  79 
symptomatic,  80 
vaccination,  77 
Smegma  bacillus,  304 
Smell,  center  for,  947 
"Softening"  of  brain,  1020 

chronic,  1027 
Solar  plexus,  in  Addison's  disease,  878 
Soor,  575 
Spanocardia,  456 
Spasm,  cardiac,  644 

of  facial  nerve,  1163 
of  fifth  nerve,  1157 
of  glottis  in  whooping-cough,  184 
habit,  1215 
masticatory,  1157 
mobile,  974 
ocular,  1154 
phrenic,  1175 
pyloric,  624,  644 
of  spinal  accessory  nerve,  1172 
vagus,  1167 
of  vocal  cords,  1169 
Spastic  sjiinal  paraplegia,  1124 
Speech,  centres  for,  947,  948,  952 


Speech,  disturbances  of,  948 

mechanism  of,  948 
Spina  ventosa,  syphilitic,  293 

tuberculous,  357 
Spinal    atrophy,    progressive    muscular. 
1128 
cord,  anaemia  of,  1083 
anatomy  of,  1057 
concussion  of,  1088 
degeneration      of,      ascending, 
1064 
descending,  1060,  1061 
in  pernicious  anaemia,  843 
embolism,  1083 
functions  of,  1057 
hemorrhage  of,  1083 
diagnosis,  1084 
etiology,  1083 
pathology,  1083 
symptoms,  1084 
hyperaemia  of,  1083 
inflammation  of,  1089 
lesions  of,  in  diphtheria,^167 
localization  of,  1062 
physiology  of,  1057 
reflexes  of,  1067 
symptomatology  of,  1057 
syphilis  of,  286 
tracts  of,  motor,  1058  to  1061 

sensory,  1063 
thrombosis,  1083 
transverse  lesion  of,  1067 
trauma  of,  1086 
tumors  of,  1079,  1080 
diagnosis,  1081 
localization,  1080 
pathology,  1080 
prognosis,  1082 
symptoms,  1080 
treatment,  1082 
irritation,  1195 
meninges,  diseases  of,  1076 
paraplegia,  spastic,  1124 

diagnosis  of,  1126 
etiology  of,  1125 
forms  of,  1126 
pathology  of,  1126 
symptoms  of,  1126 
treatment  of,  1126 
rheumatism,  199 
Spine.  See  Vertebrae  1068. 
Spirals,  Leyden-Curschmann,  508 
Spirochaete  pallida,  263 
Spirillum  Obermeyeri,  61 
Splanchnomegaly,  899 
Splanchnoptosis,  680 
Spleen,  abscess  of,  883 
amyloid,  273,  882 
cysts  of,  883 
diseases  of,  882 
embolism  of,  882 
endothelioma  of,  883 
enlargement   of,    differentiation    of, 

from  pleurisy,  559 
extirpation  of,  866,  885 
floating,  884 


INDEX 


1319 


Spleen,  movable,  884 
neoplasms  of,  883 
rupture  of,  884 
syphilis  of,  273 
tuberculosis  of,  316,  350,  885 
tumors  of,  acute,  882 
chronic,  882,  885 
Splenectomy,  866 
Splenic  anaemia,  864 

tumor,  in  typhoid  fever,  22 
Splenitis,  acute,  882 
chronic,  882 
suppurative,  883 
Splenomegaly,  with  i^olycythtemia  and 

cyanosis,  885 
Splenopexy,  885 
Spondylitis,  ankylosing,  928 
Spondylose  rhizomy clique,  928 
Spotted  fever,  1049 
Sputum,    disinfection  and    dangers    of, 

359 
Staphylococcus.  See  Septic  Affections. 

endocarditis,  396 
Status  lymphaticus,  886 

thymicus,  886 
Stegomyia  fasciata,  213 
Stellwag's  sign,  890 
Stenocardia,  458 
Stenosis,  aortic,  405 
of  bronchi,  504 
mitral,  410 
of  oesophagus,  590 
.      pulmonary,  413 

congenital,  430 
of  trachea,  504 
tricuspid,  417 

congenital,  432 
Stereognostic  sense,  946 
Still's  disease,  929 
Stokes-Adams  syndrome,  443 
Stomach,  abscess  of,  600 

analysis  of  contents,  602,  603,  604, 

605 
anomalies  of,  616 
arteriosclerosis  of,  469 
atony  of,  610 
atrophy  of,  609 
cancer  of,  629 

complications  of,  631 
diagnosis  of,  635 
differentiation    of,    gastralgia, 
626 
gastritis,  626 
hyperchlorhydria,  626 
other  tumors,  636 
ulcer,  624,  626 
etiology  of,  629 
frequency  of,  629 
histology  of,  630 
localization  of,  631 
pathology  of,  630 
prognosis  of,  636 
symptoms  of,  631 
anaemia,  634 
ascites,  635 
cachexia,  634 


Stomach,  cancer  of,  symptoms  of,  coma, 
635 
constipation,  632 
digestive,  632 
fever,  635 
general,  631 
haematemesis,  632,  634 
metastases,  635 
pain,  632 
jDhlebitis,  635 
toxaemia,  635 
urine,  635 
vomiting,  632 
treatment  of,  medical,  636 
surgical,  637 
cardia  of,  cancer  of,  635 
catarrh  of,  acute,  598 

chronic,  601 
cirrhosis  of,  609 
dilatation  of,  acute,  610 
etiology  of,  610 
prognosis  of,  611 
symptoms  of,  610 
treatment  of,  611 
chronic,  611 

complications  of,  614 
diagnosis  of,  614 
etiology  of,  611 
signs  of,  613 
symptoms  of,  612 
treatment  of,  615 
dimensions  of,  614 
diseases  of,  598 
hemorrhage  from,  637 
hemorrhagic  erosions  of,  624 
hour-glass,  616 
inflation  of,  614 
insufficiency  of,  612 
lavage  of,  607 
motility  of,  tests,  612,  613 
neuroses  of,  639 
mixed,  648 
motor,  644 
secretory,  639 
sensory,  648 
pain  in,  619,  626,  640,  647 
perforation  of,  in  cancer,  631 

in  ulcer,  623,  629 
round  ulcer  of,  617 

complications  of,  623 
course  of,  622 
diagnosis  of,  623 
differentiation    of    cancer, 
624,  626 
duodenal  ulcer,  624 
gall-stones,  624 
gastralgia,  626 
gastritis,  626 
hemorrhagic  erosions, 

624 
hyperchlorliydria,  626 
pyloric  spasm,  624 
etiology  of,  617 
frequency  of,  617 
localization  of,  623 
pathology  of,  618 


1320 


INDEX 


Stomach,   round  ulcer  of,  prognosis  of, 
625 
symptoms  of,  619 
general,  619 
haematemesis,  620 
hj-perchlorhydria,  621 
pain,  619 
vomiting,  621 
treatment  of,  diet,  627 
gastric  rest,  625 
hyperacidity,  627 
medicinal,  628 
pain,  627 
prevention,  625 
rest,  625 
surgical,  628 
symptomatic,    628 
types  of,  622 
spasm  of,  treatment,  608 
syphilis  of,  271 
tuberculosis  of,  347 
tumors  of,  632,  633,  636 
ulceration  of,  30,  31 
syphilitic,  271 
_    typhoid,  30,  31 
Stomatitis,  aphthous,  575 
etiology  of,  575 
symptoms  of,  575 
catarrhal,  573 

etiology  of,  573 
symptoms  of,  573 
treatment  of,  573 
epidemic,  375 
gangrenous,  576 
etiology  of,  576 
symptoms  of,  576 
treatment  of,  577 
parasitic,  575 

etiology  of,  575 
symptoms  of,  576 
treatment  of,  576 
ulcerative,  574 

etiology  of,  574 
symptoms  of,  574 
treatment  of,  575 
varieties  of,  574 
Stomatomycosis  oidica,  575 
Stone  of  kidney,  817 
Strabismus,  1150 

Strawberry  tongue,  scarlatinal,  88 
Streptococcus.      See  Septic  Affections, 
in  diphtheria,  160 
endocarditis,  396 
in  scarlatina,  83 
Streptothricosis,  307,  332 
Streptothrix,    pseudotuberculosis,    307, 

332 
Stricture  of  the  bowel,  673 

of  oesophagus,  591 
Strongyloides  intestinalis,  1274 
Struma  lipomatodes  aberrans  renis,  825 
Strumitis,  887 

Strychnine,  poisoning,  diagnosis  of,  250 
Sublingual  gland  in  mumps,  189 
Submaxillary  gland  in  mumps,  189 
Subphrenic  abscess,  756 


Subphrenic  abscess,  differentiation,  from 
pneumothorax,  566 
pyopneumothorax,  756 
Subsultus  tendinum  in  tj'phoid  fever,  28 
Succusio  Hippocratis,  566 
Sudor  anglicus,  372 
Sugar,  tests  for,  906 
Summer  catarrh,  486 
Sunstroke,  diagnosis  of,  1254 
etiologj'  of,  1254 
symptoms  of,  1254 
treatment  of,  1254 
Supernumerary  kidney,  794 
Suppuration  of  mesentery,  691 
Suppurative  encephalitis,  1013 
meningitis,  1043 
pylephlebitis,  723 
splenitis,  883 
Suprarenal  glands,  degenerations  of,  881 
diseases  of,  877 
physiology  of,  877 
tuberculosis  of,  877 
tumors  of,  881 
Suralimentation,  362 
Sympathetic  nerves,  irritation  of,  1154 

paralysis  of,  1154 
Symptomatic  purpura,  866 
Synechia  pericardii,  387 
Synovitis,  syphilitic,  293 
Syphilis,  262 

accidental,  264,  265 
acquired,  263 

associated  conditions,  294 
course  of,  abnormal,  294 
diagnosis  of,  298 
etiology  of,  263 

accidental,  264 
sexual  intercourse,  263 
life  assurance  in,  295 
svmptoms  of,  264 
blood,  268 
bone,  292 
chancre,  264 

characteristics,  264 
course  of,  265 
differentiation  of,  266 
extragenital,   265 
female,  265 
histology  of,  265 
male,  264 
perigenital,  265 
circulatory,  277 
aorta,  278 
bloodvessels,   277 
pulmonary     artery, 

278 
veins,  278 
ear,  290 
eye,  287 

choroid,  288 
conjunctiva,  287 
cornea,  287 
iris,  288 
muscles,  288 
orbit,  290 
retina,  288 


INDEX 


1321 


Syphilis,  acquired,  symptoms  of,  fever, 
267,  268 

gastro-intestinal,  270 

intestine,   272 
mouth,  270 
oesophagus,  271 
pancreas,  273 
rectum,  272 
stomach,  271 

genitalia,  290 
cervix,  291 
ovaries,  292 
penis,  290 
testes,  290 
tubes,  292 
vagina,  291 
vas  deferens,  291 
vulva,  291 

gummata  of  aorta,  278 
of  bones,  292 
of  brain,  285 
of  bronchi,  280 
of  ear,  290 
of  eye,  287 
of  heart,  277 
of  intestines,  272 
of  joints,  293 
of  kidney,  276 
of  larynx,  279 
of  liver,  274 
of  lungs,  281 
of  mamma,  294 
of  meninges,  282 
of  mouth,  271 
of  muscles,  294 
of  nose,  278 
of  oesophagus,  271 
of  ovary,  292 
of  penis,  290 
of  peritoneum,  273 
of  pharynx,  271 
of  rectum,  272 
of  skin,  269 
of  spleen,  273 
of  stomach,  272 
of  tendons,  294 
of  testis,  290 
of  trachea,  280 
of  tubes,  292 
of  uterus,  291 
of  vagina,  291 
of  vessels,  278 
of  vulva,  291 

joints,  293 

kidney,  276 

liver,  273 

lymphadenitis,  267 

lymphangitis,  266 

mamma,  294 

muscles,  293 

nervous,  281 

primary  lesion,  264 

Tesj)iratory,  278 
bronchi,  280 
larynx,  279 
lungs,  280 


Syphilis,  symptoms  of,  respiratory,  tra- 
chea, 280 
secondary,  267 

enanthem,  267 
exanthem,  267 
lymphadenitis,  267 
skin,  268 
spleen,  273 
syphilides,  268 
tertiary,  267 
treatment  of,  298 
initial  stage,  299 
local,  299 
prophylactic,  298 
secondary,  299 
of  bones,   differentiation  of,   from 

rickets,  935 
of  brain,  280,  1000 

differentiation  of,  from  multi- 
ple sclerosis,  1108 
from  paretic  dementia, 

1025 
from  tabes  dorsalis,  1122 
of  bronchi,  280 
cachexia,  294 

cerebral  diabetes  insipidus  in,  282 
mellitus  in,  282 
polyuria  in,  282 
congenital,  296,  298 
diagnosis,  ex  juvantibus,  302 
differentiation  of,  from  chickenpox, 
83 
from  smallpox,  76 
gummata,  263,  267 
hemorrhagica  neonatorum,  869 
hereditary,  295 

diagnosis  of,  298 
influence  on  child,  296 
parental,  295 
symptoms  of,  296 
incubation  of,  263 
of  larynx,  279 
leukoplakia,  577 
of  liver,  differentiation  of,  from 
abscess,  724 
from  cancer,  713,  724 
from       portal       cirrhosis, 
701,  702,  724 
of  lungs,  280 
malignant,  263 
of  nose,  278 
parasyphilis,  263 
primary,  263,  264 
residual,  264 
secondary,  263,  267 
of  spinal  cord,  281 
stages  of,  263 
tertiary,  263,  267 
of  trachea,  280 
Syringomyelia,  1109 
arthroiDathics,  1111 
bulbar,  1111 
diagnosis  of,  1111 

differentiation  of,  from  leprosy,  1112 
from  multiple  neuritis,  1112 
from  muscular  atrophies,  1112 


1322 


INDEX 


Syringomyelis,    differentiation    of^   from 
tabes,  1112 

etiology  of,  1105 

felons,  1111 

pathology  of,  1109 

prognosis  of,  1112 

symptoms  of,  1110 

treatment  of,  1112 
System  diseases,  1113,  1135 


Tabes  dorsalis,  1113 

complications  of,  1121 
course  of,  1121 
diagnosis  of,  1121 
differentiation  of, '1122 

from  brain  syphilis,  1122 
from  gall-stones,  733 
from  multiisle  sclerosis, 
1123 
etiology  of,  1113 
pathology  of,  1114 
prognosis  of,  1121 
stages  of,  1115 
symptoms  of,  1115 
ataxia,  1116 
crises,  1120 
gait,  1116 
motor,  1116 
reflexes,  1118 
Romberg's  sign,  1116 
sensory,  1117 
trophic,  1119 
treatment  of,  1123 
mesaraica,  340 
Tache  bleuatre  in  tjTphoid  fever,  24 

cerebrale,  1048 
Tachycardia,  454 

diagnosis  of,  455 
etiology  of,  454 
exophthalmic,  889 
prognosis  of,  455 
treatment  of,  455 
Tsenia  curcumerina,  1261 

echinococcus,  etiology  of,  1262 
localization  of,  1264 
multilocular  form,  1264 
pathology  of,  1262 
symptoms  of,  1262 
elliptica,  1261 
mediocanellata,  1260 
nana,  1261 
saginata,  1260 
solium,  etiology  of,  1257 
symptoms  of,  1258 
treatment  of,  1259 
Talma-Drummond  operation,  703 
Tapeworms,  1257 
Teeth,  Hutchinson's,  297 
Tender  toes  of  Hanford  in  typhoid  fever, 

29 
Tendons,  sj'philis  of,  294 
Terminal  infections,  130 
Test  meal,  602 


Testicles,  atrophy  of,  in  mumps,  189 
syphilis  of,  290 

dift'erentiation   of,    from    carci- 
noma, 291 
from  orchitis,  290 
from  sarcoma,  291 
from  tuberculosis,  291 
tuberculosis  of,  353 
Tetanus,  247 

in  children,  250 
diagnosis  of,  250 
differentiation  of,  250 

from  hydrophobia,  255 
etiology  of,  247 
facialis,  250 

from  diphtheria  antitoxin,  174 
head,  250 
incubation  in,  249 
neonatorum,  250 
trismus,  250 
prognosis  of,  250 
symptoms  of,  249 
treatment  of,  251 
vaccination  as  cause  of,  78 
Tetany,  1218 

diagnosis  of,  1220 
etiology  of,  1218 
in  gastric  dilatation,  614 
prognosis  of,  1220 
symptoms  of,  1219 
treatment  of,  1220 
thyroid  operation  causing,  895,  896 
Thomsen's  disease,  1222 
Thoracocentesis,  561 
Thrombophlebitis  in  tuberculosis,  334 
Thrombosis  of  aorta,  484 
arterial,  of  brain,  985 
of  heart,  451 
portal  vein,  722 
of  spinal  cord,  1083 
venous,  in  chlorosis,  834 
Thrush,  575 
Thymus  asthma,  897 

gland,  abscess  of,  897 
cyst  of,  897 
diseases  of,  897 
functions  of,  897 
hemorrhage  of,  897 
hjTDertrophy  of,  897 
persistence  of,  897 
tumors  of,  897 
ThjToid  extract,  896 

gland,  aberrant,  887 
accessory,  887 
cancer  of,  887 
chondroma  of,  887 
cysts  of,  887 
diseases  of,  886 
echinococcus  of,  887 
goitre,  886 

hj-pertrophy  of,  886,  888 
inflammation  of,  887 
myxoma  of,  887 
overactivity  of,  888 
perversion  of,  888 
strumitis,  887 


INDEX 


1323 


Thyroid  gland,  tumors  of,  SS7 

in  typhoid  fever,  29 
Tlayroidectomy,  892 
Thyroidism,  8.96 
Thyroiditis,  rheumatic,  199 
Tic  complex,  1216 
convulsif,  1163 
douloureaux,  1230 
simple,  1215 

with  explosive  utterances,  1216 
Tinnitus  aurimn,  1164 
Tobacco,  leukoplakia,  577 
Toe  phenomenon,  972 
Tongue,  cat's,  88 
diseases  of,  577 
eczema  of,  577 
glossitis,  578 
ichthyosis  of,  577 
keratosis  of,  577 
leukoplakia  of,  577 
psoriasis  of,  577 
scarlatinal,  88 
strawberry,  88 
tuberculosis  of,  346 
in  typhoid  fever,  30 
Tonsillar  hypertrophy,  587 
Tonsillitis,  acute  follicular,  584 

complications  of,  585 
diagnosis  of,  585 
differentiation  of,  585 
etiology  of,  584 
symptoms  of,  585 
treatment  of,  586 
chronic,  587 

diagnosis  of,  588 
etiology  of,  587 
symptoms  of,  587 
treatment  of,  589 
diphtheria,  163 
in  influenza,  178 
rheumatic,  192 
suppurative,  etiology  of,  586 
symptoms  of,  586 
treatment  of,  587 
Tonsils,  diseases  of,  584 
tuberculosis  of,  347 
Tophi  arthritici,   922,  923 
Tormina  ventriculi>  644 
Torticollis,  1172 

rheumatic,  197 
Tourette's  disease,  1216 
Toxajmia,  tuberculous,  316 
Trachea,  diseases  of,  495 

stenosis  of,  etiology  of,  504 

symptoms  of,  504 
syphilis  of,  280 
Tracheal  tugging,  aneurysmal,  476 
Tracheitis  in  influenza,  178 
Tracheotomy  in  diphtheria,  175 

laryngeal  perichonditis  and  typhoid 
35 
Transudates,  character  of  fluid,  761,  762 
Traube's  space,  547 

tones,  504 
Trauma,  neuroses  from,  1199 
of  spinal  cord,  1086 


Trauiuatic  neuroses,  1199 
Trematodes,  diseases  caused  by,  1275 
Trembles,  374 
Tremor,  exophthalmic,  890 
intention,  1105 
varieties  of,  1225 
Trichina  spiralis,  diagnosis  of,  1269 
etiology  of,  1267 
prognosis  of,  1269 
symptoms  of,  1268 
treatment  of,  1269 
Trichinosis,  1267 

differentiation     of,     from     typhoid 
fever,  46 
Trichocephalus  dispar,  1274 
Trichuris  trichura,  1274 
Tricuspid  insufficiency,  414 
diagnosis  of,  416 
etiology  of,  414 
mechanism  of,  414 
signs  of,  415 
stenosis,  417 

congenital,  432 
Trismus,  249,  1157 
Trophic  neuroses,  1234 
Trophoedema,  hereditary,  1236 
Trousseau's  sign,  1219 
Trypanosoma,  fever,  1276 
Trypanosomiasis,  1276 
Tubercle  bacilli,  "acid-fast"  bacilli,  499 

of  brain,  999 
Tuberculin  injections,  331 
Tuberculosis,  303 

of  alimentary  tract,  346 

of  aorta,  356 

arthritis,  differentiation,  from^arth- 

ritis  deformans,  930 
atrium  of,  307 

by  digestive  tract,  308 
by  direct  inoculation,  308 
by  respiratory  tract,  308 
of  bladder,  352 
of  bloodvessels,  356 
of  bones,  357 
bovine,  306 
of  brain,  346,  999 
of  bronchial  glands,  339 
choroidal,  1051 
congenital,  309 

differentiation    of,    from    broncho- 
pneumonia, 519 
of  ear,  354 
etiology  of,  304,  309 
extension  of,  mode  of,  313 
of  Fallopian  tubes,  353 
of  genitalia,  353 
of  genito-urinary  tract,  350 
of  gums,  346 
of  heart,  356 
herpes  in,  317 

histopathology  of  tubercle,  312 
of  intestines,  348 
etiology  of,  348 
symptoms  of,  349 
of  joints,  357 

symptoms  of,  357 


1324 


INDEX 


Tuberculosis  of  jointSj  treatment  of,  357 
of  kidney,  351 

etiology  of,  351 
pathology  of,  351 
symptoms  of,  351 
general,  352 
local,  352 
urinary,  352 
of  larynx,  354 

etiology  of,  354 
forms  of,  355 
pathology  of,  354 
symptoms  of,  354 
treatment  of,  355 
of  lips,  346 
of  liver,  350 
of  lungs,  318 

in  aged,  331 
in  children,  330 
complications  of,  333 

amyloid  degeneration,  336 
circulatory,  334 
digestive,  335 
genito-urinary,  336 
muscular,  334 
nervous,  334 
pneumothorax,  563 
respiratory,  333 
skin,  336 
course  of,  327 
diagnosis  of,  331 
extension  of,  318 
forms  of,  acute,  327 

desseminated,  328 
galloping,  327 
miliary,  329 
pneumonic,  327 
ulcerative,  329 
chronic,  329 

fibrous  phthisis,  329 
pleuritic,  330 
ulcerative,  329 
pathology  of,  318 
prognosis  of,  332 
stages  of,  confirmed,  327 
consummated,  327 
incipient,  327 
symptoms  of,  319 
general,  322 
physical  signs,  323 
respiratory,  local,  319 
lymphadenitis,  differentiation  from 

pseudoleuksemia,  863 
of  lymph  glands,  337 

bronchial  adenitis  of,  339 
atrium  of,  339 
diagnosis  of,  340 
issues  of,  340 
signs  of,  339 
symptoms  of,  339 
cervical  adenitis,  338 

atrium  of,  338 
pathology  of,  338 
symptoms  of,  338 
characteristics,  337 
etiology  of,  337 


Tubercolosis  of  lymph  glands,  general- 
ized adenitis  of,  340 
mesenteric  adenitis  of,  340 
pathology,  337 
treatment  of,  340 
of  mammse,  353 
measles,  as  cause  of,  99 
of  meninges,  346 
of  mesenteric  glands,  340 
miliary,  acute,  313 

diagnosis  of,  317 
etiology  of,  313 
prognosis  of,  318 
remissions  of,  318 
symptoms  of,  314 

choroidal       tubercles, 

316 
circulatory,  315 
digestive,  316 
fever,  315 
nervous,  316 
respiratory,  315 
types,  317 
chronic,  318 

differentiation   of,    from   influ- 
enza, 181 
mixed  infection,  305 
of  muscles,  357 
of  nasopharynx,  354 
of  nose,  354 
of  oesophagus,  347 
of  palate,  347 
of  pericardium,  341 
of  peritoneum,  341 
course  of,  345 
diagnosis  of,  345 
etiology  of,  342 
symptoms  of,  343 
adhesions,  343 
ascites,  344 
exudation,  344 
fever,  344 
friction,  344 
gastro-intestinal,  345 
marasmus,  345 
meteorism,  344 
pain,  345 
palpation,  344 
pelvic  effusion,  344 
retraction,  343 
treatment  of,  345 
types  of,  342 
of  pharynx,  347 
of  pleura,  341 
prevalence  of,  in  animals,  306 

in  man,  306 
prognosis  of,  results  from  treatment, 

360 
of  prostate,  353 
pseudotuberculosis,  307,  332 
pulmonary,  in  diabetes,  912 
roseolffi  in,  317 
of  salivary  glands,  347 
of  serous  membranes,  341 
of  skin,  323,  358 
of  spine,  1071 


INDEX 


1325 


Tuberculosis  of  spleen,  316,  350,  885 
of  stomach,  348 
of  suprarenal  glands,  877 
of  testicle,  353 
of  tongue,  346 
of  tonsils,  347 
treatment  of,  359 
expectant,  363 
anaemia,  366 
cardiants,  365 
cough,  363 

digestive  disorders,  365 
dyspnoea,  365 
fever,  363 
haemoptysis,  365 
insomnia,  365 
pain,  365 

sexual  symptoms,  366 
sweats,  364 
hygienic,  360 
food,  361 
fresh  air,  360 
rest,  362 
prophylactic,  359 

antibacillary,  359 
governmental,  359 
individual,  359 
specific,  362 
in  typhoid  fever,  36 
of  ureter,  352 
urine  in,  316 

vaccination  as  cause  of,  78 
Tuberculous  anaemia,  311 
arteriosclerosis,  311 
bronchitis,  311 
cirrhosis  of  liver,  311 
cyanosis,  315 
dyspnoea,  315 
endocarditis,  356 
meningitis,  316,  1049 

differentiation  of,  from  syphilis, 
283 
psychoses,  311 
rheumatism,  357 
spina  ventosa,  357 
toxaemia,  316 
valvular  disease,  311 
Tuffnell  treatment,  480 
Tumor  albus,  syphilitic,  293 
Tumors  of  bile-ducts,  742 
of  brain,  999 
of  gall-bladder,  741 
of  heart,  451 
of  intestines,  677 
of  kidneys,  822 
of  larynx,  494 
of  liver,  711 

differentiation  of,  from  abscess, 
724 
of  lungs,  531 

differentiation   of,   from  pneu- 
monia, 153 
of  mediastinum,  569 
of  meninges,  1079 
of  mesentery,  691 
of  oesophagus,  596 


Tumors  of  pancreas,  749 
of  pleura,  569 
of  rectum,  677,  679 
renal,  differentiation  of,  from  cancer 

of  liver,  714 
of  spleen,  acute,  882 

chronic,  882,  885 
of  stomach,  632,  633,  636 
of  suprarenal  glands,  881 
of  thymus  gland,  897 
of  thyroid  gland,  887 
of  ureter,  822 
Tussis  hepatica,  710 
Tympanites  in  typhoid  fever,  treatment 

of,  52 
Typhlitis,  tuberculous,  349 
Typhoid  fever,  17 

in  aged,  40 

anomalous  courses  of,  38 
bilious,  61 
in  children,  39 
chills  in,  21,  24 
clinical  types  of,  19 
convalescence  of,  41 
diagnosis  of,  41 

etiological,  18 
differentiation  of,  from  anthrax, 
42 
from  endocarditis,  44,  45 
from  enteritis,  43 
from  gastritis,  43 
from  malaria,  44,  45 
from  meningitis,  44,  45 
from  miliary  tuberculosis, 

42,  44,  45,  317 
from  paratyphoid,  43 
from    pernicious    malaria, 

123 
from  pneumonia,  42 
from  sepsis,  44,   45 
from  septic  affections,  135 
from     serous     meningitis, 

1055 
from  trichinosis,  46 
from  typhus  fever,  42,  60 
etiology  of,  17 

bacillus  typhosus,  17 
predisposing,  18 
exacerbations  of,  140 
gall-stones  in,  relation  of,  728 
immunity  from,  19 
incubation  of,  19 
onset  of,  20 
paratyphoid,  19,  43 
prognosis  of,  46 
recrudescences  of,  41 
relapses  of,  40 
"scarlet-typhoid,"  89 
second  attacks  of,  19 
sudoral  type  of,  21,  24 
symptoms  of,  19 
bone,  29 
cardinal,  41 
circulatory,  24 
contra-indicating,  42 
dermal,  23 


1326 


INDEX 


Typhoid  fever,    symptoms  of,  digestive 
tract,  30 
fever,  20 

genito-urinary,  36 
joint,  29 
muscle,  29 
nervous,  27 
respiratory,  35 
secondary,  42 
special  senses,  29 
splenic  tumor,  22 
thyroid  gland,  29 
treatment  of,  47 
antipyresis,  49 
antiseptic,  48 
of  bacilluria,  55 
of  bed-sores,  55 
care  of  skin,  55 
of  convalescence,  55 
diet,  50 

of  epistaxis,  54 
expectant,  52 
hygienic,  48 
of  laryngeal  lesions,  54 
of  nervous  symptoms,  54 
prophylactic,  47 
specific,  48 
symptomatic,  52 
of  thrombophlebitis,   54 
spine  in  typhoid  fever,  29 
state,  27 
Typhus  fever,  55 

differentiation  of,  59 

from  measles,  101 
etiology  of,  56 
exanthematous,  55 
prognosis  of,  60 
recurrence  of,  59 
symptoms  of,  56 
general,  56 

defervescence,  57 
exanthematous  stage, 

56 
incubation,  56 
invasion  stage,  56 
special,  57 

alimentary,  59 
circidatory,  58 
fever,  57 

genito-urinary,  59 
glands,  59 
nervous,  58 
respiratory,  58 
skin,  57 
spleen,  59 
treatment  of,  61 
icteroids,  216 

recurrens.  See  Recurrent  Fever,  61 
Tyrotoxismus,  1252 


u 


Ulcers,  bronchial,  syphilitic,  280 
duodenal,  655 


Ulcers,  gastric,  differentiation  of,   from 
gall-stones,  733 
of  intestines,  655,  657 

in  tuberculosis,  335 
of  larynx,  494 

in  typhoid  fever,  35 
of  oesophagus,  590 
of  pharynx,  583 
of  stomach,  round,  617 
typhoid,  of  appendix,  31,  32 
of  oesophagus,  31 
of  pharynx,  31 
of  stomach,  31 
Ulcerative  stomatitis,  574 
Ulcus  perforans  of  stomach,  618 
rotundum  of  stomach,  618 
simplex  of  stomach,  618 
Uncinaria  duodenalis,  etiology  of,  1269 
symptoms  of,  1270 
treatment  of,  1272 
Uncinariasis,  1269 
Uraemia,  781 

acute,  treatment  of,  773 
causes  of,  781 
coma  from,  976 
diagnosis  of,  784 
differentiation  of,  784,  785 
etiology  of,  781 
latent,  820 
scarlatinal,  89,  95 
symptoms  of,  782 
cardiac,  783 
digestive,  783 
nervous,  782 
respiratory,  783 
treatment  of,  785-791 
in  yellow  fever,  217 
Urates  in  urine,  807 
Ureter,  calculus  of,  822 
tuberculosis  of,  352 
tumor  of,  824 
Urethritis  in  mumps,  189 
Uric  acid,  calculus,  817 

in  urine,  807 
Urine,  albumin  in,  799 
alkaptone  in,  808 
blood  in,  802 
chyle  in,  806 

in  cirrhosis  of  liver,  699,  705 
cryoscopy  of,  780 
fat  in,  806 
febrile,  36 

hgematoporphyrin  in,  809 
in  heart  disease,  421 
hydrochinon  in,  809 
in  icterus,  726 
indican  in,  808 
in  nephritis,  768 
oxalates  in,  808  , 

phosphates  in,  807 
pus  in,  805 
tests  of,  elimination,  780 

permeability,  780 
in  tuberculosis,  316 
urates  in,  807 
uric  acid  in,  807 


INDEX 


1327 


Urine  in  yellow  fever,  217 
Urobilin,  icterus,  7^5 
Urobilinuria,  726 
Urostealiths,  SIS 
Urticaria,  visceral  crises  in,  867 
Uterus,  syi^hilis  of,  291 


V 


Yaccinatiox,  64,  77,  78,  79 
Vaccinia,  77 
Vagina,  syphilis  of,  291 
Valsalva's  experiment,  384 
Valvular    disease,    chronic,    401.       See 
Aortic  Insufficiency,  etc. 
general  symptoms  of,  418 
tuberculous,  311 
heart   disease.     See  Aortic  Insuffi- 
ciency, etc. 
Varicella,  81 

differentiation  of,  from  smallpox,  74 
Variola,  64 

differentiation  of,  from  measles,  101 
Vas  deferens,  syphilis  of,  291 
Vasomotor  neuroses,  1234 
Veins,  syphilis  of,  278 
Venesection,  158 

in  apoplexy,  978 
in  cardiac  disease,  425 
Ventricles,  cerebral,  hemori'hage  in,  976 
Vertebrae,    carcinoma   of,    diagnosis   of, 
1075 
symptoms  of,  1075 
caries  of,  1071 

diagnosis  of,  1074 
etiology  of,  1071 
localization  of,  cervical,  1072 
dorsal,  1072,  1073 
lumbar,  1074 
pathology  of,  1071 
prognosis  of,  1074 
symptoms  of,  1072 
treatment  of,  1075 
diseases  of,  1068 
dislocation  of,  1070 
fracture  of,  1068 
course  of,  1070 
diagnosis  of,  1070 
etiology  of,  1068 
symptoms  of,  1069 
treatment  of,  1070 
tuberculosis  of,  1071 
Vertigo,  auditory,  1165 
cerebellar,  960 
e  stomacho  laeso,  605 
Vincent's  angina,  170,  583 
Visceral  rlieumatism,  194 
Visceroptosis,  680 
Vision,  centre  for,  946 
Visual  centre,  946 
Vocal   cords,   paralysis   of,    1168,    1169, 

spasm  of,  1169 
Volvulus,  612 

diagnosis  of,  675 
differentiation  of,  (i76 


Volvulus,  etiology  of,  672 

pathology  of,  672 

symptoms  of,  673 

treatment  of,  676 
Vomiting,  in  brain  tumor,  1002,  1008 

in  cholera  asiatica,  209 

differentiation  of,  645 

in  gastric  cancer,  632 

in  gastric  ulcer,  619,  620,  621 

nervous,  645 

causes  of,  645 
differentiation  of,  645 

in  pneumonia,  146 

in  tuberculosis,  335 

in  typhoid  fever,  30 

treatment  of,  52 
Vomitus,  coffee-grounds,  620 

cruentus,  638,  637 
V.  Eiselsberg's  sign,  in  hour-glass  stom- 
ach, 617 
Voussure,  pericarditic,  380 
Vulva,  syphilis  of,  291 
Vulvovaginitis,  diphtheritic,  166 


W 


Wandering  liver,  719 
War  fever,  655 
Weber's  test,  639 
Weil's  disease,  372 

diagnosis  of,  373 
etiology  of,  373 
prognosis  of,  373 
symptoms  of,  373 
treatment  of,  374 
Werlhof's  disease,  868 
Westphal's  sign,  1118 
Whip-worm,  1274 
Whooping-cough,  182 

"after-pertussis,"  185 
complications  of,  184 
bronchitis,  184 
bronchopneumonia,  184 
convulsions,  184 
glottis,  spasm  of,  184 
hemorrhages,  184 
oedema,  184 
pneumonia,  lobar,  184 
course  of,  184 
diagnosis  of,  185 
differentiation  of,  185 
from  croup,  185 
from  false  croup,  185 
from  glottis,  spasm  of,  185 
from  hysteria,  185 
fi-om  laryngeal  disease,  185 
from  periodic  asthma,  185 
etiology  of,  182 
prognosis  of,  186 
sequels  of,  185 
symptoms  of,  183 

convulsive  stage,  183 
decline,  1S3 
toxaMiiia.  185 
\'oiiiit  inji'.  184 


1328 


IKDEX 


Whooping-cough,  treatment  of,  186 
hygienic,  188 
intubation,  187 
medicinal,  186 
prophylaxis,  186 
in  typhoid  fever,  26 
Williamson's  test  of  diabetic  blood,  912 
Winckel's  disease,  869 
Wintrich  change  of  note,  326 

of  pitch  in  pneumonia,  144 
palpatory  percussion  in  pneumonia, 
144 
Wolfier's  sign,    in    hour-glass    stomach, 

617 
Wooden-tongue,  257 
Woolsorters'  disease,  243 
Word  deafness,  947,  948,  949,  950 
Wound  diphtheria,  166 
Writer's  cramp,  1221 

diagnosis  of,  1221 
etiology  of,  1221 
symptoms  of,  1221 
treatment  of,  1221 
Writing,  disturbances  in,  948,  952 
Wryneck,  1172 


Xanthin  calculus,  818 
Xanthoma  in  icterus,  728 
Xanthopsia  in  icterus,  728 
Xerostomia,  579 


Yellotv  atrophy  of  liver,  acute,  692 
fever,  213 

complications  of,  217 

diagnosis  of,  217 

epidemiology,  214 

etiology  of,  213 

sequels  of,  217 

prognosis  of,  218 

symptoms  of,  general,  214 
incubation,  214 
stages  of,  214,  215 
special,  215 

black  vomit,  216 
circulatory,  216 
digestive,  216 
fever,  215 
hemorrhages,  217 
icterus,  216 
liver,  216 
nervous,  215 
respiratory,  216 
urine,  217 
vomito-negro,  216 

treatment  of,  218 


ZOMOTHERAPY,   362 

Zoonoses,  239 

Zuckergussleber,  758 


^:i 


s 


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